- Emergency Medicine
Clinical Assistant Professor, Emergency Medicine
Director of Quality, Stanford Department of Emergency Medicine (2021 - Present)
Associate Medical Director, Stanford Department of Emergency Medicine (2021 - Present)
Assistant Medical Director, Stanford Department of Emergency Medicine (2020 - 2021)
Value-based Care Department Champion, Stanford Health Care (2019 - Present)
Boards, Advisory Committees, Professional Organizations
National Committee Member, ACEP Clinical Emergency Data Registry Committee (2019 - Present)
National Committee Member, ACEP Quality and Patient Safety Committee (2019 - Present)
Chair, ACEP Quality Improvement and Patient Safety Section (2019 - 2021)
Member, Society of Academic Emergency Medicine (SAEM) (2014 - Present)
Member, American College of Emergency Physicians (ACEP) (2014 - Present)
Board Certification: American Board of Emergency Medicine, Emergency Medicine (2019)
BS, Stanford University, Chemical Engineering (2010)
MBA, Yale University School of Management (2019)
Fellowship: Yale School of Medicine Dept of Emergency Medicine (2019) CT
Residency: University of Wisconsin Emergency Medicine Residency (2017) WI
Medical Education: University of Wisconsin School of Medicine Registrar (2014) WI
OPERATIONALIZING A PANDEMIC-READY, TELEMEDICINE-ENABLED DRIVE-THROUGH AND WALK-IN CORONAVIRUS DISEASE GARAGE CARE SYSTEM AS AN ALTERNATIVE CARE AREA: A NOVEL APPROACH IN PANDEMIC MANAGEMENT
JOURNAL OF EMERGENCY NURSING
2021; 47 (5): 721-732
Emergency departments face unforeseen surges in patients classified as low acuity during pandemics such as the coronavirus disease pandemic. Streamlining patient flow using telemedicine in an alternative care area can reduce crowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment use. This quality improvement project describes critical elements and processes in the operationalization of a telemedicine-enabled drive-through and walk-in garage care system to improve ED throughput and conserve personal protective equipment during 3 coronavirus disease surges in 2020.Standardized workflows were established for the operationalization of the telemedicine-enabled drive-through and walk-in garage care system for patients presenting with respiratory illness as quality improvement during disaster. Statistical control charts present interrupted time series data on the ED length of stay and personal protective equipment use in the week before and after deployment in March, July, and November 2020.Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the telemedicine-enabled drive-through and walk-in garage care system. On average, the ED length of stay decreased 17%, from 4.24 hours during the week before opening to 3.54 hours during the telemedicine-enabled drive-through and walk-in garage care system operation. There was an estimated 25% to 41% reduction in personal protective equipment use during this time.Lessons learned from this telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce crowding, improve throughput, and conserve personal protective equipment during a pandemic.
View details for DOI 10.1016/j.jen.2021.05.010
View details for Web of Science ID 000762175400001
View details for PubMedID 34303530
View details for PubMedCentralID PMC8173460
Fair Play: Application of Normalized Scoring to Emergency Department Throughput Quality Measures in a National Registry.
Annals of emergency medicine
2021; 77 (5): 501-510
The measurement of emergency department (ED) throughput as a patient-centered quality measure is ubiquitous; however, marked heterogeneity exists between EDs, complicating comparisons for payment purposes. We evaluate 4 scoring methodologies for accommodating differences in ED visit volume and heterogeneity among ED groups that staff multiple EDs to improve the validity and "fairness" of ED throughput quality measurement in a national registry, with the goal of developing a volume-adjusted throughput measure that balances variation at the ED group level.We conducted an ED group-level analysis using the 2017 American College of Emergency Physicians Clinical Emergency Data Registry data set, which included 548 ED groups inclusive of 889 unique EDs. We calculated ED throughput performance scores for each ED group by using 4 scoring approaches: plurality, simple average, weighted average, and a weighted standardized score. For comparison, ED groups (ie, taxpayer identification numbers) were grouped into 3 types: taxpayer identification numbers with only 1 ED; those with multiple EDs, but no ED with greater than 60,000 visits; and those with multiple EDs and at least 1 ED with greater than 60,000 visits.We found marked differences in the classification of ED throughput performance between scoring approaches. The weighted standardized score (z score) approach resulted in the least skewed and most uniform distribution across the majority of ED types, with a kurtosis of 12.91 for taxpayer identification numbers composed of 1 ED, 2.58 for those with multiple EDs without any supercenter, and 3.56 for those with multiple EDs with at least 1 supercenter, all lower than comparable scoring methods. The plurality and simple average scoring approaches appeared to disproportionally penalize ED groups that staff a single ED or multiple large-volume EDs.Application of a weighted standardized (z score) approach to ED throughput measurement resulted in a more balanced variation between different ED group types and reduced distortions in the length-of-stay measurement among ED groups staffing high-volume EDs. This approach may be a more accurate and acceptable method of profiling ED group throughput pay-for-performance programs.
View details for DOI 10.1016/j.annemergmed.2020.10.021
View details for PubMedID 33455841
The cost of waiting: Association of ED boarding with hospitalization costs.
