Emergency

Sheridan Emergency Medicine was created in 1994, and we treat more than 600,000 patients annually.

We transition weak emergency department programs into strong programs that meet our client’s throughput reporting metrics. Our devotion to patients gives us high marks in patient satisfaction, low patient wait times and outstanding national quality measures compliance.

Sheridan’s Seamless Emergency Department Transition

  • Ensures quality care and productivity, and that providers are directly accountable for their performance.
  • Our on-site clinical and operations teams offer tangible solutions to department leadership and management issues, including billing and revenue cycles.
  • Our programs focus on lean enterprise, peer review, PQRS, leadership and risk occurrence define best practices and process improvements.
  • Offers flexible, scalable solutions and dedicated recruitment for the best EM staff results in stable, longstanding programs for any facility.

Learn more about our emergency medical solutions.

Read our emergency medicine related posts:

22 November2016

Getting Creative with Emergency Room Care Starts with the Human Element

There is a new authority ruling emergency rooms across San Diego County, created to combat the influx of patients overwhelming the health care system in recent years. Known as “bed czars” and “zoomer nurses,” as featured in the San Diego Union-Tribune, medical personnel at Sharp Grossmont Hospital and Tri-City Medical Center monitor the ED and help make decisions to “fast track” patient care. They determine the patients with minor medical problems and allow them to remain for treatment and discharge, while patients with more severe conditions requiring at minimum an overnight stay are quickly transferred to the appropriate department.

The creation of these new positions highlights a heightening dilemma in ED overcrowding. Over the past 20 years, annual ED visits have increased by 40 percent, from 97 million in 1995 to 136.3 million in 2012. After two decades of steadily rising visits, hospitals have seen a rapid spike in ED use over the last several years due to increased health care coverage and several public health concerns, including:

  • Nearly half of ED physicians (.pdf) believe that the severity of illness or injury among patients has increased since 2014, which necessitates spending more time determining whether their illness or injury can be addressed in the ED.
  • Physicians also note a rise in behavioral health-related visits, spurred by a nationwide shortage of funding for psychiatric inpatient services, which account for 12.5 percent of all ED patient visits.
  • Further, the ED has become the first stop in hospital readmittance for patients with chronic health care issues, which include not only mental illness but also diabetes, hypertension and congestive heart failure. About one in five hospitalized patients visited an ED within 30 days of their discharge, and 55 percent of these patients were readmitted to an inpatient department after being examined. 

With these multifaceted concerns straining ED staffing, time and resources, it is no wonder that hospitals are getting creative in their efforts to manage and eventually eradicate overcrowding. To deal with specific causes of readmittance, particularly mental health concerns, hospitals such as Sinai Health System in Chicago and the SSM Health St. Mary’s Hospital in Madison, Wis. are greatly expanding community access to mental health care through new psychiatric services and facilities. The Nassau University Medical Center in Long Island is addressing staffing and space concerns by building a new primary care unit to relieve the patient burden in the ED.

Meanwhile, several upstate New York hospitals have joined the Community Partners of WNY, a performing provider system which provides follow-up calls to ED “super-utilizers” to coordinate patient care and redirect patients to relevant hospital services based on ailment severity. The Charleston Area Medical Center has also employed technological solutions through the use of TeleHealth Services, an interactive patient education platform that has helped reduce readmission rates by 30 percent.

While these solutions address long-term issues in the health care industry, most programs designed to solve ED overcrowding rely on access to funding and administrative support. Many hospitals across the country do not have these resources readily available, thus in the struggle to deal with overwhelming patient needs EDs are increasingly ill equipped to adhere to practices that ensure efficiency and patient safety.

However, EDs can make many immediate and low-cost improvements to begin to address overcrowding, as examined in Sheridan Healthcare’s white paper "The Evolving Emergency Department."  Training ED teams in crew resource management (CRM) proactively increases collaboration and improves team communication, as individuals are encouraged to monitor, identify and communicate information such as potential patient harm. Improving triage processes by having medical personnel treat patients as soon as they are available, rather than based on a traditional waitlist, reduces patient wait times while allowing the ED team to quickly determine the severity of the emergency and required departmental treatments for the ailment. Finally, medical personnel can be empowered to continuously contribute to the improvement of ED efficiency through the Kaizen principle of management. 

10 November2016

Online Symptom Checkers List Correct Diagnosis First Only One-Third of the Time

Patients increasingly rely on online sources of medical information, including WebMD and Google. Patients’ increasing engagement in their healthcare is a good thing, but they often come in with an incorrect diagnosis based on online research, as Dr. Catherine Polera, Chief Medical Officer for Sheridan’s Emergency Services division explained in a MedPage Today article. Now physicians can show their patients concrete evidence that a doctor’s diagnosis is far more likely to be correct than that of a computer algorithm.

