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BackgroundAs mobile devices and apps grow in popularity, they are increasingly being used by health care providers to aid clinical care. At our institution, we developed and implemented a point-of-care clinical photography app that also permitted the capture of video recordings; however, the clinical findings it was used to capture and the outcomes that resulted following video recording were unclear. ObjectiveThe study aimed to assess the use of a mobile clinical video recording app at our institution and its impact on clinical care. MethodsA single reviewer retrospectively reviewed video recordings captured between April 2016 and July 2017, associated metadata, and patient records. ResultsWe identified 362 video recordings that were eligible for inclusion. Most video recordings (54.1%; 190/351) were captured by attending physicians. Specialties recording a high number of video recordings included orthopedic surgery (33.7%; 122/362), neurology (21.3%; 77/362), and ophthalmology (15.2%; 55/362). Consent was clearly documented in the medical record in less than one-third (31.8%; 115/362) of the records. People other than the patient were incidentally captured in 29.6% (107/362) of video recordings. Although video recordings were infrequently referenced in notes corresponding to the clinical encounter (12.2%; 44/362), 7.7% (22/286) of patients were video recorded in subsequent clinical encounters, with 82% (18/22) of these corresponding to the same finding seen in the index video. Store-and-forward telemedicine was documented in clinical notes in only 2 cases (0.5%; 2/362). Videos appeared to be of acceptable quality for clinical purposes. ConclusionsVideo recordings were captured in a variety of clinical settings. Documentation of consent was inconsistent, and other individuals were incidentally included in videos. Although clinical impact was not always clearly evident through retrospective review because of limited documentation, potential uses include documentation for future reference and store-and-forward telemedicine. Repeat video recordings of the same finding provide evidence of use to track the findings over time. Clinical video recordings have the potential to support clinical care; however, documentation of consent requires standardization.

Objective: Evaluate an established scribe program on throughput and revenue capture in an Emergency Department (ED) undergoing an EMR transition.Methods: A prospective cohort design comparing patients managed with and without scribes in an academic ED. Throughput metrics (medians, min) and relative value units (RVUs, means) were collected. Data was evaluated in its entirety (three months), as well as in two subsets: go live (immediate two weeks) and adoption (two weeks post implementation to end).Results: All patients: There was no significant difference in throughput or RVUs during the three month period. During go-live, scribes showed improvement in total RVUs per patient (4.63 vs 4.40, p = 0.048). During adoption, scribed patients had decreased length of stay (LOS, 221 vs 231, p = 0.023). Adults: Door to provider (28 vs 37, p = 0.014) and total RVUs (5.20 vs 4.92, p = 0.042) were improved with scribes in the go-live period. Scribes improved go-live morning and overnight shifts, while lengthening provider to disposition during afternoon shifts. No significant differences were seen in the adoption period, except for increased provider to disposition time overnight with scribes (154 vs 146, p = 0.030). Pediatrics: When all pediatric patients were compared, scribe patients had a decreased professional RVU charge (2.78 vs 2.90, p = 0.037). During go live and adoption, no significant differences were found in any other parameter or subgrouping.Conclusions: A scribe's ability to mitigate operational inefficiencies introduced by an EMR transition seems limited in an academic hospital. Previous research highlighting the impact of scribes on revenue was not replicated during this study. [ABSTRACT FROM AUTHOR]

Background: Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting.Objective: Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates.Methods: This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included.Results: Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5).Conclusion: Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it. [ABSTRACT FROM AUTHOR]

