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:

19 January2017

Integrating Telemedicine Responsibly

Providers and patients alike view telemedicine as an increasingly important healthcare delivery modality. Per a recent article in Medical Economics, “How to balance telemedicine advances with ethics,” the American Telemedicine Association (ATA) reports that more than half of all U.S. hospitals use some form of telemedicine; and IHS Technology predicts the number of patients using telehealth services will jump from fewer than 350,000 in 2013 to 7 million in 2018.

But this modality can also be challenging to implement responsibly.

Telehealth Benefits

The dramatic growth of telemedicine is driven by its ability to further the goals of the “quadruple aim” framework for value-based care.

More Efficient Care

The recent American Hospital Association (AHA) issue brief on telehealth cited several examples of significant telehealth-driven savings, including the Veterans Health Administration’s “nearly $1 billion in system-wide savings associated with the use of telehealth in 2012.” A major contributor was the dramatic decrease in hospitalizations.

In addition, doctors who offer telehealth services can spend more time caring for additional patients – time that otherwise would have been spent traveling between offices or facilities.

Better Outcomes

The AHA brief also describes the efficiencies and improved outcomes resulting from the innovative Hospital at Home (HaH) care model developed by Johns Hopkins researchers. HaH is being used effectively to provide hospital-level care at home in place of acute hospital care for older adults. Per the brief, “When a patient is treated at home, clinical staff travel to the home as needed to provide treatment, while telehealth is used to monitor the patient’s condition and enable daily meetings with the physician.” According to the program’s website, HaH patients experience better clinical outcomes, higher patient and family satisfaction, reduced caregiver stress and better functional outcomes compared to similar hospitalized patients.

Expanded Access to Care

Traveling to medical facilities can be a hardship for people who are physically challenged/housebound, live far from the nearest medical center or cannot afford to take time off from work. The ability to meet with a clinician remotely via a secure audiovisual device or application can mean the difference between those patients seeking – and getting – the care they need versus going without.

More Convenient Care

While it’s early days yet, “virtual visits” are beginning to be offered for more and more types of medical care. For example, St. Vincent Heart Center in Indianapolis is piloting a telecardiology program, per a recent article in Cardiovascular Business.

There is also increasing demand by health care consumers for “at home” virtual visits. A recent ATA-WEGO Health survey of active health care users found that consumers are very interested in using telehealth to complement (or even replace) their in-person care, primarily because of convenience. Other commonly cited reasons included scheduling conflicts and issues with transportation. 

Expanded Access to Specialized Clinical Expertise

Many small or rural hospitals often don’t have the budget or volume to support staffing a range of staff specialists or subspecialists. Even hospitals that have the budget may be in areas that make it difficult to recruit those types of physicians.

Dr. Lynn Palmeri, National Medical Director of Telehealth for Sheridan’s Women’s and Children’s Division, explains that telehealth carts can allow doctors at these facilities to consult remotely with specialists or subspecialists as needed. For example, an obstetrician may see an expectant mother with high-risk findings that require her to be referred out to see a perinatologist. Rather than having the mother drive three or four hours to the nearest perinatologist – potentially putting her and her baby at even greater risk – the obstetrician could have a remote telehealth consult with the subspecialist to determine whether the mother can be given appropriate care locally with the help of follow-up telehealth consults with the perinatologist.

Telemedicine is equally valuable in emergency medicine. Physicians in the adult emergency department (ED) at Jupiter Medical Center consult remotely with neurologists at the Cleveland Clinic using a telehealth cart approximately 10–30 times per month, most often to expedite implementation of tissue plasminogen activator (tPA) therapy for stroke patients.

Sophisticated telemedicine robots can allow remote specialists and subspecialists to perform much more in-depth examinations. Dr. Palmeri says “there are robots with sensors that can, for example, allow a neonatologist to remotely inspect a patient, auscultate bowel, breath and heart sounds, examine a neonate’s eyes for retinal findings, and even palpate to see if there is abdominal pathology or edema. These patient care modalities augment the in-person physical examinations by the nurse and neonatal nurse practitioner at the bedside.”