Researchers at Harvard Medical School and Brigham and Women’s Hospital in Boston recently tested the diagnostic accuracy of trained physicians compared to that of online symptom checkers. In a previous study published last July in BMJ, the researchers had evaluated the diagnostic accuracy of 23 symptom checkers (both websites and apps) using 45 clinical vignettes. According to a research letter published in JAMA Internal Medicine, the new study asked 234 internal medicine, family practice and pediatrics physicians to evaluate the same vignettes, each of which was solved by at least 20 physicians. As with the symptom checkers in the previous study, the physicians were asked to identify the most likely diagnosis along with two additional possible diagnoses for each case. The vignettes comprised 15 high-acuity, 15 medium-acuity and 15 low-acuity condition scenarios involving 26 common and 19 uncommon conditions, and included the symptoms and history of the patient but no physical exam or test findings. 

Physicians Outperformed Symptom Checkers in Diagnostic Accuracy by a 2-to-1 Margin

The physicians significantly outperformed the symptom checkers in all scenarios. Across all cases, the physicians listed the correct diagnosis first 72.1% of the time, compared to 34% of the time for the symptom checkers. Physicians also included the correct diagnosis in their top three diagnoses 84.3% of the time, compared to 51.2% of the time for the symptom checkers.

Interestingly, physicians were more likely to list the correct diagnosis first for high-acuity cases (71% of the time) than for low-acuity cases (65.3%), and for uncommon cases (75.5%) versus common cases (69.6%). Conversely, symptom checkers were more likely to list the correct diagnosis first for low-acuity cases (40.5%) than for high-acuity cases (24.3%), and for more common cases (38.1%) versus uncommon cases (28.1%). 

Can Technology Help Improve Diagnostic Accuracy?

Despite their much higher diagnostic accuracy rate versus the algorithms, physicians provided an incorrect diagnosis in about 15% of the cases. Per a recent Modern Healthcare article, Ateev Mehrotra, M.D., author of the new study and associate professor of health care policy and medicine at Harvard Medical School, said it would be useful to study how computers could improve physicians' diagnostic accuracy. In a MedPage Today article responding to the study’s findings, Dr. Art Papier, associate professor of dermatology and medical informatics at the University of Rochester School of Medicine and Dentistry and co-founder and CEO of VisualDx, said new professional systems that model variation in presentation already exist and “clinicians should be augmenting their knowledge with tools to help them do their job better.” And the new Watson Medical Imaging Collaborative is using IBM’s Watson supercomputer to try to help physicians reduce diagnostic errors.

24 October2016

Using CRM and Time-Outs to Focus Hurried OR Teams on Patient Safety

The shift to value-based care and the imminent implementation of MACRA have made efficiency healthcare’s new mantra, and U.S. hospitals and healthcare systems have made operating rooms a high-priority target for optimization. ORs in U.S. hospitals generate about 70% of a hospital’s revenues and operate at a staffed-capacity utilization of 60-70% and OR time costs roughly $80 an hour, so it’s not surprising that metrics like on-time starts, turnover times, same-day cancellations and OR under- and overutilization are under scrutiny. But speed is not the same thing as efficiency, and the faster OR teams work, the greater the risk of something going wrong. 

Dr. Adam Blomberg, National Education Director for Sheridan’s Anesthesiology Division, has long been an advocate of improving efficiency in the OR, calling it a win for “the anesthesiologists, surgeons, nurses, administrators, and most of all, the patients.” But he also worries that the enormous pressure on healthcare providers nationwide to speed up care delivery could eventually result in rushing at the expense of patient safety. An April 2016 analysis commissioned by The Leapfrog Group conservatively estimated that more than 206,000 avoidable deaths in U.S. hospitals each year are caused by medical errors, and those numbers could increase if hospitals’ drive for greater efficiency isn’t paired with an equally strong push to improve patient safety.

In a recent interview with Becker’s ASC Review, Dr. Blomberg urged surgical teams to slow down while speeding up – to work quickly and efficiently but also to remember to “slow down, take a deep breath and still think of the patient first.” He is a strong proponent of crew resource management (CRM) for OR teams. CRM training brings all team members together to learn how to communicate, make decisions and work together as a team both efficiently and effectively. It also standardizes the routine use of checklists and protocols, such as empowering any team member who identifies potential harm to the patient to call a “time-out,” immediately causing the entire team to pause and discuss that member’s safety concern. 

Dr. Blomberg is also Chief of Anesthesiology at Memorial Regional Hospital (MRH) in Hollywood, FL, which is part of the Memorial Healthcare System (MHS) that has experienced significant quality and safety improvements, fewer untoward outcomes and sentinel events, and improved patient experience and satisfaction after implementing CRM.

Dr. Blomberg stresses to his teams the importance of time-outs and has standardized the use of an anesthesia time-out at MRH to make sure the patient and the OR team are on the same page prior to induction of anesthesia. Sheridan’s standard anesthesia time-out is a brief conversation between the anesthesia care team and the circulating nurse to verify that the team has the correct patient, correct side and correct equipment in the OR, and that any necessary vendor or representative for surgical equipment is available prior to induction. The anesthesia time-out can take place after the patient has had pre-op sedation but before he or she is under general anesthesia. Sheridan anesthesiologists also do a surgical time-out with the surgeon as a final double-check prior to incision.