Medical photographs have been used for decades to document clinical findings. The ease with which medical photographs can be captured and integrated into the electronic health record (EHR) has increased as digital cameras obviated the need for the film development process. Today, cameras integrated into smartphones allow for high-resolution images to be instantly uploaded and integrated into the EHR. With major EHR vendors offering mobile smartphone applications for the conduct of point-of-care medical photography, health care providers and institutions need to be aware of legal questions that arise in the conduct of medical photography. Namely, (1) what are the requirements for consent when taking medical photographs, and how may photographs be used after consent is obtained, (2) are medical photographs admissible as evidence in court, and (3) how should a provider respond to a request by a patient or parent requesting that a photograph be deleted from the medical record? Herein, we review relevant laws and legal cases in the context of accepted standards of medical practice pertaining to point-of-care medical photography. This review is intended to aid health care providers and institutions seeking to develop or revise policies regarding using a mobile application at their clinical practice. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the 'Number of Unnecessary Waits (NUW)' and the corresponding 'Unnecessary Wait Hours (UWH)', to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED.Methods: UWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA.Results: We retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect.Conclusions: Situational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department's operations. [ABSTRACT FROM AUTHOR]

The article reports on the management and assessment of abscesses in the Department of Medicine in the U.S. It mentions that Methicillin-resistant Staphylococcus aurus (MRSA) is considered the most prevailing isolate from the disease in the country which is diagnosed through bedside ultrasonography. It also notes its treatment by oral trimethoprim-sulfamethoxazole.

Background: In general, hematogenous spread of bacteria in children is uncommon. Bacteremia, however, is a known complication of dental procedures and severe caries, but is infrequently associated with primary, asymptomatic, non-procedural-related, dentoalveolar infection.Case Report: The patient is a 7-year-old previously healthy boy who presented to the Emergency Department (ED) with "fever, mottling, and shaking chills." In the ED, he appeared systemically ill with fever, mottling, delayed capillary refill, and rigors. Physical examination by three different physicians failed to reveal any focus of infection. Laboratory evaluation, including blood cultures, was obtained. The patient later developed unilateral facial swelling and pain, and a dentoalveolar abscess was found. He was started on antibiotics, underwent pulpectomy and eventually, extraction, prior to improvement in symptoms. Blood cultures grew two separate anaerobic bacteria (Veillonella and Lactobacillus). This is, to our knowledge, one of the first reported cases of pediatric sepsis with two different anaerobic organisms secondary to occult dentoalveolar abscess in a pediatric patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is imperative for emergency physicians to recognize the possibility of pediatric sepsis in the setting of acute maxillary or mandibular pain, as well as in patients for whom no clear focus of infection can be found. This is particularly important for those who appear ill at presentation or meet systemic inflammatory response syndrome criteria and would benefit from further laboratory evaluation, including blood cultures, and possibly antibiotic therapy. [ABSTRACT FROM AUTHOR]

The article discusses skin abscesses, focusing on the management of the diseases. It notes the medical definition of an abscess, which is collection of pus resulting from the disintegration of tissue, and states clinical features of the condition like erythematous, tender areas with surrounding edema. It mentions treatment methods like incision and drainage (I&D), and notes the need of irrigation of the wound after I&D, along with factors to be considered for I&D.

The article reviews management options for simple cutaneous abscesses in children at the emergency department (ED), with topics including differential diagnosis and diagnostic studies, changing practice of wound cultures and antibiotic therapy, and incision and drainage (I&D) and loop techniques.