Radiology’s many subspecialties make it a prime candidate for expanding access to highly specialized clinical expertise remotely while also increasing efficiency. For example, Sheridan’s distributed teleradiology network includes hundreds of the country’s best radiology subspecialists who can provide hospitals of any size with affordable, 24/7/365 coverage and faster turnaround times for final reads. 

Challenges to Responsible Implementation

The promise of telemedicine is exciting, and pertinent logistical and quality matters will be ensured prior to its implementation and expansion.

Protecting Patient Privacy

Maintaining patient confidentiality is a cornerstone of ethical medical practice. Telemedicine systems will be HIPAA-compliant and hospitals must make data security a top criterion when selecting robot cart and software options.

Maintaining Care Quality

The same standards of care must be maintained regardless of the delivery modality, and that’s a key challenge of telemedicine. The American Medical Association (AMA) released its Guidance for Ethical Practice in Telemedicine in June. In the policy announcement, AMA Board Member Jack Resneck, M.D. said, "Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions. The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians' fundamental ethical responsibilities do not change.” The AMA also released its Principles to Promote Safe, Effective mHealth Applications in November. 

Telemedicine can make continuity of care challenging, especially when patients seek care from doctors who are not affiliated with their primary care physicians or who use different EHRs. But in some situations telehealth can improve care continuity. “In a pediatric unit, for example, an attending physician might see the baby during morning rounds, but by the time the parents can come to the hospital that evening after work that physician’s shift may have ended and the parents may not speak directly to that same doctor,” explains Dr. Palmeri. “Telemedicine has the potential to overcome those types of scheduling conflicts so that parents can speak with the doctor ‘face-to-face’ through the telemedicine robot screen whenever needed.”

Telehealth will play an increasingly important role in care delivery and physicians will carefully adopt remote care technology in a manner that ensures patient safety and privacy.

17 January2017

Study Identifies Risk Factors for Congenital Heart Disease in Infants

A study in the Canadian Medical Association Journal identified the chronic conditions that may predispose women to give birth to infants with congenital heart disease, also known as congenital heart defects or CHD.

The study reviewed the Taiwan Maternal and Child Health Database’s records of 1,387,650 live births from 2004 to 2010. The researchers investigated three data sets including:

  • Birth Registrations data on the sociodemographic characteristics of live births
  • Birth Notifications data on prenatal care and the lifestyles of pregnant women
  • Medical claims data from Taiwan’s National Health Insurance program

The researchers found that several maternal chronic diseases were associated with higher rates of CHD in babies. These conditions include type 1 and type 2 diabetes, hypertension, CHD, anemia, connective tissue disorders, epilepsy and mood disorders. Pregnant women who are identified as at risk can receive preconception counselling and developing fetuses can be more closely screened for CHD via fetal echocardiography. Early recognition of CHD can additionally help clinicians optimize the care of both women and infants.

That said, there are some limitations to the study. The detection period for the study was restricted to the first year of life. Potential cases of CHD may have developed in later years; however, under-identification should be minimal, given the high frequency of prenatal care and health checkups for infants under National Health Insurance coverage. Additionally, researchers noted that maternal lifestyle factors, including smoking and alcohol consumption, were likely to be underreported in the Birth Notifications data set.

About CHD

CHD affects nearly 1 percent of births per year in the United States and is a leading cause of birth defect-associated infant illness and death, according to the CDC. About 25 percent of babies with CHD have a critical CHD and generally require surgery or other procedures in their first year of life.

Although a few states track CHD among newborns and young children, no tracking system exists for older children and adults with heart defects. A study published last July estimates that approximately 2.4 million people – including 1.4 million adults and one million children – were living with CHD in the U.S. in 2010. Nearly 300,000 of those individuals had severe CHD.

Research projects like the review published in the CMAJ continue to improve care for people affected by CHD. Improved counseling and screening procedures for CHD have the potential to both reduce the prevalence of CHD and its resulting fatalities.

12 January2017

Research Suggests Discussing Opioid Risks With Patients Reduces Misuse

Patients who were counseled by their physicians about the long-term risks of abusing prescription opioid pills were significantly less likely to save those medications – a high-risk abuse behavior – according to a research brief published in the November/December 2016 issue of Annals of Family Medicine

The researchers analyzed data from two April 2015 random-digit-dial telephone surveys, both conducted by the Harvard T. H. Chan School of Public Health and The Boston Globe, of adults 18 and older. One survey targeted Massachusetts residents; the other was national in scope. The researchers restricted their analysis to data from respondents who reported having been prescribed strong painkillers within the past two years. 

