Attending Coverage Research Articles

Results of the 2021-2022 Survey of the American Alliance of Academic Chief Residents in Radiology

An annual survey of chief residents in accredited North American radiology programs is conducted by the American Alliance of Academic Chief Residents in Radiology (A3CR2). Special topics surveyed for the 2021-2022 academic year were procedural competency and virtual radiology education in the COVID-19 pandemic. The purpose of this study is to summarize the 2021-2022 A3CR2 chief resident survey. An online survey was distributed to chief residents from 197 Accreditation Council on Graduate Medical Education-accredited radiology residency programs. Chief residents responded to questions regarding their individual procedural readiness and attitudes on virtual radiology education. A single chief resident from each residency answered programmatic questions including the use of virtual education, faculty coverage, and fellowship choices among their graduating classes. We received 110 individual responses from 61 programs, yielding a 31% program response rate. Although the majority (80%) of programs maintained purely in-person attending readout throughout the COVID 19 pandemic, only 13% of programs reported purely in-person didactics and 26% converted to all virtual didactics. The majority (53%-74%) of chief residents perceived virtual learning (in read-out, case conference, and didactic formats) to be less effective than in-person learning. One third of chief residents reported decreased procedural exposure during the pandemic, and 7%-9% of chief residents felt uncomfortable with basic procedures (basic fluoroscopy examinations, basic aspiration/drainage procedures, and superficial biopsy procedures). The number of programs with 24/7 attending coverage increased from 35% in 2019 to 49% in 2022. Body, neuroradiology, and interventional radiology were the most popular advanced training options among graduating radiology residents. The COVID-19 pandemic had a profound impact on radiology training, particularly in terms of virtual learning. These survey results suggest that although digital learning offers increased flexibility, most residents still prefer in-person readout and didactics. Despite this, virtual learning will likely remain a viable option as programs continue to evolve following the pandemic.

Emergency Departments' Uptake of Telehealth for Stroke Versus Pediatric Care: Observational Study.

BackgroundTelehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted.ObjectiveOur primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth.MethodsWe used the 2016 National Emergency Department Inventory–USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both.ResultsOf the 442 EDs surveyed, 378 (85.5%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1% (45/320) of EDs with telestroke services reported weekly use versus 2.9% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was “improving level of clinical care.” Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8%) than for pediatric telehealth adoption (1/272, 0.4%; P=.003).ConclusionsIn 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care.

Measuring without a ruler: Limited data to characterize the relationship between physician assistant/nurse practitioner staffing and emergency department performance.

ObjectivePhysician assistant (PA) and nurse practitioner (NP) staffing is increasingly common in emergency departments (EDs), with variable physician supervision. We examined the feasibility of using publicly reported metrics as a measure of ED performance by staffing model.MethodsWe classified a convenience sample of 915 EDs by staffing model using the National Emergency Department Inventory‐USA 2016 and a follow‐up survey. Staffing models included 24/7 attending coverage with PAs/NPs, 24/7 attending coverage without PAs/NPs, and PAs/NPs without 24/7 attending coverage. We linked EDs with Hospital Compare data to examine availability of metrics and compared metric performance by staffing model. We used regression modeling to examine the independent relationship between staffing model and ED performance after adjusting for ED characteristics.ResultsOf 915 EDs surveyed, 767 (83%) responded and 436 (48%) had complete staffing data and any Hospital Compare data. The 216 EDs without any Hospital Compare data more frequently had no 24/7 attending coverage, were smaller, and were more often rural. Of 5 clinical metrics, 3 had data from < 100 EDs (range: 2%–21%), and 2 had data from 0 EDs. Of the 5 clinical metrics, only median time‐to‐ECG had enough data for analysis and found no difference among staffing models. Among the 3 process metrics, only time to discharge was significantly faster in EDs with any PA/NP staffing.ConclusionMany EDs in our national sample lacked sufficient Hospital Compare data to evaluate performance, likely because of lower patient volumes for condition‐specific metrics. Alternative strategies to measure quality of care delivery in these settings should be developed.