Twelve years after The Joint Commission’s Universal Protocol was introduced, creating widespread adoption of pre-procedure verification, site marking and time-outs, embedding patient safety into surgical teams’ SOP is more important than ever. It’s time we made National Time Out Day redundant.

19 October2016

Sheridan’s 2016 Leadership Conference Recognizes Eight Outstanding Clinical Leaders

The annual three-day Sheridan Leadership Conference is Sheridan Leadership Academy’s flagship event. This year’s conference took place Sept. 30-Oct. 2 in Orlando, Florida and was attended by nearly 600 physician and allied health leaders. 

 

Strengthening the Core

President of Physician Services Robert Coward and CEO Chris Holden provided opening remarks and introduced this year’s conference theme, “Strengthening the Core,” which focused on the key attributes required to succeed as a Sheridan clinical leader. Throughout the conference, each service line held multiple breakout sessions to promote discussion and knowledge sharing of topics related to the conference theme.

New Leadership Academy Programs

This year’s conference also marked the expansion of the Leadership Academy’s programs, whose participants are nominated by their leaders. In addition to the Emerging Leaders Program that began in 2014, the Academy added two new programs this year, the Physician Chiefs Program and the Allied Health Chiefs Program. Each of the three leadership programs kicked off its first course at the conference.

The 2016 Sheridan Leadership Award Winners

One of the highlights of the conference was the awards dinner, which took place on Oct. 1. Eight outstanding Sheridan physicians were honored with 2016 Leadership Awards:

Dr. Mike Adkins, Anesthesia Services Chief of the Year

Michael Adkins has been with Valley Anesthesiology since 1994 – providing cardiac anesthesia services for 13 years, serving as medical director at an outpatient plastic surgery center, and currently is chairman of anesthesia at Banner University Medical Center-Phoenix.

He also has filled important administrative roles during his tenure, including scheduling coordinator, division manager, board member, and principal in the formation and launch of Valley’s Mobile Services Division.

He is a former board member of the Arizona Medical Association and is president-elect of the Arizona Society of Anesthesiologists. He earned his medical degree from the University of Minnesota-Minneapolis, did a surgical internship at the University of Illinois in Chicago and received training in cardiothoracic and neuroanesthesia at Stanford University.

 

Dr. Joseph Toscano, Emergency Medicine Chief of the Year

Dr. Toscano has been an attending emergency physician at San Ramon Regional Medical Center since 1999 and chief of the department since 2013.

He has extensive experience and expertise in the field. In the early 2000s, he was a partner and corporate medical director for Pinnacle Medical Group, which operated five urgent care clinics in California and Arizona. He lectures frequently at urgent care conferences and is on the board of directors of the Urgent Care Association of America. He has been medical director of San Ramon Regional’s occupational medicine clinic since 1999.

He graduated from Dartmouth College and earned his medical degree from the Duke University School of Medicine. He trained in internal medicine at the naval hospital in San Diego and began practicing emergency medicine during an operational tour of duty with the U.S. Navy in the early 1990s. He moved to California in 1994 and has been an EM physician there ever since.

Dr. Frank Seidelmann, Radiology Chief of the Year

Dr. Frank Seidelmann is co-founder, chairman, and visionary force driving the success of Radisphere. Dr. Seidelmann brings a wealth of experience in radiology with subspecialty expertise in MRI and neuroradiology. He has more than 25 years’ experience in interpreting MRI cases and functions as a consultant on difficult cases for radiologists and clinicians around the country. He has lectured on MRI, both nationally and internationally.

Before venturing into subspecialty teleradiology in 1996, Dr. Seidelmann co-founded a highly successful hospital and outpatient imaging center based radiology group with 20 contracts in the Midwest and central states, at one time employing more than 50 physicians, which was acquired by Med Partners and later became Team Health. He also has owned several diagnostic imaging centers in Ohio and co-founded RIS Logic, a leading radiology software company that targeted diagnostic imaging centers. RIS Logic was later acquired by Merge Healthcare in 2003. Additionally, he has held staff positions at the Cleveland Clinic Foundation and Case Western Reserve University, and has expertise in small joint imaging.

Dr. Mitchell Stern, Women’s and Children’s Chief of the Year

Mitchell Stern, MD joined what was then known as Neonatology Certified in 1987, immediately after completing his Neonatal Fellowship at Babies Hospital (Columbia Presbyterian Medical Center) in New York City. He did his residency, including a chief residency, at Brookdale Hospital Medical Center in Brooklyn, New York. He attended medical school at St. George’s University School of Medicine in Grenada, WI and attended college at Cornell University in Ithaca, New York. 

Dr. Stern joined the staff of Plantation General Hospital in 1987 and became a Director of the unit shortly after Neonatology Certified became a part of Sheridan Healthcare in 1996. Besides being the clinical and administrative leader of the PGH Level III NICU, Dr. Stern has also been the Principal Investigator in several multicentered research projects and has been involved with several committees at both the hospital and HCA Corporate Levels.