Retention of unused opioids has been found to be an important source of opioid diversion and misuse, and the researchers wrote that they “fit multivariable logistic regressions to estimate the association between reporting having talked with a physician about the risk of prescription painkiller addiction (‘discussed risk of addiction’) and reporting having saved prescription painkillers for personal medical use or to share with family members (‘saved pills for later’).”  The researchers concluded that, even after adjusting for covariates, respondents who said they talked with their physicians about the risks of prescription painkiller addiction were 60 percent less likely to save the pills.

The authors of the study authors acknowledged that the observed associations don't prove conclusively a causal relationship, but wrote that their findings "offer a first look at evidence to support a common recommendation from opioid prescribing guidelines for which no evidence currently exists and suggest that future exploration into the effectiveness of physician-patient communication on the risks of opioids may be fruitful."

An American Academy of Family Physicians (AAFP) News story about the research brief said that study co-author Joachim Hero, M.P.H., of the Interfaculty Initiative in Health Policy at Harvard University in Boston, told AAFP News that "The encouraging news is that our data suggest that patient education in this context may be effective even today, when clear guidelines about the what, when and how are lacking." 

10 January2017

Retail Clinics Near EDs Do Not Decrease Low-Acuity ED Visits

The opening of retail clinics within a 10-minute drive of emergency departments (EDs) has not resulted in reduced ED utilization for low-acuity conditions such as influenza, urinary tract infections and earaches, according to a recent study by RAND Corporation researchers. The study was published in the Annals of Emergency Medicine, the peer-reviewed scientific journal for the American College of Emergency Physicians (ACEP).

The findings contradict the assertions of some healthcare experts and policymakers that increasing the number of retail clinics could reduce ED visits by patients with low-acuity conditions. The study notes that about 13.7% of all emergency department visits are for low-acuity conditions, per a Modern Healthcare article. During the past 10 years, the number of retail clinics, usually located within large retail chains such as Walmart, has surged from 130 clinics in 2006 to nearly 1,400 clinics in 2012 and to more than 2,000 in 2016. 

Researchers found no correlation between the opening of a retail clinic and a reduction in ER visits for low-acuity conditions during the period they analyzed, 2007–2012. A possible factor is that Medicaid patients represent the largest proportion of ED visitors with low-acuity conditions, and only 60% of retail clinics accept Medicaid. Low-acuity visits among EDs with a significant (10 percent per quarter) increase in retail clinic penetration decreased slightly, by 0.03 percent per quarter, and only among patients with private insurance. That is equivalent to approximately 17 fewer emergency department visits among privately insured patients over the course of the year for the average emergency department if the retail clinic penetration rate increased by 40 percent in that year, per an ACEP news release on the study.

Interestingly, Grant Martsolf, PhD, MPH, RN the study’s lead author and a policy researcher at RAND Corporation, said that retail clinics may be motivating patients to seek care when they normally wouldn't, according to the Modern Healthcare article. He explained that the convenience of a local clinic may be encouraging people to seek out healthcare services more often in situations when they usually wouldn’t seek care from their primary care providers or the ED, such as when they have an ear infection. 

An accompanying editorial, “Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care,” by Jesse Pines, MD, MBA, FACEP of the George Washington University School of Medicine and Health Sciences in Washington, D.C. offered three theories as to why retail clinics (referred to in the editorial as “convenience settings”) increase health care use. Per the ACEP news release, Dr. Pine theorized that they meet unmet demands for care; that motivations for seeking care differ in emergency departments and convenience settings; and that groups of people who are more likely to use emergency departments for low-acuity conditions do so because they have little access to other types of care, including convenience settings.

5 January2017

Our 10 Most Popular Blog Posts of 2016

The most-read posts on the Sheridan blog in 2016 focused on key topics – ranging from the challenges involved in the transition to value-based care and this country’s physician burnout epidemic to exciting technology innovations and trends in clinical practice.