Background: Point-of-care clinical photography using mobile devices is coming of age as a new standard of care for clinical documentation. High-quality cameras in modern smartphones facilitate faithful reproduction of clinical findings in photographs; however, clinical photographs captured on mobile devices are often taken using the native camera app on the device and transmitted using relatively insecure methods (eg, SMS text message and email) that do not preserve images as part of the electronic medical records. Native camera apps lack robust security features and direct integration with electronic health records (EHRs), which may limit patient acceptability and usefulness to clinicians. In March 2015, Mayo Clinic overcame these barriers by launching an internally developed mobile app that allows health care providers to securely capture clinical photographs and upload them to the EHR in a manner that is compliant with patient privacy and confidentiality regulations.Objective: The study aimed to understand the perceptions, attitudes, and experiences of patients who were photographed using a mobile point-of-care clinical image capture app.Methods: The study included a mail-out survey sent to 292 patients in Rochester, Minnesota, who were photographed using a mobile point-of-care clinical image capture app within a preceding 2-week period.Results: The surveys were completed by 71 patients who recalled being photographed. Patients were seen in 18 different departments, with the most common departments being dermatology (19/71, 27%), vascular medicine (17/71, 24%), and family medicine (10/71, 14%). Most patients (49/62, 79%) reported that photographs were taken to simply document the appearance of a clinical finding for future reference. Only 16% (10/62) of patients said the photographs were used to obtain advice from a specialist. Furthermore, 74% (51/69) of the patients said they would recommend medical photography to others and 67% (46/69) of them thought the photos favorably affected their care. Patients were largely indifferent about the device used for photography (mobile device vs professional camera; 40/69, 58%) or the identity of the photographer (provider vs professional photographer; 52/69, 75%). In addition, 90% (64/71) of patients found reuse of photographs for one-on-one learner education to be acceptable. Acceptability for other uses declined as the size of the audience increased, with only 42% (30/71) of patients deeming reuse on social media for medical education as appropriate. Only 3% (2/71) of patients expressed privacy or confidentiality concerns. Furthermore, 52% (33/63) of patients preferred to provide consent verbally, and 21% (13/63) of them did not think a specific consent process was necessary.Conclusions: Patient attitudes regarding medical photography using a secure EHR-integrated app were favorable. Patients perceived that photography improved their care despite the most common reason for photography being to simply document the appearance of a clinical finding for future reference. Whenever possible, health care providers should utilize secure EHR-integrated apps for point-of-care medical photography using mobile devices. [ABSTRACT FROM AUTHOR]

Background: It is unclear how workflow interruptions impact emergency physicians at the point of care.Objectives: Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians.Methods: This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms.Results: A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ2(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ2 [2, n = 2355] = 78.43, p < 0.001).Conclusions: Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the 'Number of Unnecessary Waits (NUW)' and the corresponding 'Unnecessary Wait Hours (UWH)', to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED., Methods: UWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA., Results: We retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect., Conclusions: Situational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department's operations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Manually documented trauma flow sheets contain critical information regarding trauma resuscitations in the emergency department (ED). The American College of Surgeons (ACS) has enforced certain thresholds on trauma surgeons' arrival time to the trauma bay. Due to the complex and fast-paced ED environment, this information can be easily overlooked or erroneously recorded, affecting compliance with ACS standards. This paper is a retrospective study conducted at a Level I trauma center equipped with an RFID system to investigate an automated solution to evaluate and improve the accuracy of measuring trauma surgeons' response time to the highest level (red) trauma activations.Clinical Relevance- Demonstration of timely response to trauma activations is required for ACS verification. As real-time location systems become more prevalent, they may improve a hospital's ability to report accurate response times for trauma team activations.