Dr. Adam Blomberg, Diamond Award Winner

Adam L. Blomberg, M.D. is the Chief of Anesthesiology for Memorial Regional Hospital in Hollywood, Florida., as well as the National Education Director for Sheridan Healthcare’s Anesthesia Division. He serves on the Anesthesia Quality Committee at Sheridan as the co-chair of the Clinical Education & Best Practice Subcommittee. He has held positions at Memorial on the Physician's Satisfaction Committee and the Multidisciplinary Peer Review Committee as well as the Co-Chair of the Surgical Services Executive Committee.

Dr. Blomberg has had numerous articles published on anesthesia trends and best practices in leading industry publications, such as the Wall Street Journal, CNN Health, ASA Newsletter, Anesthesia Patient Safety Foundation Newsletter, HealthLeaders, Managed Care Outlook and Becker’s Hospital Review. In addition, he has spent more than 15 years as the national speaker for the “Driving Responsibly” campaign.

Dr. Blomberg completed his training at Brigham & Women's Hospital, a teaching affiliate of Harvard Medical School in Boston in the Department of Anesthesiology, Perioperative and Pain Medicine. During his final year of residency, he served as Chief Resident. He is a graduate of the University of Miami School of Medicine in Miami, Florida.

Cindy Houck, CRNA, Platinum Award Winner

Cynthia Houck, CRNA joined Sheridan Healthcare in 1984 after graduating from George Washington University’s Nurse Anesthesiology Program. She has witnessed the growth of Sheridan from a small private anesthesia group to the nation’s largest anesthesia outsourcing provider.

Cynthia has served as the Chief of Allied Health at Memorial Regional Hospital, a 700-bed tertiary care level-one trauma center, since 1993. She has also been the Regional Director of Allied Health, South Florida Region since 2009. Her responsibilities include oversight of all Allied Health in Dade and Broward Counties, 14 hospitals and 6 ambulatory facilities. She was the Clinical Coordinator for SRNAs from FIU from 2006 until 2012.

In addition to her clinical duties, Ms. Houck is also co-chair of the Policy & Procedure Subcommittee for Quality Improvement

 

Dr. Gary Gomez, Innovation Award Winner

Dr. Gary Gomez has served as chief of anesthesiology at Memorial Hospital Miramar since 2013 and has led several clinical improvement projects. These include enhanced recovery after surgery protocols, PONV prophylaxis tools and i

ntrathecal catheter management protocols. He also was one of three lead physicians to develop the ClearPATh anesthesia patient readiness program and is currently collaborating to develop further clinical pathways as part of Sheridan/AMSURG’s nationwide initiatives.

Dr. Gomez received his medical degree from the University of Florida and is currently enrolled at UF’s executive MBA program. He lives in South Florida with his wife and three children.

Dr. Jonathan Katz, Innovation Award Winner

Dr. Jonathan Katz started with Sheridan eight years ago as a member of the cardiac team at a 227-bed hospital. He was promoted to vice chief a year later and has been a regional medical director for 1.5 years.

Dr. Katz graduated from the University of Pennsylvania School of Dental Medicine and got his medical degree from the University of Connecticut in oral and maxillofacial surgery. He completed his anesthesia residency at the University of Miami, where he served as chief resident and did his cardiothoracic anesthesia fellowship. He also worked as an attending in UM’s cardiac anesthesia subdivision and was assistant program director for the anesthesia residency.

 

 

Please join us in congratulating this year’s Sheridan Leadership Award winners.

15 August2016

Six Physician Communication Strategies to Increase Patient Engagement and Improve Outcomes

Effective physician-patient communication that builds trust and a shared sense of responsibility for the patient’s care is an increasingly important skill for physicians. Doctors whose communication fosters patient engagement has been linked to a wide range of benefits, from increased patient satisfaction, trust and higher quality of care to better patient adherence to treatment and improved physical outcomes. Communication skills are especially important in a hospital setting, which patients often perceive as more impersonal than a visit to their primary care physician’s office.

The challenge is that while the need to involve patients in decisions about their own care continues to grow in importance, the current health care environment – including shorter hospital stays, more complex medical care and a drive for efficiency – makes it harder to achieved good communication among providers, patients and family members.

The Negative Effects of Poor Physician Communication on Patient Experiences … and Outcomes

A 2015 study published in PLOS ONE synthesized qualitative studies exploring patients’ experiences in communicating with a primary care physician to identify the determinants of positive and negative experiences in physician-patient communication and their subsequent outcomes. It found that, overall, primary care physicians’ communications create more negative than positive patient experiences. Patients report that physicians usually lead consultations and sometimes in a paternalistic manner – deciding on the treatment plan without engaging the patient in a conversation about care decisions, asking too few questions or too many closed-ended question, and rushing through explanations of the patients’ illnesses while using complicated, unfamiliar medical jargon. Doctors often orient conversations toward physical symptoms without leaving room to discuss psychosocial aspects related to the condition. As a result, patients say they feel powerless, vulnerable and intimidated and, therefore, less likely to engage in their own care decisions by asking questions or volunteering psychosocial or other information that might affect their diagnosis or treatment. Those who attempt to address psychosocial issues proactively report being dismissed.