The 10 most popular posts from the past year are:

  1. How to Manage the Burdens of Change on Physicians and Health Care Practitioners, a summary of Chief Quality Officer Dr. Gerald Maccioli’s presentation at the 2016 Health:Further Summit about the overwhelming burdens on providers created by current and planned changes to the U.S. health care landscape and strategies for managing them.

  2. Sheridan’s 2016 Leadership Conference Recognizes Eight Outstanding Clinical Leaders: Dr. Mike Adkins, Anesthesia Services Chief of the Year; Dr. Joseph Toscano, Emergency Medicine Chief of the Year; Dr. Frank Seidelmann, Radiology Chief of the Year; Dr. Mitchell Stern, Women’s and Children’s Chief of the Year; Dr. Adam Blomberg, Diamond Award Winner; Cindy Houck, CRNA, Platinum Award Winner; Dr. Gary Gomez, Innovation Award Winner; and Dr. Jonathan Katz, Innovation Award Winner.

  3. Six Physician Communication Strategies to Increase Patient Engagement and Improve Outcomes, including encouraging patients to talk about psychosocial factors that might be related to their conditions, tailoring communications to each patient based on his/her culture, values and beliefs to avoid inadvertent offense or mistrust, educating patients on care best practices and about responsible antibiotic stewardship, providing compassionate, personalized care and reassurance, and providing online information resources to educate patients and set appropriate expectations.

  4. Technology Innovations That Will Transform the Future of Radiology, including the groundbreaking work of the IBM Watson Health medical imaging collaborative, in which Sheridan and its chief of teleradiology, Dr. Glenn Kaplan, are playing a key role.

  5. Five Medical Practices That Soon May Be Outdated, including hospitals advising doctors not to apologize, prescription labels that don’t include what condition the drug is treating, monitoring handwashing by hospital staff, doctors spending more time on paperwork than on patient care, and making it difficult for patients to get their medical records quickly.

  6. The AMA’s New Tools to Ease MACRA Transition for Physicians, including the MACRA Assessment (aka Payment Model Evaluator), new MACRA-focused modules in the AMA STEPS Forward interactive, online practice transformation series, and the Inside Medicare’s New Payment System ReachMD podcast series.

  7. The Physician Burnout Epidemic, Part 1: Root Causes of This Alarming Trend, which looked at the factors fueling the increase in U.S. physician burnout. Part 2 offered strategies physician leaders can use to help combat burnout.

  8. Career Advice from Sheridan’s Chief Medical Officer for Radiology Services, Dr. Frank Seidelmann, including being proactive in managing your career, embracing technology and investing in your professional development and of the physicians you lead. 

  9. How Video Laryngoscopy Is Shaping the Future of Anesthesiology, which highlighted a discussion by Regional Medical Director Dr. Joseph Loskove, Chief Quality Officer Dr. Gerald Maccioli and National Education Director, Anesthesiology Division, Dr. Adam Blomberg in their Anesthesia News article, The Shift Toward Video Laryngoscopy: The Good, the Bad, and the Future.

  10. Pain Management Boosts Patient Satisfaction, which addressed the significant impact of addressing patients’ and caregivers’ concerns and setting their expectations appropriately – as well as treating patients’ physical pain – on their satisfaction with their pain management and overall care. 

15 December2016

U.S. Surgeon General Calls for Action on the Opioid Crisis

Opioid abuse remains a devastating public health concern, and the health care community has grappled with its role in the crisis and medical professionals’ responsibility to patients struggling with substance use. U.S. Surgeon General Vivek Murthy has responded with a report released last month analyzing the current opioid crisis and providing several recommendations for treating and preventing substance use disorders. These recommendations include:

1. Eliminate stigma

Misconceptions and negative judgments about people with substance use disorder abound, and the report stresses that even medical professionals are not immune to seeing addiction as a “moral failing or character flaw.” Murthy’s report states that substance use disorder is a medical problem, and that as such doctors should lead a cultural shift in thought through advocating for medicine and counseling treatment for affected patients.  

2. Provide effective screening

Along with its goal of changing societal perceptions of addiction, the report calls for changing the health care system’s process for identifying substance use disorder. Effective screening must occur in general health settings, including primary, psychiatric, and emergency care centers. With this change, physicians can identify affected patients earlier and create individual treatment plans for them.