Workforce demographics and unit structure in paediatric cardiac critical care in the United States.

To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States. REDCap surveys were sent by email from May till August 2019 to medical directors ("directors") of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure. Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%). Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

Update on establishing and managing an overnight emergency radiology division

Emergency department (ED) radiology divisions that serve to provide overnight attending coverage have become an increasingly common feature of radiology departments. The purpose of this article is to review the common ED radiology coverage models, describe desirable traits of emergency radiologists, and discuss workflow in the ED radiology setting. ED radiologists may be trained as ED radiologists or may develop the necessary skills and adopt the subspecialty. Choosing radiologists with the correct traits such as being a “night owl” and remaining calm under pressure and implementing an acceptable work schedule such as shift length of 9–10 h and a “one week on, two weeks off” schedule contribute to sustainability of the position. Strategies to address the unique stressors and workflow challenges of overnight emergency radiology coverage are also presented. Workflow facilitators including trainees, PAs, radiology assistants, and clerks all have roles to play in managing high case volumes and in making sure that the service is well staffed. Usage of artificial intelligence software is the latest technique to streamline workflow by identifying cases which should be prioritized on a busy worklist. Implementing such strategies will maintain quality of care for patients regardless of time of day as well as sustainability and quality of life for overnight emergency radiologists.

Practice variation in the immediate postoperative care of pediatric liver transplant patients: Framework for a national consensus.

Advancements in critical care management have led to improvement in pediatric LT outcomes. However, there are no specific guidelines for many aspects of immediate post-LT care. This survey examines practice variations in the immediate postoperative care of pediatric LT patients at a large number of active US centers. This study is a cross-sectional survey of medical directors at PALISI-affiliated PICU in the United States. Centers performing pediatric LT were analyzed. Study measures included PICU practices regarding staffing, composition of the multidisciplinary team, early post-LT graft and patient monitoring, and anticoagulation. Of the thirty-five responding centers, twenty-five had a LT program which accounted for one-half of all US pediatric LTs. For analysis, centers were categorized by volume: high (7), medium (11), and low (7). The majority of PICU teams included an intensivist (80%) and hepatologist (84%). High-volume centers were less likely to have 24-hour in-house attending coverage (29%, compared to 64% (medium) and 100% (low)). High-volume centers were most likely to have pre-printed orders, but least likely to have written PICU management protocols. Most centers utilize routine daily liver ultrasound. Routine prophylactic anticoagulation, and the agent of choice, was variable. There is marked inconsistency in post-LT practice across PALISI centers in regards to team composition and immediate post-LT management. A national US consensus for post-LT PICU practices would facilitate outcomes research and would establish a platform for multicenter studies.

Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90.