Patients say these negative experiences leave them feeling not only helpless, frustrated, unheard and unrecognized but also unmotivated to comply with their treatment plans.

While this study focused specifically on primary care doctors, these problems can be exacerbated in a hospital setting, where a physician-patient relationship may not have been established.

Communication Skills That Promote Patient Engagement

Patients also shared the communication-related skills they value most in physicians:

  • Empathy.
  • Careful listening.
  • An open mind.
  • Friendliness.
  • Compassion.
  • A genuine interest in the patient.
  • Attentiveness.
  • Willingness to ask questions and initiate conversations.
  • Investing time and effort to educate patients and make sure they understand the illness.

These skills are key to fostering collaborative, two-way communication and building trust and mutual respect – things that can provide important contextual information and enable doctors to do a better job of tailoring care and fostering patient engagement.

Cultural Barriers to Effective Communication

Ultimately, whether patients experience a physician’s communication with them as positive or negative is heavily influenced by the context of a patient’s individual background and values. Some of the ethnic minority patients report experiencing additional communication difficulties resulting from language barriers, discrimination, differences in values and beliefs, and acculturation-related issues.

The study offers several examples of how acculturation affects physician-patient communication. One such example is that Hispanic migrants to the U.S. say they need to develop a warm relationship with their physicians before they feel safe sharing private information, while U.S.-born Hispanics attach less importance to developing warm relationships with their doctors because they appear to understand that the physician’s primary role in this country is to heal.

Interestingly, patients who need to consult with informal interpreters during medical visits say those consultations make them feel embarrassed, guilty and uncomfortable. And, not surprisingly, the presence of an informal interpreter not only inhibits patients from discussing sensitive or mental health topics but also makes disclosing intimate information difficult or impossible.

Six Ways to Improve Physician-Patient Communication and Engagement

Solicit Relevant Psychosocial Contexts

Encourage patients to talk about psychosocial factors that might be related to their condition. Try to provide a nonjudgmental atmosphere to help make them comfortable talking about difficult personal issues.

Tailor Communications to Cultural Contexts

Develop a cultural awareness and understanding of the populations you serve and tailor communications appropriately to each patient’s cultural, values- and beliefs-based context to avoid inadvertently giving offense or causing mistrust.

Educate Patients on Care Best Practices

In a recent article in MedPage Today, Dr. Catherine Polera, chief medical officer for Sheridan’s Emergency Medicine division, describes how she uses effective communicate to bridge gaps in patient expectations. For example, patients who are diagnosed with bronchitis often expect a prescription for antibiotics, yet acute bronchitis is usually viral and, therefore, usually should not be treated with antibiotics. She finds that explaining the reason for her decision not to prescribe an antibiotic in that situation, using easy to understand language and showing patients evidence that supports her decision – using online sources they trust – helps educate patients and increase their satisfaction with the care she provides.

Educate Patients About Responsible Antibiotic Stewardship

This is also an opportunity to educate patients not only on their diagnosis but also on the evolution of antibiotic-resistant superbugs and the importance of responsible antibiotic stewardship on the part of both doctors and patients to slow that evolution.

Provide Compassionate, Personalized Care and Reassurance

A great example is radiologists Dr. Lynda Frye and Dr. Orna Hadar at the Jupiter Medical Center’s Margaret W. Niedland Breast Center, who understand that breast cancer screening is often an intimate, stressful experience for patients. To engage patients in their own care, both these physicians build patient relationships based on honest communication and trust, providing timely information and reassurance during what can be a frightening time. They read mammogram imaging immediately and discuss the results with patients. They thereby connect directly with patients and eliminate the dreaded callback to inform patients that they need to take more images. If more images or biopsies are necessary, Dr. Frye and Dr. Hadar will order them at that appointment. Additionally, they insist on delivering news to patients themselves to demonstrate their total commitment to the patient. Their compassionate, personalized care builds trust and encourages their patients to return for annual breast cancer screenings.

Provide Online Information Resources to Educate Patients and Set Expectations

Providing easily accessible, curated, topic-specific information can help reduce patients’ anxiety and properly set their expectations about medical conditions, recommended treatments and upcoming procedures. A good example of the latter is Sheridan’s Anesthesia Patient Education Portal, which not only explains the different types of anesthesia, the roles of anesthesia care team members, and what patients should expect before, during and after surgery, but also provides guidance on the types of questions patients may want to ask the anesthesiologist during the preoperative evaluation. Setting expectations, particularly around pain management, also can have a positive impact on patient experience and satisfaction

11 July2016

Engaging Physicians Collaboratively to Innovate Emergency Medicine

In today’s value-based care environment, healthcare providers are feeling the urgency of finding better ways to improve their processes and communications.   The problems caused by inefficient processes and poor communication are magnified exponentially in emergency departments (EDs) because of the high patient volume and high proportion of patients needing urgent care.  Sheridan physicians have already implemented innovative ED process and communication improvements that have improved patient care, cleared ED bottlenecks, dramatically lowered “left before being seen” rates and increased patient satisfaction. In 2015, the organization launched an annual Innovate Emergency Medicine (iEM) conference to bring Sheridan physicians together to share best practices throughout its partner hospitals and to engage doctors collaboratively to explore further innovation in emergency medicine. 