3. Make use of medication

One of the many misconceptions about the opioid crisis is the assumed futility of medical treatment – it is essentially seen as “substituting one substance for another,” so abstinence is believed to be the best treatment plan. Murthy’s report extensively disputes this belief, asserting that using approved medicines within a broader behavioral therapy plan can help treat substance use disorder.

4. Involve an integrated medical team

Ultimately, Murphy’s report declares that effective substance use treatment plans must involve an integrated team of social workers, recovery specialists, nutritionists, and other caregivers. As with programs designed for diabetes or cancer treatment, all aspects of the affected patient’s life must be considered to address and treat the disorder.

Programs to Aid in the Fight Against the Opioid Crisis

Many patients first encounter opioids during the surgical period. As the nation’s largest anesthesia provider, Sheridan is piloting several initiatives aimed at combating the opioid crisis by reducing the opportunity for exposure. 

  • Sheridan anesthesiologists and their surgical colleagues are piloting ERAS (enhanced recovery after surgery) programs, using a combination of non-steroidal anti-inflammatory agents and specialized regional nerve blocks with local anesthetics to optimize recovery and minimize narcotics use. 
  • We are also preparing to pilot pre-operative pharmacogenetic testing next year. Not only will this testing help anesthesiologists tailor medication based on a patient’s genetic data, thereby minimizing negative drug reactions, but it will also help identify patients predisposed to narcotic addiction. For these patients, Sheridan physicians can find pathways for treatment using limited to no opioids during the perioperative period. 

Our goal is to gather and share data on the effectiveness of these programs to help enrich the health care community’s efforts to stop the opioid crisis. 

13 December2016

Five Key Strategies for Driving Change in the OR

Now more than ever, hospitals and ambulatory surgery centers are seeking anesthesia partners capable of driving positive change in their operating rooms. However, for many anesthesia providers, there are hurdles that must be overcome before such change can be realized.

Anesthesia groups of any size, regardless of their financial strength, can employ proven strategies to ensure the success of facility-wide patient care improvement initiatives. Here are five such strategies that Dr. Adam Blomberg, Sheridan’s national education director, has found to be effective.

Collaborate with nursing and surgeons on incremental steps toward larger improvements

Securing the buy-in of nursing and surgical staff is crucial for ensuring that improvements are universally adopted. Regular status meetings and Kaizen lean process improvement events are examples of methods used for promoting collaboration among all stakeholders in the OR.

Break down the silos

Collaboration is only possible when individuals involved in improvement activities are able to communicate freely across departmental boundaries. Traditionally, the hierarchical structure of the operating room inhibits the flow of information upward. By establishing relationships early on, it is possible to avoid the political turmoil that hampers most improvement efforts.

Work with the C-suite to form a collaborative governance structure

Once key stakeholders have been brought into the fold, the structure and operations of the core improvement team need to be formalized. Often, this will require a significant investment in resources and time; however, the return on such investments usually outweigh upfront costs. Clearly communicating the proposed benefits of the program will help to ease any uncertainty on the part of administrators.

Practice evidence-based medicine

No amount of investment in time and resources can make up for variability in the provision of anesthesia. This is why it is imperative to standardize processes early on and in accordance with evidence-based best practices. Collaboration with other local anesthesia groups can facilitate this process through the sharing of best practices; however, it is ultimately up to anesthesiologists, CRNAs and AAs to determine which practices fit the unique cultural and financial requirements of their facility.

Develop sound preadmission testing guidelines

One of the most significant challenges anesthesiologists, CRNAs and AAs face today is addressing the inconsistencies associated with a variable preadmission testing process. Overcoming this obstacle is no easy feat, given that surgeons’ ordering patterns often reflect years of deeply engrained practices. However, by slowly introducing standards in collaboration with local surgeons, anesthesia staff can realize significant returns almost immediately through fewer canceled cases and greater OR efficiency.

As clinical outcomes begin to take center stage under MACRA, anesthesia providers will be increasingly called upon to address the myriad of challenges facing surgical service lines at facilities across the United States. Confronting the root cause of these problems will require close collaboration among surgical, nursing and anesthesia staff, as well as the buy-in of administration. Learn how our anesthesia leaders have used collaboration and expertise to support higher quality patient care and improved stakeholder satisfaction.

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.

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