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Importance Cyberattacks on health care delivery organizations are increasing in frequency and sophistication. Ransomware infections have been associated with significant operational disruption, but data describing regional associations of these cyberattacks with neighboring hospitals have not been previously reported, to our knowledge. Objective To examine an institution’s emergency department (ED) patient volume and stroke care metrics during a month-long ransomware attack on a geographically proximal but separate health care delivery organization. Design, Setting, and Participants This before and after cohort study compares adult and pediatric patient volume and stroke care metrics of 2 US urban academic EDs in the 4 weeks prior to the ransomware attack on May 1, 2021 (April 3-30, 2021), as well as during the attack and recovery (May 1-28, 2021) and 4 weeks after the attack and recovery (May 29 to June 25, 2021). The 2 EDs had a combined mean annual census of more than 70 000 care encounters and 11% of San Diego County’s total acute inpatient discharges. The health care delivery organization targeted by the ransomware constitutes approximately 25% of the regional inpatient discharges. Exposure A month-long ransomware cyberattack on 4 adjacent hospitals. Main Outcomes and Measures Emergency department encounter volumes (census), temporal throughput, regional diversion of emergency medical services (EMS), and stroke care metrics. Results This study evaluated 19 857 ED visits at the unaffected ED: 6114 (mean [SD] age, 49.6 [19.3] years; 2931 [47.9%] female patients; 1663 [27.2%] Hispanic, 677 [11.1%] non-Hispanic Black, and 2678 [43.8%] non-Hispanic White patients) in the preattack phase, 7039 (mean [SD] age, 49.8 [19.5] years; 3377 [48.0%] female patients; 1840 [26.1%] Hispanic, 778 [11.1%] non-Hispanic Black, and 3168 [45.0%] non-Hispanic White patients) in the attack and recovery phase, and 6704 (mean [SD] age, 48.8 [19.6] years; 3326 [49.5%] female patients; 1753 [26.1%] Hispanic, 725 [10.8%] non-Hispanic Black, and 3012 [44.9%] non-Hispanic White patients) in the postattack phase. Compared with the preattack phase, during the attack phase, there were significant associated increases in the daily mean (SD) ED census (218.4 [18.9] vs 251.4 [35.2];P < .001), EMS arrivals (1741 [28.8] vs 2354 [33.7];P < .001), admissions (1614 [26.4] vs 1722 [24.5];P = .01), patients leaving without being seen (158 [2.6] vs 360 [5.1];P < .001), and patients leaving against medical advice (107 [1.8] vs 161 [2.3];P = .03). There were also significant associated increases during the attack phase compared with the preattack phase in median waiting room times (21 minutes [IQR, 7-62 minutes] vs 31 minutes [IQR, 9-89 minutes];P < .001) and total ED length of stay for admitted patients (614 minutes [IQR, 424-1093 minutes] vs 822 minutes [IQR, 497-1524 minutes];P < .001). There was also a significant increase in stroke code activations during the attack phase compared with the preattack phase (59 vs 102;P = .01) as well as confirmed strokes (22 vs 47;P = .02). Conclusions and Relevance This study found that hospitals adjacent to health care delivery organizations affected by ransomware attacks may see increases in patient census and may experience resource constraints affecting time-sensitive care for conditions such as acute stroke. These findings suggest that targeted hospital cyberattacks may be associated with disruptions of health care delivery at nontargeted hospitals within a community and should be considered a regional disaster.

Background and objectivesTurnover time (TOT), defined as the time between surgical cases in the same operating room (OR), is often perceived to be lengthy without clear cause. With the aim of optimising and standardising OR turnover processes and decreasing TOT, we developed an innovative and staff-interactive TOT measurement method.MethodsWe divided TOT into task-based segments and created buttons on the electronic health record (EHR) default prelogin screen for appropriate staff workflows to collect more granular data. We created submeasures, including ‘clean-up start’, ‘clean-up complete’, ‘set-up start’ and ‘room ready for patient’, to calculate environmental services (EVS) response time, EVS cleaning time, room set-up response time, room set-up time and time to room accordingly.ResultsSince developing and implementing these workflows, measures have demonstrated excellent staff adoption. Median times of EVS response and cleaning have decreased significantly at our main hospital ORs and ambulatory surgery centre.ConclusionOR delays are costly to hospital systems. TOT, in particular, has been recognised as a potential dissatisfier and cause of delay in the perioperative environment. Viewing TOT as one finite entity and not a series of necessary tasks by a variety of team members limits the possibility of critical assessment and improvement. By dividing the measurement of TOT into respective segments necessary to transition the room at the completion of one case to the onset of another, valuable insight was gained into the causes associated with turnover delays, which increased awareness and improved accountability of staff members to complete assigned tasks efficiently.

