Preferences of Iranians to select the emergency department physician at the time of service delivery

Background Understanding patient preferences in emergency departments (EDs) can provide useful information to enhance patient-centred care and improve patient’s experience in hospitals. This study sought to find evidence about patients’ preference for physicians when receiving services in EDs in Iran. Methods In this discrete choice experiment survey, 811 respondents completed the scenarios with 5 attributes, including type of physicians, price of services, time to receive services, physician work experience, and physician responsibility. Analyses were conducted for different social and economic groups as well as for the total population. Results This study showed that the willingness to pay (WTP) for being visited by a physician with a high sense of responsibility was 67.104US$. WTP for being visited by an emergency medicine specialist (EMS) was 22.148US$. WTP for receiving ED services 1 min earlier was 0.417US$ and for being visited by 1 year higher experienced physician was 0.866US$. WTP varied across different age groups, sex, health status, education, and income groups. Conclusion As the expertise and experience of providers are important factors in selecting physicians in EDs by the patients, providing this information to patients when they want to select their providers can promote patient-centred care. This information can decrease patients’ uncertainty in the selection of their services and improve their experience in hospitals.

The emergency department physician rostering problem: obtaining equitable solutions via network optimization

In this study, we address workload balancing in Emergency Department Physician Rostering Problems. We propose a two-phase approach to deal with two common workload balancing issues: (1) the even distribution of worked weekends and weekend night shifts across physicians in the long term, and (2) the even distribution of morning and afternoon shifts in the medium term. To implement such an approach, we have developed two Integer Linear Programming (ILP) models, one for each phase. In the first phase, we determine the weekends that each physician will be on duty over the long term planning horizon (6-months) while evenly distributing the workload (worked weekends and weekend night shifts) across physicians. In the second phase, month by month, we iteratively determine the workday shifts of each physician while pursuing the even distribution of workload (morning and afternoon shifts) across physicians. The second phase relies on the solution of the first phase, i.e., the weekend shifts assigned to each physician in the first phase are considered preassigned shifts in the second phase. In both phases, we consider the constraints deriving from collective as well as individual contractual agreements (e.g. constraints limiting the maximum number of night shifts each physician can work every month, their maximum weekly and monthly workload, etc.) as well as individual physician’s preferences and desiderata. The problems addressed in the two phases differ in terms of the planning horizon, objective function, and constraints, yet they are both modeled as multicommodity ow problems and share the same network structure. Also, we define some families of simple yet effective, valid inequalities that are crucial to address the computational complexity of the first-phase problem. The proposed optimization models have been tested on real data from a leading European Hospital and on benchmark instances from the literature. The models’ effectiveness has been assessed through six key performance indicators purposely defined. Results demonstrate that the presented models allow considering the complex nature of physicians rostering problems and obtaining well-balanced and thus equitable work schedules.

Abstract P138: Improving Emergency Medical Services Documentation of Time Last Known Well

Background and Purpose: In a systems of care model, Emergency Medical Services (EMS) reporting a patient’s last known well (LKW) time to the receiving hospital is crucial for activation of the hospitals Acute Stroke Team. There is evidence that LKW is critical information for determining an acute ischemic stroke patient’s eligibility for advanced stroke therapy which includes intravenous Alteplase and/or mechanical endovascular reperfusion therapy. The 70 Wisconsin (WI) Coverdell Stroke Program (Coverdell) hospitals represent 80% of stroke admissions in WI. Coverdell developed a pre-arrival report card in Q3 2018 in which LKW was a tracked measure. Data entered into Get With The Guidelines®- Special Initiatives (SI) tab was collated to create the report card. After analysis of the data it was determined our performance improvement (PI) project would be to improve EMS’s documentation and reporting of time LKW. In Q3 2018, of those cases entered into the SI tab, EMS reporting a LKW time was 50%. Since LKW is not always obtainable, the project goal was set at 60%. Methods: We recognized implementation of this PI initiative would require a multi-prong approach. To assist EMS agencies in understanding the difference between LKW and symptom onset, we developed a document entitled, The Importance of an Accurate Last Known Well and Symptom Onset Time . A Coverdell team member attended WI’s EMS Physician Advisory Committee meetings where LKW data was discussed. In addition, an Emergency Department Physician hosted a webinar where the presentation highlighted the importance of documenting LKW. This webinar was recorded and sent to EMS agencies and hospitals. For loop closure and with the support of the WI’s EMS Director, LKW became a validated field for EMS in the WI Ambulance Run Data System. Findings: In Q2 2019 there was an improvement in documented LKW as evidenced by an increase to 59.2% The data has remained consistent even as more hospitals have begun to enter the data as demonstrated by the increasing N. Conclusion: The actions taken by the Coverdell program in educating EMS providers on the rationale and importance of LKW documentation was successful. However, additional efforts are required to reach and maintain the project goal of 60% with an additional stretch goal to 70%.

“What is the actual goal of the pathway?”: examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

Background Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. Methods Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. Results The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2–4 predominant topics that can be condensed into six overarching themes regarding clinicians’ views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. Conclusion Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

Developing an emergency medicine handoff tool: an electronic Delphi approach

Background Handoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation. Methods An electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements. Results Twenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach’s alpha 0.93). Conclusions This study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.