Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review.
Annals of emergency medicine
2019; 74 (2): 285?96
The Impact of an Emergency Department Front-End Redesign on Patient-Reported Satisfaction Survey Results.
The western journal of emergency medicine
2017; 18 (6): 1068?74
As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED).A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias.A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials.Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
View details for DOI 10.1016/j.annemergmed.2018.10.034
View details for PubMedID 30611639
View details for PubMedCentralID PMC6610851
A Biomechanical Comparison of Shape Design and Positioning of Transforaminal Lumbar Interbody Fusion Cages.
Global spine journal
2016; 6 (5): 432-438
For emergency department (ED) patients, delays in care are associated with decreased satisfaction. Our department focused on implementing a front-end vertical patient flow model aimed to decrease delays in care, especially care initiation. The physical space for this new model was termed the Flexible Care Area (FCA). The purpose of this study was to quantify the impact of this intervention on patient satisfaction.We conducted a retrospective study of patients discharged from our academic ED over a one-year period (7/1/2013-6/30/2014). Of the 34,083 patients discharged during that period, 14,075 were sent a Press-Ganey survey and 2,358 (16.8%) returned the survey. We subsequently compared these survey responses with clinical information available through our electronic health record (EHR). Responses from the Press-Ganey surveys were dichotomized as being "Very Good" (VG, the highest rating) or "Other" (for all other ratings). Data abstracted from the EHR included demographic information (age, gender) and operational information (e.g. - emergency severity index, length of stay, whether care was delivered entirely in the FCA, utilization of labs or radiology testing, or administration of opioid pain medications). We used Fisher's exact test to calculate statistical differences in proportions, while the Mantel-Haenszel method was used to report odds ratios.Of the returned surveys, 62% rated overall care for the visit as VG. However, fewer patients reported their care as VG if they were seen in FCA (53.4% versus 63.2%, p=0.027). Patients seen in FCA were less likely to have advanced imaging performed (12% versus 23.8%, p=0.001) or labs drawn (24.8% vs. 59.1%, p=0.001). Length of stay (FCA mean 159 ±103.5 minutes versus non-FCA 223 ±117 minutes) and acuity were lower for FCA patients than non-FCA patients (p=0.001). There was no statistically significant difference between patient-reported ratings of physicians or nurses when comparing patients seen in FCA vs. those not seen in FCA.Patients seen through the FCA reported a lower overall rating of care compared to patients not seen in the FCA. This occurred despite a shorter overall length of stay for these patients, suggesting that other factors have a meaningful impact on patient satisfaction.
View details for DOI 10.5811/westjem.2017.7.33664
View details for PubMedID 29085539
View details for PubMedCentralID PMC5654876
Blueprint for a Successful Resident Quality and Safety Council.
Journal of graduate medical education
2016; 8 (3): 328?31
Outcomes of Two Different Techniques Using the Lateral Approach for Lumbar Interbody Arthrodesis.
Global spine journal
2015; 5 (4): 308-314
Cadaveric biomechanical analysis.The aim of this study was to compare three interbody cage shapes and their position within the interbody space with regards to construct stability for transforaminal lumbar interbody fusion.Twenty L2-L3 and L4-L5 lumbar motion segments from fresh cadavers were potted in polymethyl methacrylate and subjected to testing with a materials testing machine before and after unilateral facetectomy, diskectomy, and interbody cage insertion. The three cage types were kidney-shaped, articulated, and straight bullet-shaped. Each cage type was placed in a common anatomic area within the interbody space before testing: kidney, center; kidney, anterior; articulated, center; articulated, anterior; bullet, center; bullet, lateral. Load-deformation curves were generated for axial compression, flexion, extension, right bending, left bending, right torsion, and left torsion. Finally, load to failure was tested.For all applied loads, there was a statistically significant decrease in the slope of the load-displacement curves for instrumented specimens compared with the intact state (p?0.05) with the exception of right axial torsion (p?=?0.062). Among all instrumented groups, there was no statistically significant difference in stiffness for any of the loading conditions or load to failure.Our results failed to show a clearly superior cage shape design or location within the interbody space for use in transforaminal lumbar interbody fusion.
View details for DOI 10.1055/s-0035-1564568
View details for PubMedID 27433426
View details for PubMedCentralID PMC4947403
Study Design?Retrospective cohort study. Objective?To determine the short-term outcomes of two different lateral approaches to the lumbar spine. Methods?This was a retrospective review performed with four fellowship-trained spine surgeons from a single institution. Two different approach techniques were identified. (1) Traditional transpsoas (TP) approach: dissection was performed through the psoas performed using neuromonitored sequential dilation. (2) Direct visualization (DV) approach: retractors are placed superficial to the psoas followed by directly visualized dissection through psoas. Outcome measures included radiographic fusion and adverse event (AE) rate. Results?In all, 120 patients were identified, 79 women and 41 men. Average age was 64.2 years (22 to 86). When looking at all medical and surgical AEs, 31 patients (25.8%) had one or more AEs; 22 patients (18.3%) had a total of 24 neurologically related AEs; 15 patients (12.5%) had anterior/lateral thigh dysesthesias; 6 patients (5.0%) had radiculopathic pain; and 3 patients (2.5%) had postoperative weakness. Specifically, for neurologic AEs, the DV group had a rate of 28.0% and the TP group had a rate of 14.2% (p?0.18). When looking at the rate of neurologic AEs in patients undergoing single-level fusions only, the DV group rate was 28.6% versus 10.2% for the TP group (p?0.03). Conclusion?Overall, 18.3% of patients sustained a postoperative neurologic AE following lateral interbody fusions. The TP approach had a statistically lower rate of neurologic-specific AE for single-level fusions.
View details for DOI 10.1055/s-0035-1546816
View details for PubMedID 26225280
View details for PubMedCentralID PMC4516734