At the second annual iEM Conference on April 14, Sheridan physicians from across the U.S. came together to share their individual perspectives on ED practices and the results of process improvements, learn from their colleagues’ experiences, discuss how best to apply or adapt others’ best practices within their own environments, and explore and refine ideas for innovative process improvements.

The conference succeeded in engaging and inspiring participants as they collaborated on new ways to tackle important challenges, including improvements to clinical quality, patient communications and satisfaction, physician satisfaction and throughput. Since every ED is different, the participants focused on developing broad strategies that can be adapted to the context of each ED. The conference also provided an opportunity for a more strategic group discussion of how best to prepare Sheridan’s Emergency Medicine division for the future.

Some of the organizers and participants share their thoughts on the Sheridan iEM conference in the following video.

 

6 July2016

Physician Spotlight: Jody Crane, MD, MBA

Dr. Jody Crane is the chief clinical operations officer for Sheridan’s Emergency Medicine Division. A respected expert in emergency department (ED) operations, Dr. Crane wears many hats. In addition to his responsibilities at Sheridan, he’s the co-author of “The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the ‘No Wait’ Department.” He’s also a very active educator who is helping to drive healthcare process and clinical improvements around the world.

Dr. Crane’s work in these varied roles focuses on ED and hospital-wide operations, the application of lean principles within the healthcare environment, and innovations in ED design. Over the past decade, he has worked with hundreds of emergency departments and other organizations globally to adopt innovations in the delivery of emergency and hospital care.

Dr. Crane received his MBA from the University of Tennessee, and is a faculty member in the university’s Physician Executive MBA (PEMBA) program, teaching doctors from all specialties about operational improvement, change management and leadership. He also serves as an ED faculty member for the Institute for Healthcare Improvement (IHI), recently teaching a patient safety program for the Australasian College of Emergency Medicine in Melbourne, Australia and leading a 2-year patient safety initiative in Denmark focusing on ED and inpatient patient flow of the country’s 12 largest EDs. He is also a faculty member of the American College of Emergency Physicians’ ED Directors Academy (EDDA), a four-phase program that helps current and future ED directors develop leadership skills that will advance their careers, their local emergency departments and the specialty of emergency medicine.

Before joining Sheridan in 2014, Dr. Crane was an ED physician for at Mary Washington Hospital for more than 14 years. He also served as the Senior Medical Director for Stafford Hospital and was on the Mary Washington Healthcare Board of Trustees from 2011-2013. He was the Associate Regional Medical Director for the Mid-Atlantic Permanente Medical Group, with oversight of acute care services, telemedicine, innovation and Medicare/Medicaid for Virginia, Washington D.C., and Maryland.

Leading teams in settings as diverse as Sao Paulo, Brazil and Riyadh, Saudi Arabia; teaching with academic institutions from Harvard to Cambridge, and holding leadership positions in progressive organizations such as Kaiser Permanente has given Dr. Crane a robust set of experiences to frame his work with Sheridan. This will help to guide our organization through the rapidly changing world of healthcare reform in the United States through insights into managed care, population medicine, global payments and alternative care delivery models.

Sheridan is proud to have Dr. Crane as part of its innovative, expert leadership team.

15 June2016

Slowing the Superbug Evolution: Improving Antibiotic Stewardship in the ED

Scientists have warned for years that overuse of antibiotics would eventually lead to bacterial infections against which these “miracle drugs” would be ineffective. A world in which antibiotics are powerless to fight infections seems almost unimaginable. But the threat of untreatable infections is very real, and we’re getting closer to that ominous scenario.

In May, a bacterium that is resistant to an antibiotic of last resort was found in a patient in the U.S. for the first time. The presence of the mcr-1 gene was discovered in an E. coli bacteria cultured from a patient who had been treated for a urinary tract infection on April 26 at an outpatient military facility in Pennsylvania. Tests showed that the E. coli found in this patient were resistant not only to first-line antibiotics but also to colistin, an antibiotic whose use was largely discontinued in the 1970s because of its serious side effects but that is being used again to treat certain dangerous types of superbugs that do not respond to other antibiotics. In this case, the infection was treated successfully with another type of antibiotic. But the authors of a study published on May 26 in Antimicrobial Agents and Chemotherapy wrote that the discovery of the mcr-1 gene in the U.S. “heralds the emergence of a truly pan-drug resistant bacteria.” Dr. Tom Frieden, director of the Centers for Disease Control and Prevention (CDC) warned that this alarming development "is the end of the road for antibiotics unless we act urgently."