During 2016-2018, San Diego County, California, USA, experienced one of the largest hepatitis A outbreaks in the United States in 2 decades. In close partnership with local healthcare systems, San Diego County Public Health led a public health response to the outbreak that focused on a 3-pronged strategy to vaccinate, sanitize, and educate. Healthcare systems administered nearly half of the vaccinations delivered in San Diego County. At University of California San Diego Health, the use of informatics tools assisted with the identification of at-risk populations and with vaccine delivery across outpatient and inpatient settings. In addition, acute care facilities helped prevent further disease transmission by delaying the discharge of patients with hepatitis A who were experiencing homelessness. We assessed the public health roles that acute care hospitals can play during a large community outbreak and the critical nature of ongoing collaboration between hospitals and public health systems in controlling such outbreaks.

We applied the event-related brain potential (ERP) technique to investigate the involvement of two neuromodulatory systems in learning and decision making: The locus coeruleus-norepinephrine system (NE system) and the mesencephalic dopamine system (DA system). We have previously presented evidence that the N2, a negative deflection in the ERP elicited by task-relevant events that begins approximately 200 ms after onset of the eliciting stimulus and that is sensitive to low-probability events, is a manifestation of cortex-wide noradrenergic modulation recruited to facilitate the processing of unexpected stimuli. Further, we hold that the impact of DA reinforcement learning signals on the anterior cingulate cortex (ACC) produces a component of the ERP called the feedback-related negativity (FRN). The N2 and the FRN share a similar time range, a similar topography, and similar antecedent conditions. We varied factors related to the degree of cognitive deliberation across a series of experiments to dissociate these two ERP components. Across four experiments we varied the demand for a deliberative strategy, from passively watching feedback, to more complex/challenging decision tasks. Consistent with our predictions, the FRN was largest in the experiment involving active learning and smallest in the experiment involving passive learning whereas the N2 exhibited the opposite effect. Within each experiment, when subjects attended to color, the N2 was maximal at frontal-central sites, and when they attended to gender it was maximal over lateral-occipital areas, whereas the topology of the FRN was frontal-central in both task conditions. We conclude that both the DA system and the NE system act in concert when learning from rewards that vary in expectedness, but that the DA system is relatively more exercised when subjects are relatively more engaged by the learning task.

With the emergence of the COVID-19 pandemic and shortage of adequate personal protective equipment (PPE), hospitals implemented inpatient telemedicine measures to ensure operational readiness and a safe working environment for clinicians. The utility and sustainability of inpatient telemedicine initiatives need to be evaluated as the number of COVID-19 inpatients is expected to continue declining. In this viewpoint, we describe the use of a rapidly deployed inpatient telemedicine workflow at a large academic medical center and discuss the potential impact on PPE savings. In early 2020, videoconferencing software was installed on patient bedside iPads at two academic medical center teaching hospitals. An internal website allowed providers to initiate video calls with patients in any patient room with an activated iPad, including both COVID-19 and non–COVID-19 patients. Patients were encouraged to use telemedicine technology to connect with loved ones via native apps or videoconferencing software. We evaluated the use of telemedicine technology on patients’ bedside iPads by monitoring traffic to the internal website. Between May 2020 and March 2021, there were a total of 1240 active users of the Video Visits website (mean 112.7, SD 49.0 connection events per month). Of these, 133 (10.7%) connections were made. Patients initiated 63 (47.4%) video calls with family or friends and sent 37 (27.8%) emails with videoconference connection instructions. Providers initiated a total of 33 (24.8%) video calls with the majority of calls initiated in August (n=22, 67%). There was a low level of adoption of inpatient telemedicine capability by providers and patients. With sufficient availability of PPE, inpatient providers did not find a frequent need to use the bedside telemedicine technology, despite a high census of patients with COVID-19. Compared to providers, patients used videoconferencing capabilities more frequently in September and October 2020. We did not find savings of PPE associated with the use of inpatient telemedicine.

