Abstract
Emergent policy changes related to telemedicine and the Emergency Medical Treatment and Labor Act during the novel coronavirus disease 2019 (COVID-19) pandemic have created opportunities for ...technology-based clinical evaluation, which serves to conserve personal protective equipment (PPE) and protect emergency providers. We define electronic PPE as an approach using telemedicine tools to perform electronic medical screening exams while satisfying the Emergency Medical Treatment and Labor Act. We discuss the safety, legal, and technical factors necessary for implementing such a pathway. This approach has the potential to conserve PPE and protect providers while maintaining safe standards for medical screening exams in the emergency department for low-risk patients in whom COVID-19 is suspected.
Abstract
Objective
To determine if ChatGPT can generate useful suggestions for improving clinical decision support (CDS) logic and to assess noninferiority compared to human-generated suggestions.
...Methods
We supplied summaries of CDS logic to ChatGPT, an artificial intelligence (AI) tool for question answering that uses a large language model, and asked it to generate suggestions. We asked human clinician reviewers to review the AI-generated suggestions as well as human-generated suggestions for improving the same CDS alerts, and rate the suggestions for their usefulness, acceptance, relevance, understanding, workflow, bias, inversion, and redundancy.
Results
Five clinicians analyzed 36 AI-generated suggestions and 29 human-generated suggestions for 7 alerts. Of the 20 suggestions that scored highest in the survey, 9 were generated by ChatGPT. The suggestions generated by AI were found to offer unique perspectives and were evaluated as highly understandable and relevant, with moderate usefulness, low acceptance, bias, inversion, redundancy.
Conclusion
AI-generated suggestions could be an important complementary part of optimizing CDS alerts, can identify potential improvements to alert logic and support their implementation, and may even be able to assist experts in formulating their own suggestions for CDS improvement. ChatGPT shows great potential for using large language models and reinforcement learning from human feedback to improve CDS alert logic and potentially other medical areas involving complex, clinical logic, a key step in the development of an advanced learning health system.
Abstract
The COVID-19 national emergency has led to surging care demand and the need for unprecedented telehealth expansion. Rapid telehealth expansion can be especially complex for pediatric ...patients. From the experience of a large academic medical center, this report describes a pathway for efficiently increasing capacity of remote pediatric enrollment for telehealth while fulfilling privacy, security, and convenience concerns.
The design and implementation of the process took 2 days. Five process requirements were identified: efficient enrollment, remote ability to establish parentage, minimal additional work for application processing, compliance with guidelines for adolescent autonomy, and compliance with institutional privacy and security policies.
Weekly enrollment subsequently increased 10-fold for children (age 0–12 years) and 1.2-fold for adolescents (age 13–17 years). Weekly telehealth visits increased 200-fold for children and 90-fold for adolescents.
The obstacles and solutions presented in this report can provide guidance to health systems for similar challenges during the COVID-19 response and future disasters.
Throughout the coronavirus disease 2019 pandemic, many emergency departments have been using passive protective enclosures (“intubation boxes”) during intubation. The effectiveness of these ...enclosures remains uncertain. We sought to quantify their ability to contain aerosols using industry standard test protocols.
We tested a commercially available passive protective enclosure representing the most common design and compared this with a modified enclosure that incorporated a vacuum system for active air filtration during simulated intubations and negative-pressure isolation. We evaluated the enclosures by using the same 3 tests air filtration experts use to certify class I biosafety cabinets: visual smoke pattern analysis using neutrally buoyant smoke, aerosol leak testing using a test aerosol that mimics the size of virus-containing particulates, and air velocity measurements.
Qualitative evaluation revealed smoke escaping from all passive enclosure openings. Aerosol leak testing demonstrated elevated particle concentrations outside the enclosure during simulated intubations. In contrast, vacuum-filter-equipped enclosures fully contained the visible smoke and test aerosol to standards consistent with class I biosafety cabinet certification.
Passive enclosures for intubation failed to contain aerosols, but the addition of a vacuum and active air filtration reduced aerosol spread during simulated intubation and patient isolation.
Left atrial ablation to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is a technologically intensive procedure utilizing innovative and continually improving ...technology. Changes in the technology utilized for PVI can in turn lead to changes in procedure costs. Because of the proximity of the esophagus to the posterior wall of the left atrium, various technologies have been utilized to protect against thermal injury during ablation. The impact on hospital costs during PVI ablation from utilization of different technologies for esophageal protection during ablation has not previously been evaluated.
To compare the costs of active esophageal cooling to luminal esophageal temperature (LET) monitoring during left atrial ablation.
We performed a time-driven activity-based costing (TDABC) analysis to determine costs for PVI procedures. Published data and literature review were utilized to determine differences in procedure time and same-day discharge rates using different esophageal protection technologies and to determine the cost impacts of same-day discharge versus overnight hospitalization after PVI procedures. The total costs were then compared between cases using active esophageal cooling to those using LET monitoring.
The effect of implementing active esophageal cooling was associated with up to a 24.7% reduction in mean total procedure time, and an 18% increase in same-day discharge rate. TDABC analysis identified a $681 reduction in procedure costs associated with the use of active esophageal cooling after including the cost of the esophageal cooling device. Factoring in the 18% increase in same-day discharge resulted in an increased cost savings of $2,135 per procedure.
The use of active esophageal cooling is associated with significant cost-savings when compared to traditional LET monitoring, even after accounting for the additional cost of the cooling device. These savings originate from a per-patient procedural time savings and a per-population improvement in same-day discharge rate.
In the present study, we quantified the effect of the coronavirus disease 2019 (COVID-19) on the volume of adult and pediatric neurosurgical procedures, inpatient consultations, and clinic visits at ...an academic medical center.