Objective: To understand the ways in which providers use a mobile photography application integrated with the electronic health record (EHR) to facilitate clinical care, and the process outcomes that result from the application's use., Methods: An e-mail survey was sent on November 13, 2017, to 1,463 health care providers at Mayo Clinic who had used an internally developed, EHR-integrated medical photography application., Results: The survey was completed by 712 (49%) providers. Providers reported using the application on approximately 1 in 7 days spent in clinical practice. Median provider satisfaction with the use of the application (0-100 scale; higher numbers indicate favorable response) was 94 (interquartile range [IQR]: 74-100). Although the use for store-and-forward telemedicine was reported (22% often or frequently used the application to send photographs to a specialist for advice), the most common use was for clinical documentation (65% often or frequently used the application to supplement text-based notes with photographs, and 71% often or frequently used the application to take photographs for reference by a colleague who may see the patient in the future). Of the health care providers, 36% indicated that the application's use often or frequently expedited treatment., Discussion: Health care providers reported using a mobile point-of-care medical photography application regularly in clinical practice and were generally satisfied with the application., Conclusion: Point-of-care medical photography using a secure mobile, EHR-integrated application has potential to become a new standard of care for clinical documentation and may facilitate continuity across the continuum of care with multiple providers who see a patient., Competing Interests: The PhotoExam application is the institutional intellectual property of Mayo Clinic. All coauthors are employees or trainees at Mayo Clinic. Mayo Clinic is currently only using the PhotoExam application internally for clinical care and has not licensed the application for sale., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Mobile applications allow health care providers to capture point-of-care medical photographs and transfer them to the electronic health record (EHR). It is unclear how providers use these photographs or how they affect clinical care., Objectives: We aimed to understand the content, purpose, and outcomes of point-of-care medical photography performed in the pediatric emergency department (ED) at large academic medical center., Methods: A retrospective chart review was conducted of patients <21 years of age who were seen in the ED and photographed between March 29, 2015 and July 1, 2017 using a secure smartphone application integrated with the EHR. Inter-rater agreement and reliability between the two reviewers was assessed for the first 50 charts, and any discrepancies in interpretation were resolved before proceeding with the remaining data abstraction. The documented rationale for photography, content of photographs, and outcomes were recorded., Results: We identified 619 clinical encounters involving photographs of 605 patients who were eligible for inclusion. Skin was photographed in 499 (81%). The most common finding was rash ( N  = 177; 29%). Photos were of acceptable quality, with 569 (94%) achieving a score between 4 and 5 out of 5. The primary use of photography was documentation ( N  = 334; 54%), though teleconsultation was noted in 38 (6%). Nearly one-third ( N  = 187; 30%) of patients were seen in the ED or outpatient clinic for any reason within 2 weeks, and in 25 (13%), clinical notes explicitly referenced the initial photograph(s). In 53 (9%) cases, patients were photographed at a clinical visit in the subsequent 2 weeks, suggesting that photography was used to track changes over time., Conclusion: Documentation of findings using mobile point-of-care photography allows for high-fidelity documentation and facilitates continuity of care., Competing Interests: The authors have no personal conflicts of interest to declare. However, all authors are either current or former employees (C.M.L., T.R.H.) or trainees (R.M.C., G.Y.K., K.D.W.) at Mayo Clinic. The PhotoExam application is institutional intellectual property of Mayo Clinic. The PhotoExam application is currently only used internally at Mayo Clinic and is not currently licensed outside of Mayo Clinic. Statistical analysis was funded by discretionary funds provided by the Mayo Clinic Department of Emergency Medicine. RedCap support was funded by the National Institute of Health (Grant UL1TR002377)., (Georg Thieme Verlag KG Stuttgart · New York.)

Real-time location systems (RTLS) has found extensive application in the healthcare setting, that is shown to improve safety, save cost, and increase patient satisfaction. More specifically, some studies have shown the efficacy of RTLS leading to an improved workflow in the emergency department. However, due to substantial implementation costs of such technologies, hospital administrators show reluctance in RTLS adoption. Our previous preliminary studies with RFID data in the emergency department (ED) demonstrated for the first time the quantification of `patient alone time' and its relationship to outcomes such as 30-day hospitalization. In this study, we use ED RTLS data to analyze patient-care team contact time (PCTCT) and its relationship to the total treatment length of stay (LOS) in ED. An observational cohort study was performed in the ED using RTLS data from Jan 17 - Sep 17, 2017, which included a total of 51,697 patients. PCTCT within the first hour of a patient's placement in a treatment bed was calculated and its relationship to treatment LOS was analyzed while controlling for confounding factors affecting treatment LOS. Results show that treatment LOS is highly correlated with the ED crowding captured by the patient-perprovider ratio, negatively correlated to the physician and resident visit frequency, and positively correlated to nurse visit frequency. The results can inform designing new guidelines for ideal patient-care team interactions and be used to determine optimal ED staffing levels and care team composition for effective care delivery.