Patient portals tethered to electronic health records can improve patient experience, activation, and outcomes. However, adoption of inpatient portals has been challenging. One way to potentially increase inpatient portal usage is to integrate it with a room control (RC) app on a common tablet computer. The aim of this study was to perform a retrospective analysis of patient usage of an RC app provided on tablet computers in patient rooms of our new inpatient tower. We identified all patients who were admitted for >24 hours to our new inpatient tower over a 90-day period from September 1 to November 30, 2017. After excluding newborn patients from our analysis, we then identified patients who used the RC app at least one time during their admission. We linked these data to patient demographics (including age, sex, and race) and admitting service. We then performed univariable and multivariable logistic regression to assess patterns of RC app usage. A total of 3411 patients were admitted over the course of the study period; 2242/3411 (65.73%) used the RC app during their hospitalization. Compared with white patients, other/mixed/unknown race and Asian, Hawaiian, Pacific Islander, American Indian race were significantly associated with increased use of the RC app in a multivariable analysis. Increasing age was significantly associated with increased usage of the RC app. Usage of the RC app also varied by admitting services. Compared with general medicine, bone marrow transplant and general surgery patients had increased usage of the RC app. Conversely, critical care, medical specialties, neurology, surgical subspecialties, and obstetrics/gynecology were all associated with decreased usage of the RC app. Our study shows that one-third of patients are not using the RC app for critical room functions. Future initiatives to increase RC usage should take these populations into consideration. Contrary to common belief, older patients may use tablet-enabled RCs just as often, if not more often, than younger patients. Certain admitting services, such as neurology and surgical subspecialties, may have had lower usage rates owing to accessibility issues. Our study allows hospitals to tailor support for specific patient populations to increase RC app usage.

Patients' journeys across the care continuum can be improved with patient-centered technology integrated into the care process. Misaligned financial incentives, change management challenges, and privacy concerns are some of the hurdles that have prevented health systems from deploying technology that engages patients along the care continuum. Despite these sociotechnical challenges, some health care organizations have developed innovative approaches to engaging patients. We describe promising technology-enabled consumer engagement practices at two community-based delivery organizations and two academic medical centers to demonstrate the approaches, sociotechnical challenges, and outcomes associated with their implementation. Leadership commitment and payer policies that align with the quadruple aim-enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers-would encourage further deployment and lead to greater consumer engagement along the care continuum.

Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

Emergency department (ED) boarding drives overcrowding, worsens outcomes, and strains hospital operations. Accurate short-term forecasts of boarding volumes can enable proactive resource management. In this prospective study, we compared six forecasting approaches across econometric, machine-learning, and foundation-model paradigms to predict ED boarding volumes up to four days ahead (T + 1–T + 4). Using data from two UC San Diego Health EDs (October 2022–October 2024), models incorporated prior boarding volumes, scheduled surgeries, hospital census, and expert-selected covariates. We evaluated vector autoregression (VAR), extreme gradient boosting (XGBoost), and Google TimesFM, including hybrids (VAR+XGBoost; TimesFM+XReg), against a two-week moving-average baseline. During a four-month validation period, the VAR+XGBoost hybrid achieved the lowest root mean square error—reducing forecast error by 16–42% at La Jolla and 5–19% at Hillcrest—while showing only slight gains over VAR (0–3%). VAR alone performed robustly and outperformed baseline at both sites. The VAR model has been deployed within the health system’s Mission Control to guide proactive interventions such as discharge acceleration and surgical rescheduling. These findings underscore the enduring value of econometric models and demonstrate how forecast-driven decision support can enhance emergency care coordination and system responsiveness.

The criminal justice system in the United States has tried to reduce repeat offending through various tactics over the years including reentry/rehabilitation programs in the past 2 two decades. The state of Missouri was one of the first states to participate in this type of transitional model. While the recidivism rate has dropped, it is still one of the highest in the nation. The purpose of this qualitative phenomenological study was to determine if a program called the Missouri Reentry Process (MRP) has been effective at aiding men at (re)integrating and (re)acclimating in society. Social disorganization theory and desistance theory informed this study. The study used a qualitative research method with phenomenological design to learn from the lived experiences of former offenders. Fifteen adult male participants were interviewed and asked a series of 24 questions. After the interview process, the collected data was were analyzed by using coding and developing themes to determine the findings of the study. Based on the findings, it was determined that the MRP has been mostly unsuccessful in its mission and goal. While most many of the participants were able to learn and gain valuable information while taking programs under the umbrella of the MRP; most felt that there was little to no help at (re)integrating into society. These break downs in the prison system and MRP give the biggest opportunity for social change. Making the prison safer and providing more opportunities for learning healthy lifestyles helps develop well-rounded individuals. By building better relationships within the community, former offenders can experience success after release and build better and stronger communities. Ultimately, when the individual becomes healthy they will help change the communities where they reside making them safer and more productive for generations resulting in positive social change.