23K People Die Each Year From Antibiotic-Resistant Bacterial Infections

The CDC estimates that at least 2 million people in the U.S. become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. Experts are concerned about the spread of colistin resistance to other bacteria. A CDC media statement explained: “The mcr-1 gene exists on a plasmid, a small piece of DNA that is capable of moving from one bacterium to another, spreading antibiotic resistance among bacterial species,” which could lead to superbugs that could cause untreatable infections.

Exacerbating the problem, the number of F.D.A.-approved antibiotics has decreased steadily in the past two decades, according to an opinion piece in The New York Times by oncologist Ezekiel J. Emanuel, a vice provost at the University of Pennsylvania, and there are relatively few new antibiotics under development. Because antibiotics are taken only for short periods of time, and because any new ones are likely to be prescribed only when no other alternative exists, developing new antibiotics is far less profitable than developing new cancer drugs, for example.

Nearly One-Third of Antibiotic Prescriptions Are Unnecessary

While the popularity of antimicrobial consumer products and widespread use of antibiotics in food-producing animals certainly contribute to the rise of antibiotic-resistant superbugs, the most important factor is overprescribing and misuse of antibiotics. According to a May report on Antibiotic Use in Outpatient Settings by the Pew Charitable Trusts, an analysis of U.S. antibiotic prescribing data from 2010 to 2011 by a panel of CDC representatives and other public health and medical experts found that “Approximately 13 percent of all outpatient office visits in the United States, or about 154 million visits annually, result in an antibiotic prescription; about 30 percent of these, or some 47 million prescriptions, are unnecessary.”

This widespread unnecessary use of antibiotics and the resulting acceleration of superbug evolution are so serious that in March 2015, the White House released a National Action Plan for Combating Antibiotic-Resistant Bacteria. One of its targets is to reduce inappropriate outpatient antibiotic use by 50 percent in outpatient settings and by 20 percent in inpatient settings by 2020. Hitting that target would require a 15% reduction in overall antibiotic prescriptions over the next four years.

EDs Are Uniquely Positioned to Change Antibiotic Use and Slow Resistance

Because of the consistently high patient volume in most emergency departments, overuse of antibiotics in emergency departments (EDs) has been a significant factor in creating this problem, and curbing the inappropriate use of these drugs in EDs – especially in adult patients – will be required to solve it.

According to the Journal of Pharmacy Practice article “Antimicrobial Stewardship in the Emergency Department,” the misuse of antibiotics to treat conditions such as upper respiratory infection, urinary tract infections and cellulitis that are commonly encountered in the ED, both in ambulatory patients and in patients requiring admission to a hospital, has led to increased resistance to drugs commonly used to treat those infections. The author points out that “The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings.”

One of the most prevalent problems has been the widespread use of antibiotics to treat minor acute respiratory tract infections (ARTIs) in ED patients. Many common ARTIs, such as rhinitis, sinusitis, bronchitis, viral pneumonia and influenza, are often caused by viruses and do not require antibiotics. But according to a study published in Antimicrobial Agents and Chemotherapy, an analysis of ED visits between over a 10-year period (2001–2010) found that antibiotics were prescribed in 61% of the 126 million ED visits with a diagnosis of ARTI. During that period, antibiotic use did decrease significantly for antibiotic-inappropriate ARTI patients up to the age of 19. But despite longstanding calls for better antibiotic stewardship, utilization remained stable (and excessive) for antibiotic-inappropriate ARTI in adult ED patients aged 20-64 years, and usage rates of quinolones (a family of synthetic broad-spectrum antibiotic drugs) for ARTI in adult patients increased significantly.

Achieving Effective Antibiotic Stewardship in the ED

Antibiotic stewardship in the ED – as well as in other clinical settings – is essential to curbing inappropriate use of these drugs nationwide. The findings of the panel of experts convened by the Pew Charitable Trusts to analyze antibiotic prescription and include the recommendation that antibiotics should be prescribed only when a bacterial infection is known or suspected, and that healthcare providers need to implement stewardship activities in their practices. The Pew report cites the effectiveness of evidence-based clinical decision support (CDS) in reducing inappropriate antibiotic prescribing for common outpatient infections. 

Another important element of antibiotic stewardship is patient education. In today’s patient-centered healthcare environment, doctors often find themselves in a difficult position when a patient with the flu, a common cold or other another viral disease insists on a prescription for antibiotics. Patients often self-diagnose based on online research, usually via Google or WebMD, or even based on social media conversations. Dr. Catherine Polera, chief medical officer at Sheridan Healthcare's Division of Emergency Services, says these patients often either assume the worst, arrive at an incorrect self-diagnosis, or expect treatment that is contrary to evidence-based quality measures. For example, acute bronchitis is usually caused by a virus and CMS’s Physician Quality Reporting System says it should not be treated with antibiotics, yet many patients with bronchitis insist on a prescription for them. So how can doctors provide the best care in this situation without causing patient dissatisfaction?