Benefits of overnight attending radiologist final reports are debated, often stating low resident discrepancy rates, usually assessed retrospectively. The objective of this study was to assess the impact of overnight final reporting on the recall rates for patients in the emergency department (ED) receiving overnight imaging. Retrospective matched cohorts of two separate years prior (prior-16 and prior-17) and 1year after (post-18) introduction of overnight attending radiologist final reporting. Patients receiving imaging between 22:00 and 07:00h and returned to ED within 48h of initial visit discharge were electronically identified. String matching identified return visits possibly related to imaging completed on first visit. Identified return visit notes were scored by three observers individually. Unclear and discrepant cases were resolved by consensus meeting, using full patient charts where needed. Incidences were provided and logistic regression analysis defined if coverage model was a predictor for recall. Odds ratios were calculated. ED patient count with imaging completed overnight in prior-16 was 9200, in prior-17 was 9543, and in post-18 was 9992. The number of overnight imaging studies performed was respectively 13,883, 14,463, and 15,112. Imaging-related ED recalls were respectively 54, 61, and 7, a decrease with the new coverage model of 89% to true and at least 90% of expected recalls.Logistic regression demonstrated that coverage model was a significant predictor of ED recalls with chi-square of 59.86 and p< 0.001, an R2 of 0.03 (Hosmer and Lemeshow). Compared to post-18, ED patients had an odds ratio of 8.42 (prior-16) and 9.18 (prior-17) to be called back to ED. Overnight final reporting significantly decreases ED recalls for patients receiving diagnostic imaging overnight. While numbers are low even prior to rollout, the number should be minimized wherever possible to diminish patient anxiety and discomfort, reduce ED overcrowding and expedite definitive management. Section 1: What is already known on this subject • Radiology resident preliminary report discrepancy rates are low. • Overnight attending radiologist coverage is a model increasingly applied in academic and large non-academic centers. • Patient recalls to the ED are a burden to the patient and impact patient throughput in (over)crowded EDs. Section 2: What this study adds • First study to look at the impact of overnight attending final reports on the recall rate for ED patients with overnight imaging performed. • While absolute numbers are low, there is a significant decrease in patients returning to ED for imaging related issues after introducing overnight attending coverage. • Resident autonomy can be preserved and training enhanced while increasing patient safety and comfort.

Effect of 24/7 attending coverage in the neonatal intensive care unit on fellow education

BackgroundThere is a current change in type of attending coverage in the Neonatal Intensive Care Unit (NICU) from home calls to 24/7 in house coverage. Effects of this increased attending physician presence on education of NICU fellows has not been studied. The objective of this study is to evaluate the fellows’ perception of in house attending coverage on their education and evaluate its effect on their perceived autonomy.MethodsA secure, anonymous, web-based survey was designed using RedCap. The web-based survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training & Early Career Neonatologists. Questions were focused on perception of IH attending coverage on fellows’ educational experience including the respondent’s perceived ability to make independent decisions (autonomy). Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small.ResultsOne hundred and twenty-three surveys were analyzed, that included responses from 82 fellows & 41 early career neonatologists. 52% reported having 24/7 attending in-house (IH) coverage. Thirty of the 123 respondents experienced a change in model of attending coverage during their training. Among these 30, only 26.6% preferred the model of attending IH coverage. The respondents currently working in IH models, when compared to those in non-IH coverage models felt IH attending coverage was beneficial for fellow education (p < 0.05) but was less likely to give fellows autonomy for decision making (p = 0.02).ConclusionIn our survey respondents with in house attending, had a more favorable view of its benefit on fellow education. Institutions practicing or considering IH attending coverage should consider use of adequate measures to balance fellow supervision and education.

Results of the 2019 Survey of the American Alliance of Academic Chief Residents in Radiology

An annual survey of chief residents in accredited North American radiology programs is conducted by the American Alliance of Academic Chief Residents in Radiology (A3CR2). The purpose of this study is to summarize the 2019 A3CR2 chief resident survey. An online survey was distributed to chief residents from 194 Accreditation Council on Graduate Medical Education-accredited radiology residencies. Questions were designed to gather information about residency program details, call and weekend coverage, interventional radiology training, fellowship, social media use, healthcare reform, artificial intelligence, and job market status. One hundred and forty-two unique responses from 99 programs were provided, yielding a 51% program response rate. There was a mean of 7.3 women per residency with a mean program size of 28 residents (26% women). Only 3 of the 99 (3%) programs had a proportion of women that was 50% or higher. The proportion of women in radiology residencies is unchanged since 2014 (p= 0.93) and is significantly lower than 2019 graduating women medical students (49.3%; p < 0.001). Thirty-five percent of programs had 24/7 attending coverage and 40% of programs had extended hours attending shifts. Of programs without 24/7 attending coverage, the proportion of programs without face-to-face readout has increased from 34% in 2014 to 55% in 2019 (p = 0.015). The majority (67%) of respondents had no concerns about the radiology job market; compared to 2014, where only 4% had no concerns (p < 0.001). Women remain underrepresented in radiology, face-to-face readout is decreasing, and there has been a shift towards a positive job market outlook.

