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Abstract Background Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system. Methods We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process. Results Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported. Conclusions Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.

Objective The identification of aerosol-generating procedures (AGPs) is important during the current SARS-CoV-2 pandemic due to aerosol-mediated virus transmission. Aerosol measurement during clinical procedures using particle counting may be confounded by variable natural background aerosol levels or limited by partial volume sampling. The study objective was to quantify any significant aerosol generated from simulated suction clearance procedures. Study Design Prospective quantification of aerosol generation during clinical suction simulation. Setting Clean chamber. Methods We created a clean environment for particle counting in a transparent neutralized polypropylene chamber. Air was passed through a HEPA 14 class filter to maintain a constant chamber inlet pressure. An optical particle counter was connected in line to the chamber exhaust vent to measure all of the vented particles. The chamber background count was 1 particle ≥0.3 µm per 15 minutes at a flow rate of 1 chamber air change per minute. We used this system to quantify very low aerosol counts generated from suction clearance of a silicone ear canal and at an open air-fluid interface. Results No clinically significant aerosol generation was found by particle counting of the whole chamber air volume during simulated suction procedures. Conclusion Simulated ear suction clearance and air-fluid interface suction does not generate any significant aerosol. It appears likely that any aerosol potentially generated at the suction tube tip is entrained by incoming air flow. This is the first study to quantify aerosols generated by suction in a controlled environment; further research is required to determine its clinical implications.