The American journal of emergency medicine
2021; 40: 169-172
Emergency Department (ED) boarding, the practice of holding patients in the ED after they have been admitted to the hospital due to unavailability of inpatient beds, is common and contributes to the public health crisis of ED crowding. Prior work has documented the harms of ED boarding on access and quality of care. Limited studies examine the relationship between ED boarding and an equally important domain of quality-the cost of care. This study evaluates the relationship between ED boarding, ED characteristics and risk-adjusted hospitalization costs utilizing national publicly-reported measures.We conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear regression analysis to examine the association between ED boarding and Medicare spending per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation time, and ED patient volume.A total of 2903 hospitals were included in the analysis. ED boarding was significantly correlated with MSPB (r = 0.1774; p-value: < 0.0001). In multivariate regression, ED boarding was also positively associated with MSPB (Beta: 0.00015; p < 0.0001) after adjustment for other hospital level crowding indicators.We found a strong relationship between measures of ED crowding, including ED boarding, and risk-adjusted hospital spending. Future work should elucidate the mediators of this relationship. Policymakers and administrators should consider the financial harms of ED boarding when devising strategies to improve hospital care access and flow.
View details for DOI 10.1016/j.ajem.2020.10.058
View details for PubMedID 33272871
Improving Emergency Department Throughput Using Audit-and-Feedback With Peer Comparison Among Emergency Department Physicians.
Journal for healthcare quality : official publication of the National Association for Healthcare Quality
2021; 44 (2): 69-77
We sought to determine if audit-and-feedback with peer comparison among emergency physicians is associated with improved emergency department (ED) throughput and decreased variation in physician performance.We implemented an audit-and-feedback with peer comparison tool at a single urban academic ED from March 1, 2013, to July 1, 2018. In the first study period, physicians received no reports. In the second period, they received daily reports. In the third period, they received daily, quarterly, and annual reports. Outcomes included patients per hour, admission rate, time to admission, and time to discharge.A total of 272,032 patient visits and 36 ED physicians were included. The mean admission rate decreased 6.8%; the mean time to admission decreased 43.8 minutes; and the mean time to discharge decreased 40.6 minutes. Variation among physicians decreased for admission rate, time to admission, and time to discharge. Low-performing outliers showed disproportionately larger improvements in patients per hour, admission rate, time to admission, and time to discharge.Automated peer comparison reports for academic emergency physicians was associated with lower admission rates, shorter times to admission, and shorter times to discharge at the departmental level, as well as decreased practice variation at the individual level.
View details for DOI 10.1097/JHQ.0000000000000329
View details for PubMedID 34570029
- Drive-through Medicine for COVID-19 and Future Pandemics. The western journal of emergency medicine 2020; 22 (2): 252-256
Association between patient-physician gender concordance and patient experience scores. Is there gender bias?
The American journal of emergency medicine
Patient satisfaction, a commonly measured indicator of quality of care and patient experience, is often used in physician performance reviews and promotion decisions. Patient satisfaction surveys may introduce gender-related bias.Examine the effect of patient and physician gender concordance on patient satisfaction with emergency care.We performed a cross-sectional analysis of electronic health record and Press Ganey patient satisfaction survey data of adult patients discharged from the emergency department (2015-2018). Logistic regression models were used to examine relationships between physician gender, patient gender, and physician-patient gender dyads. Binary outcomes included: perfect care provider score and perfect overall assessment score.Female patients returned surveys more often (n=7 612; 61.55%) and accounted for more visits (n=232 024; 55.26%). Female patients had lower odds of perfect scores for provider score and overall assessment score (OR: 0.852, 95% CI: 0.790, 0.918; OR: 0.782, 95% CI: 0.723, 0.846). Female physicians had 1.102 (95% CI: 1.001, 1.213) times the odds of receiving a perfect provider score. Physician gender did not influence male patients' odds of reporting a perfect care provider score (95% CI: 0.916, 1.158) whereas female patients treated by female physicians had 1.146 times the odds (95% CI: 1.019, 1.289) of a perfect provider score.Female patients prefer female emergency physicians but were less satisfied with their physician and emergency department visit overall. Over-representation of female patients on patient satisfaction surveys introduces bias. Patient satisfaction surveys should be deemphasized from physician compensation and promotion decisions.
View details for DOI 10.1016/j.ajem.2020.09.090
View details for PubMedID 33069544
Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review.
Annals of emergency medicine
2019; 74 (2): 285-296
As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED).A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias.A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials.Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
View details for DOI 10.1016/j.annemergmed.2018.10.034
View details for PubMedID 30611639
View details for PubMedCentralID PMC6610851
The Impact of an Emergency Department Front-End Redesign on Patient-Reported Satisfaction Survey Results.