Exploratory data analysis for pre and post 24/7/365 attending radiologist coverage support in an emergency department: fundamentals of data science.

To present a detailed exploratory data analysis for critically investigating the patterns in medical doctor (MD) to disposition time,pre and post 24/7/365 attending radiologistcoverage, for patients presenting to an emergency department (ED). The process involved presenting several modeling techniques. Toshare an understanding of concepts and techniques, we used proportions, medians, and means,Mann-Whitney Utest, Kaplan-Meier's (KM)survival analysis, linear and log-linear regression, log-ranked test, Cox proportional hazards model, Weibull parametric survival modelsand tertile analysis. Retrospective chart review was conducted to obtain adataset which wasused to determine the trends in MD to disposition time. Data comprised of patients who hadvisited the emergency department (ED) during two distincttimeperiods and whose imaging studies were read by an attending emergency and trauma radiologist. Median provided more insight into the data as compared with the mean.The Mann-Whitney U testwas appropriate to evaluate MD to disposition time, but provided limited information. The Kaplan-Meier (KM) was able to offer more insight into the data since it did not assume an underlying model and that is the reason why it was appropriate. However, KM had limited ability to handle measured confounders and was unable to describe the magnitude of difference between curves. The Cox proportional hazards semi-parametric model or some other parametric model such as the Weibull could handle multiple measured confounders and described the magnitude of difference between two (survival) groups in the data set. However, both methods assumed underlying models that may not apply to the data set such as the one used in this study. Linear regression was unlikely to be appropriate due to the shape of survival time distributions, but log transforming the outcome could address the distribution issue. Nearly all the results of the KM subgroup analyses were consistent with the results of the log-transformed linear regression subgroup analyses and the interpretation of the results was the same for both. Different statistical procedures may be applied to conduct exploratory subgroup analysisfor a data set fromapre and post 24/7/365 attending coverage model. This could guide potential areas of further research to compare trends in MD to disposition time in ED. Pattern analysis provides evidence for various stakeholders to rethink the discourse about trends in MD to disposition time, pre andpost 24/7/365 attendingcoverage. Graphical Illustration: The role of Emergency and Trauma Radiology in an Emergency Department.

95 An Analysis of Patient Complaints at a Community Teaching Hospital’s Emergency Department and Its Correlation to Litigation

The purpose of this study is to analyze emergency department (ED) complaints received at a community teaching hospital, create benchmarks with complaint rates and to correlate this with litigation. A prospective study analyzed logged patient complaints forwarded to the ED Medical Director between 2014 and 2018. Our community teaching ED has an approximate annual volume of 50,000 visits with ED attending and mid-level provider coverage. Our ED satisfaction scores place us in the 85th percentile in our peer group and 65th percentile nationally. Qualitative evaluation was performed based on a systematic taxonomy and the following data was extracted: patient’s provider, reason of complaint, origin of complaint, patient date of service, the date case opened, and the date the case closed. The complaints were totaled by year and categorized, correlating to the context of complaints, mode of case opening, and time frame for resolution. ED litigation was reviewed over the same five-year interval and correlated to the complaint log. The most common reason for a complaint was based on clinical care concerns, followed by billing issues, and then by patient satisfaction issues. Satisfaction concerns were received the earliest at 19.7 days, clinical concerns occurred in 38 days and finally billing at 160 days. Most complaints were resolved within 19.5 days after the case was opened. Cases that took more than 90 days to open from the date of service were most likely associated to billing. Most complaints originated from the Patient Satisfaction and Billing Departments. We have found that our facility had an annual complaint rate ranging from 24.2 to 33.3 per 10,000 visits during the observation period, with an overall rate of 29.1 per 10,000 visits. The hospital had nine total lawsuits attributed to the ED over the five-year period, for a rate of 9 per 251,012 or 0.36 lawsuits per 10,000 patient visits. The rate of a complaint associated with a lawsuit was 2 per 731 or 27.4 lawsuits per 10,000 complaints when extrapolated. Only one suit would assign attribution to the ED provider; all others were related to supporting services. The complaint incidence in our ED is low at 29.1 per 10,000 visits and remained constant over the five-year observation period. Only two complaints out of the 731 complaints led to litigation for a rate of 27.4 lawsuits per 10,000 complaints. This rate was substantially higher in magnitude than the general rate of 0.36 per 10,000. Moreover, most cases that ended up in litigation did not have an associated complaint filed in advance of the claim. Clinical complaints of quality of care, billing, and satisfaction were the most common. Satisfaction and quality of care complaints tend to come in earlier, while billing complaints are more likely to come in later and take longer to be resolved.