Neurosurgical procedures, inpatient consultations, and outpatient appointments at Vanderbilt University Medical Center were identified from March 23, 2020 through May 8, 2020 (during COVID-19) and March 25, 2019 through May 10, 2019 (before COVID-19). The neurosurgical volume was compared between the 2 periods.
A 40% reduction in weekly procedural volume was demonstrated during COVID-19 (median before, 75; interquartile range IQR, 72–80; median during, 45; IQR, 43–47; P < 0.001). A 42% reduction occurred in weekly adult procedures (median before, 62; IQR, 54–70; median during, 36; IQR, 34–39; P < 0.001), and a 31% reduction occurred in weekly pediatric procedures (median before, 13; IQR, 12–14; median during, 9; IQR, 8–10; P = 0.004). Among adult procedures, the most significant decreases were seen for spine (P < 0.001) and endovascular (P < 0.001) procedures and cranioplasty (P < 0.001). A significant change was not found in the adult open vascular (P = 0.291), functional (P = 0.263), cranial tumor (P = 0.143), or hydrocephalus (P = 0.173) procedural volume. Weekly inpatient consultations to neurosurgery decreased by 24% (median before, 99; IQR, 94–114; median during, 75; IQR, 68–84; P = 0.008) for adults. Weekly in-person adult and pediatric outpatient clinic visits witnessed a 91% decrease (median before, 329; IQR, 326–374; median during, 29; IQR, 26–39; P < 0.001). In contrast, weekly telehealth encounters increased from a median of 0 (IQR, 0–0) before to a median of 151 (IQR, 126–156) during COVID-19 (P < 0.001).
Significant reductions occurred in neurosurgical operations, clinic visits, and inpatient consultations during COVID-19. Telehealth was increasingly used for assessments. The long-term effects of the reduced neurosurgical volume and increased telehealth usage on patient outcomes should be explored.
INTRODUCTION: Test results are immediately released to patients through patient portals. We characterized patient and provider time-to-review of liver imaging results. METHODS: We identified 401 ...patients with cirrhosis enrolled in the portal with ≥1 liver imaging. We compared result review times for patients and providers and identified factors associated with rapid review. RESULTS: The median time-to-review for patients was shorter than providers (3.7 vs 17.6 hours, P < 0.001), with more than half of results reviewed by patients first. Rapid patient review was inversely associated with older age and Hispanic ethnicity. DISCUSSION: Patients rapidly review imaging results through the portal, often before providers.
Coronavirus disease 2019 (COVID-19) vaccination is the core strategy for pandemic management. We hypothesized that a vaccination gap might exist between emergency department (ED) patients admitted ...for trauma and other ED patients.
This was an observational quality improvement study using electronic health record data at an academic level-1 trauma center. Participants were all patients presenting to the adult ED with a Tennessee home address between January 1 and June 1, 2021. We measured the proportional difference in vaccination between admitted trauma patients and other ED patients over time (by week) and association via Spearman's rank correlation coefficient. Binary logistic regression facilitated covariate analysis to account for age, sex, race, home county, and ethnicity without and then with interaction between trauma admission and time. Geographic visual analysis compared county-level vaccination rates with odds of trauma admission by home county using a bivariate chloropleth map.
The proportional difference in vaccination between trauma-admitted and other ED patients increased over time (Spearman's = 0.699). Adjusting for age, sex, race, home county, and ethnicity, there was a statistically significant vaccination difference between trauma-admitted and other ED patients (odds ratio = 0.53, 95% CI 0.43-0.65, p < 0.0001). Geographic analysis revealed increased trauma admission odds and lower vaccination rates in surrounding counties compared with Davidson County.
We observed a widening COVID-19 vaccination gap between trauma-admitted and other ED patients. Vaccine outreach during trauma admission may provide a valuable point of contact for unvaccinated patients.
Atrial fibrillation is a condition in which the heart beats irregularly, causing symptoms such as palpitations, dizziness, shortness of breath, and chest pain. Atrial fibrillation increases the risk ...of stroke, heart failure, dementia, and death. One treatment for atrial fibrillation is a procedure called a catheter ablation. This procedure is minimally invasive and is performed by a specialized cardiologist, called an electrophysiologist. The electrophysiologist, or operator, uses an energy source, such as radiofrequency energy (radio waves), to stop erratic electrical signals from traveling through the heart. One complication of the catheter ablation is an inadvertent injury to the esophagus, the organ that passes food from the mouth to the stomach. If the injury is severe, it may develop into an atrioesophageal fistula, which often results in death. In this review, a new technology is described that helps prevent this type of injury and can provide additional benefits for the patient, operator, and hospital.
Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the esophagus can occur during this procedure, potentially creating an atrioesophageal fistula (AEF) which is 80% fatal. The ensoETM (Attune Medical, Chicago, IL), is an esophageal cooling device that has been shown to reduce thermal injury to the esophagus during RF ablation.
This review summarizes growing evidence related to active esophageal cooling during RF ablation for the treatment of AF. The review presents data demonstrating improved outcomes related to patient safety and procedural efficiency and suggests directions for future research.
The use of active esophageal cooling during RF ablation reduces esophageal injury, reduces or eliminates fluoroscopy requirements, reduces procedure duration and post-operative pain, and increases long-term freedom from arrhythmia. These effects in turn increase patient same-day discharge rates, decrease operator cognitive load, and reduce cost. These findings are likely to further accelerate the adoption of active esophageal cooling.
Reply to Barthell et al Turer, Robert W; Jones, Ian; Rosenbloom, S Trent ...
Journal of the American Medical Informatics Association,
09/2020, Letnik:
27, Številka:
9
Journal Article
PDF