The western journal of emergency medicine
2017; 18 (6): 1068-1074
For emergency department (ED) patients, delays in care are associated with decreased satisfaction. Our department focused on implementing a front-end vertical patient flow model aimed to decrease delays in care, especially care initiation. The physical space for this new model was termed the Flexible Care Area (FCA). The purpose of this study was to quantify the impact of this intervention on patient satisfaction.We conducted a retrospective study of patients discharged from our academic ED over a one-year period (7/1/2013-6/30/2014). Of the 34,083 patients discharged during that period, 14,075 were sent a Press-Ganey survey and 2,358 (16.8%) returned the survey. We subsequently compared these survey responses with clinical information available through our electronic health record (EHR). Responses from the Press-Ganey surveys were dichotomized as being "Very Good" (VG, the highest rating) or "Other" (for all other ratings). Data abstracted from the EHR included demographic information (age, gender) and operational information (e.g. - emergency severity index, length of stay, whether care was delivered entirely in the FCA, utilization of labs or radiology testing, or administration of opioid pain medications). We used Fisher's exact test to calculate statistical differences in proportions, while the Mantel-Haenszel method was used to report odds ratios.Of the returned surveys, 62% rated overall care for the visit as VG. However, fewer patients reported their care as VG if they were seen in FCA (53.4% versus 63.2%, p=0.027). Patients seen in FCA were less likely to have advanced imaging performed (12% versus 23.8%, p=0.001) or labs drawn (24.8% vs. 59.1%, p=0.001). Length of stay (FCA mean 159 ±103.5 minutes versus non-FCA 223 ±117 minutes) and acuity were lower for FCA patients than non-FCA patients (p=0.001). There was no statistically significant difference between patient-reported ratings of physicians or nurses when comparing patients seen in FCA vs. those not seen in FCA.Patients seen through the FCA reported a lower overall rating of care compared to patients not seen in the FCA. This occurred despite a shorter overall length of stay for these patients, suggesting that other factors have a meaningful impact on patient satisfaction.
View details for DOI 10.5811/westjem.2017.7.33664
View details for PubMedID 29085539
View details for PubMedCentralID PMC5654876
A Biomechanical Comparison of Shape Design and Positioning of Transforaminal Lumbar Interbody Fusion Cages.
Global spine journal
2016; 6 (5): 432-438
Cadaveric biomechanical analysis.The aim of this study was to compare three interbody cage shapes and their position within the interbody space with regards to construct stability for transforaminal lumbar interbody fusion.Twenty L2-L3 and L4-L5 lumbar motion segments from fresh cadavers were potted in polymethyl methacrylate and subjected to testing with a materials testing machine before and after unilateral facetectomy, diskectomy, and interbody cage insertion. The three cage types were kidney-shaped, articulated, and straight bullet-shaped. Each cage type was placed in a common anatomic area within the interbody space before testing: kidney, center; kidney, anterior; articulated, center; articulated, anterior; bullet, center; bullet, lateral. Load-deformation curves were generated for axial compression, flexion, extension, right bending, left bending, right torsion, and left torsion. Finally, load to failure was tested.For all applied loads, there was a statistically significant decrease in the slope of the load-displacement curves for instrumented specimens compared with the intact state (p < 0.05) with the exception of right axial torsion (p = 0.062). Among all instrumented groups, there was no statistically significant difference in stiffness for any of the loading conditions or load to failure.Our results failed to show a clearly superior cage shape design or location within the interbody space for use in transforaminal lumbar interbody fusion.
View details for DOI 10.1055/s-0035-1564568
View details for PubMedID 27433426
View details for PubMedCentralID PMC4947403
- Blueprint for a Successful Resident Quality and Safety Council. Journal of graduate medical education 2016; 8 (3): 328-31
Outcomes of Two Different Techniques Using the Lateral Approach for Lumbar Interbody Arthrodesis.
Global spine journal
2015; 5 (4): 308-314
Study Design Retrospective cohort study. Objective To determine the short-term outcomes of two different lateral approaches to the lumbar spine. Methods This was a retrospective review performed with four fellowship-trained spine surgeons from a single institution. Two different approach techniques were identified. (1) Traditional transpsoas (TP) approach: dissection was performed through the psoas performed using neuromonitored sequential dilation. (2) Direct visualization (DV) approach: retractors are placed superficial to the psoas followed by directly visualized dissection through psoas. Outcome measures included radiographic fusion and adverse event (AE) rate. Results In all, 120 patients were identified, 79 women and 41 men. Average age was 64.2 years (22 to 86). When looking at all medical and surgical AEs, 31 patients (25.8%) had one or more AEs; 22 patients (18.3%) had a total of 24 neurologically related AEs; 15 patients (12.5%) had anterior/lateral thigh dysesthesias; 6 patients (5.0%) had radiculopathic pain; and 3 patients (2.5%) had postoperative weakness. Specifically, for neurologic AEs, the DV group had a rate of 28.0% and the TP group had a rate of 14.2% (p < 0.18). When looking at the rate of neurologic AEs in patients undergoing single-level fusions only, the DV group rate was 28.6% versus 10.2% for the TP group (p < 0.03). Conclusion Overall, 18.3% of patients sustained a postoperative neurologic AE following lateral interbody fusions. The TP approach had a statistically lower rate of neurologic-specific AE for single-level fusions.
View details for DOI 10.1055/s-0035-1546816
View details for PubMedID 26225280
View details for PubMedCentralID PMC4516734