IMPACT OF A MEDICAL ICU IN-HOUSE NIGHT FELLOW ON RESIDENT EDUCATION, PROCEDURAL SUPERVISION, AND WELLNESS

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Across the United States, 24/7 in-house critical care coverage is a topic of great debate. The benefit of in-house intensivists remains unclear. Studies have evaluated the impact of in-house attending coverage on patient care, but there is limited data on the impact of medical intensive care unit (MICU) coverage by an in-house critical care fellow on resident education. Nonetheless, many programs are transitioning away from night fellow home call. The objective of this study was to evaluate if there was a perceived difference in resident education, procedural supervision and wellness after the implementation of an MICU in-house night fellow. METHODS: We conducted a retrospective, survey-based study of internal medicine residents’ perceptions of the impact of a transition to in-house fellow coverage of an MICU at night at a university-affiliated academic medical center. We developed a non-validated questionnaire for residents using a modified Likert structure. The survey was extended to all internal medicine residents and interns (n=110) regardless of prior experience in the MICU. Residents who reported having rotated through the MICU prior to the transition to an in-house night fellow (February 2017) were asked questions regarding perceptions of education, procedural supervision and wellness before that point when fellows previously took home call. All survey participants were asked questions regarding perceptions of an in-house night fellow’s effect on education, procedural supervision and wellness. All responses remained anonymous. RESULTS: The survey was extended to all internal medicine trainees. Eighty-five (77%) trainees completed the survey. Of those participants, 42 (49%) had rotated through the MICU prior to the initiation of an in-house night fellow. Regarding experiences prior to an in-house night fellow, 9 (21%) felt procedural supervision was good or excellent, 23 (55%) rated their stress level as high or very high, and 10 (24%) felt support with code blues was good or excellent. Since the implementation of an MICU in-house night fellow, 57 (67%) felt procedural supervision was good or excellent, 6 (7%) rated their stress as high or very high, and 67 (79%) rated support with code blues as good or excellent. Fifty-five (65%) felt their learning was rarely or never inhibited by an in-house night fellow. CONCLUSIONS: Prior studies have demonstrated no clear benefit to in-house attending staffing of ICUs and have raised concerns about its impact on trainee autonomy. Little has been published on the effects on an MICU in-house night fellow. Here we demonstrate that institution of in-house night fellow coverage improves residents’ perceptions of education, supervision and wellness. CLINICAL IMPLICATIONS: An MICU in-house night fellow may be an effective system for providing 24/7 in-house critical care coverage while preserving trainee autonomy and improving resident learning and supervision. DISCLOSURES: No relevant relationships by Laura Behlen, source=Web Response No relevant relationships by William Denney, source=Web Response no disclosure on file for Jessie Harvey

Pediatric Hospitalist Nocturnist Program at an Academic Medical Center - Costs and Benefits