Dr. Polera recommends that ED physicians explain their diagnosis to patients and educate them about the illness and treatment best practices in simple, easy-to-understand language. She suggests sharing the medical organizations or regulatory bodies that support your recommended treatment (even referencing Google, if that’s the patient’s preferred source of information), answering patients’ questions and addressing their concerns to build trust in the diagnosis and the prescribed treatment and improve satisfaction with the care. “Time is a scarce resource in any emergency department, but educating patients and helping them understand the validity of your treatment decisions will return a big payoff in patient satisfaction and better outcomes.”

The CDC also recommends displaying appropriate antibiotic use posters in clinical settings to help educate both clinicians and patients.

It’s also important for providers to educate their patients about the severe consequences of inappropriate antibiotic use and the threat of untreatable superbugs. Patients must learn to stop taking antibiotics for granted and thinking of them as a one-size-fits-all default cure for what ails them.

For more information about educating patients about best-practice treatments and managing their expectations, read Dr. Polera’s article “Bridging the Expectation Gap in the ED” in MedPage Today.

4 May2016

Overcrowded EDs and Population Health

Unsurprisingly, yet another study has linked ED inefficiency with poorer population health outcomes. This time from George Washington University, the study found that the most crowded quartile of EDs had a much lower rate of adoption for common techniques that reduce overcrowding, such as bedside registration and surgical schedule smoothing. This finding is made more concerning by the fact that adoption of these techniques is increasing across hospitals as a whole. While the general adoption trend is positive, the hospitals most in need are also the ones improving the slowest.

Dr. Jesse Pines, a professor of emergency medicine and health policy at GWU and one of the study's authors, believes that a lack of resources is partially to blame. In an interview with the Washington Business Journal, he argued that cost can often be a barrier to adoption, saying that “the places that have been effective at reducing crowding have had to invest a lot of time and money into it.” If CMS were to penalize hospitals based on ED crowding in the future, it could potentially exacerbate the problem.

We agree with Dr. Pines, but also want to highlight the myriad options available for low-cost efficiency improvements in EDs. In most of the cases we've seen at our hundreds of partner hospitals, major investments in time and infrastructure aren't necessary to achieve significant efficiency gains. More often than not, some small tweaks to existing processes can deliver very high returns. The challenge is figuring out what those tweaks are, and how they should be systematized.

Process and Communication Errors

Most efficiency drains fall into one of two categories: process and communication. Let's start with communication. Contrary to popular belief, miscommunication is one of the leading causes of ED errors. Fortunately, it is also one of the easiest to solve. In our work – and particularly in Dr. David Mishkin's communication drill practice – we have found that simple changes in the way ED teams communicate information to one another can significantly reduce error rates and increase efficiency. Even just a few hours of communication drills can have a noticeable impact.

Process errors can be more challenging, but still require less investment than one might think. While large investments in software, systems and infrastructure are a necessary part of the complete solution, many process problems can be solved without them. Perhaps the best example of this principle is Kaizen, a continuous process improvement methodology that invites all members of a team to collaboratively design solutions to process problems.

One of the core ideas of Kaizen is that the people who regularly execute processes are also the ones with the best ideas on how to improve them. Giving these individuals a forum in which to share and develop their ideas consistently leads to more effective and lower cost solutions than top-down approaches. We have seen this play out in hundreds of our partner hospitals and are even beginning to apply the concept to less concrete processes, such as employee engagement.

Conclusion

Dr. Pines is right to emphasize the importance of large scale, top-down efforts to address ED inefficiencies. However, equal emphasis should be placed on the simple process and communication errors that are at the heart of many common efficiency drains in the ED. In many cases, solving these problems using Kaizen and other employee-driven methodologies is more attainable and cost-effective goal than a top-down overhaul.

If you're interested in learning more about how we have used Kaizen, communication drills and other strategies to improve ED efficiency, please check out our “The Evolving Emergency Department” white paper.

25 March2016

Designing the Future of Emergency Medicine

The best emergency departments are those that consistently look for ways to optimize and streamline processes so that clinicians can reach patients as quickly as possible and care for them successfully. Mirroring these dynamic EDs, the emergency medicine field as a whole will need to look for ways to improve the delivery of care. As baby boomers age, systemic capacity for quality patient care will be strained by its sheer cost and volume. In this sense, it will be necessary for doctors to question the current best practices in emergency medicine. There is a mounting need for innovation within every facet of the workflow.

To address this need, Sheridan organized the Innovate Emergency Medicine (iEM) conference to stimulate creative thought and drive the changes necessary to make Sheridan hospitals more efficient and effective. The iEM conference provides numerous perspectives from which physicians are able to recognize inefficiencies that are taken for granted in many hospitals, and devise the best possible solutions to address these problems. The conference encourages quality patient care at reduced costs so that Sheridan may continue to set an example that will elevate the field of emergency medicine. As greater demands on quality and volume continue to challenge hospitals, events like the iEM conference allow physicians to innovate so that these demands are addressed creatively and proactively.

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