Background: In-house pediatric hospitalist attending coverage 24/7 is required for hospitals to be certified as a Level I Children’s Surgery Center by the American College of Surgeons. Little is known about the effects of having in-house attending nocturnist coverage on hospital utilization. Purpose: To examine utilization outcomes before and after the introduction of a pediatric hospitalist nocturnist program. Methods: The UC Davis Institutional Review Board determined this work does not meet the regulatory definition of human subjects research. Prior to initiation of …

Review of learning opportunity rates: correlation with radiologist assignment, patient type and exam priority

Common cause analysis of learning opportunities identified in a peer collaborative improvement process can gauge the potential risk to patients and opportunities to improve. To study rates of learning opportunities based on radiologist assignment, patient type and exam priority at an academic children's hospital with 24/7 in-house attending coverage. Actively submitted peer collaborative improvement learning opportunities from July 2, 2016, to July 31, 2018, were identified. Learning opportunity rates (number of learning opportunities divided by number of exams in each category) were calculated based on the following variables: radiologist assignment at the time of dictation (daytime weekday, daytime weekend and holiday, evening, and night) patient type (inpatient, outpatient or emergency center) and exam priority (stat, urgent or routine). A statistical analysis of rate differences was performed using a chi-square test. Pairwise comparisons were made with Bonferroni method adjusted P-values. There were 1,370 learning opportunities submitted on 559,584 studies (overall rate: 0.25%). The differences in rates by assignment were statistically significant (P<0.0001), with the highest rates on exams dictated in the evenings (0.31%) and lowest on those on nights (0.19%). Weekend and holiday daytime (0.26%) and weekday daytime (0.24%) rates fell in between. There were significantly higher rates on inpatients (0.33%) than on outpatients (0.22%, P<0.0001) or emergency center patients (0.16%, P<0.0001). There were no significant differences based on exam priority (stat 0.24%, urgent 0.26% and routine 0.24%, P=0.55). In this study, the highest learning opportunity rates occurred on the evening rotation and inpatient studies, which could indicate an increased risk for patient harm and potential opportunities for improvement.

The Influence of Inpatient Physician Continuity on Hospital Discharge.

Inpatient attending physicians may change during a patient's hospital stay. This study measured the association of attending physician continuity and discharge probability. All patients admitted to general medicine service at a tertiary care teaching hospital in 2015 were included. Attending inpatient physician continuity was measured as the consecutive number of days each patient was treated by the same staff-person. Generalized estimating equation methods were used to model the adjusted association of attending inpatient physician continuity with daily discharge probability. 6301 admissions involving 41 internists, 5134 patients, and 38,242 patient-days were studied. The final model had moderate discrimination (c-statistic = 0.70) but excellent calibration (Hosmer-Lemeshow statistic 11.5, 18 df, p value 0.89). Daily discharge probability decreased significantly with greater severity of illness, higher patient death risk, and longer length of stay, on admission day, for elective admissions, and on the weekend. Discharge likelihood increased significantly with attending inpatient physician continuity; daily discharge probability increased for the average patient from 15.3 to 20.9% when the consecutive number of days the patient was treated by the same attending inpatient physician increased from 1 to 7days. Inpatient attending physician continuity is significantly associated with the likelihood of patient discharge. This finding could be considered if resource utilization is a factor when scheduling attending inpatient physician coverage.

Intensivist staffing and outcome in the ICU: daytime, nighttime, 24/7?

Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence.

Reducing Cancellations and Optimizing Surgical Scheduling of Ophthalmology Cases at a Veterans Affairs Medical Center.

Preventable causes of ophthalmology surgical case cancellations were identified, and interventions were implemented to improve operating room utilization at our Veterans Affairs (VA) Medical Center. A retrospective review of 269 patients with cancellations from 2013 to 2015 was performed. Interventions implemented from September 2014 to March 2015 were evaluated followed by in-depth chart reviews to identify demographics and wait-time intervals. Interventions included scheduling surgeries electronically, by specialty, and with predetermined attending coverage. In addition, the preoperative templates and technology to obtain preoperative measurements were updated. Cancellation rates dropped significantly from 35% to 7% (p = .014). Preventable causes of cancellations decreased from 28% to 5% (p = .005). Operating room utilization increased significantly with 264 more scheduled cases in 2015 than in 2013 (485 vs. 749, p < .001), and surgery wait time trended downward. These findings may support the use of similar interventions at other VA medical centers or similar hospitals with the goal of improving quality of care through decreased cancellations and cost.

An Analysis of the Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate Among Practice Groups in a High-Volume Community Teaching Hospital

PURPOSE: Data regarding factors that influence the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate is limited. This study's purpose was to compare the NTSV cesarean rate across practice groups at Virginia Hospital Center (VHC). BACKGROUND: VHC is a high-volume community teaching hospital in Arlington, Virginia. Labor and Delivery is managed by different practice groups: hospitalists with resident coverage, hospitalists without resident coverage, and private attendings. Hospitalists are attending physicians who provide 24-hour in-house management of laboring patients, whereas private attendings are only expected to be in-house for patients in active labor. METHODS: This was a retrospective cohort study of all NTSV pregnant women who delivered at VHC from 2014 to 2016. Chi-square tests were used to determine whether NTSV cesarean rates were significantly different over time and across different practice groups. RESULTS: There were 2,339, 2,090, and 1,673 NTSV pregnancies in 2014, 2015, and 2016, respectively. The NTSV cesarean rate decreased significantly by 30.8% (31.8% in 2014, 27.7% in 2015, and 22.0% in 2016, 0.01). The NTSV cesarean rate was significantly lower with hospitalists, with the lowest rate in the hospitalists with resident coverage (NTSV rate of 19.8% for hospitalists plus residents, 25.7% for hospitalists without residents, 30.3% for private attendings, 0.01). All groups decreased their NTSV cesarean birth rate over time, with significant decreases in the hospitalists without residents and private attending groups (0.01). DISCUSSION: Having 24-hour in-house attending coverage is associated with lower NTSV cesarean rates. Resident involvement may also be a factor in lowering this rate.

The Current State of Radiology Call Assistant Triage Programs Among US Radiology Residency Programs

Given increasing volume and workflow interruptions in radiology, we sought to identify and characterize radiology call assistant triage (RCAT) programs among US radiology residency programs. A survey was created using Qualtrics survey software and emailed to all members of the Association of Program Directors in Radiology listserv. A total of 296 active members belong to this listserv, including program directors and assistant program directors. The survey included questions about the existence and specifics of a call triage assistant program. Data were obtained from 88 active members of the Association of Program Directors in Radiology (30% response rate). Of those, 20 programs (23%) have an RCAT program. Triage assistant staffing includes nonmedical or clerical staff (60%), medical students (30%), first-year radiology residents (5%), and technologists (5%). All respondents with RCAT programs report satisfaction with their program and plan to continue. A significant majority (75%) have no plans to change, whereas the remaining 25% are considering program expansion and pay increases. Among residency programs without RCAT programs, none reported termination of their triage program. The most common reasons for not having triage assistants include cost, lack of awareness, differing opinions on utility, and the presence of 24/7 attending coverage. Twenty US radiology residency programs report having an RCAT program. All report satisfaction with their program despite different staffing models. RCAT programs may represent an effective measure in limiting interruptions and potentially decreasing interpretative errors made by residents on call.

24/7 pediatric radiology attending coverage: times are changing.

The job of the pediatric radiologist long ago ceased to be an 8-to-5 role. Many practices have adopted evening shifts of in-house attending radiologists to cover the busy evening activity. With the ever-increasing role of imaging in clinical decisions and patient management, there is a need - if not a demand - to further extend attending pediatric radiology coverage. In this article, we discuss the needs and justification for extending pediatric radiology coverage at a tertiary-care children's hospital. We also describe the approach we took toward implementing 24/7 attending in-house coverage of pediatric radiology.