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Inappropriate cardiac monitoring leads to increased hospital resource utilization and alarm fatigue, which is ultimately detrimental to patient safety. Our institution implemented a continuous cardiac monitoring (CCM) policy that focused on selective monitoring for patients based on the American Heart Association (AHA) guidelines. The primary goal of this study was to perform a three-year median follow-up review on the longitudinal impact of a selective CCM policy on usage rates, length of stay (LOS), and mortality rates across the medical center. A secondary goal was to determine the effect of smaller-scale interventions focused on reeducating the nursing population on the importance of cardiac alarms.

A system-wide policy was developed at The Ohio State University in December 2013 based on guidelines for selective CCM in all patient populations. Patients were stratified into Critical Class I, II, and III with 72 hours, 48 hours, or 36 hours of CCM, respectively. Pre- and post-implementation measures included average cardiac monitoring days (CMD), emergency department (ED) boarding rate, mortality rates, and LOS. A 12-week evaluation period was analyzed prior to, directly after, and three years after implementation.

There was an overall decrease of 53.5% CMDs directly after implementation of selective CCM. This had remained stable at the three-year follow-up with slight increase of 0.5% (p = 0.2764). Subsequent analysis by hospital type revealed that the largest and most stable reductions in CMD were in noncardiac hospitals. The cardiac hospital CMD reduction was stable for roughly one year, then dipped into a lower stable level for nine months, then returned to the previous post-implementation levels. This change coincided with a smaller intervention to further reduce CMD in the cardiac hospital. There was no significant change in mortality rates with a slight decrease of 3.1% at follow-up (p = 0.781). Furthermore, there was no significant difference in LOS with a slight increase of 1.1% on follow-up (p = 0.649). However, there was a significant increase in ED boarding rate of 7.7% (p < 0.001) likely due to other hospital factors altering boarding times.

Implementing selective CCM decreases average cardiac monitoring rate without affecting LOS or overall mortality rate. Selective cardiac monitoring is also a sustainable way to decrease overall hospital resource utilization and more appropriately focus on patient care.

Palliative care concentrates on reducing the severity of disease symptoms, rather than providing a cure. The goal is to prevent and relieve suffering and to improve the quality of life for people facing serious, complex illness. It is therefore critical in the palliative environment that caregivers are able to make recommendations to patients and families based on reasonable assessments of amount of suffering and quality of life. This research uses statistical methods of evaluation and prediction as well as simulation to create a multiple criteria model of survival rates, survival likelihoods, and quality of life assessments. The results have been reviewed by caregivers and are seen to provide a solid analytical base for patient recommendations.

Although adverse events are less studied in the prehospital setting, the evidence is beginning to paint an alarming picture. Consequently, improvements in Emergency Medical Services (EMS) demand a paradigm shift regarding the way care is conceptualized. The chapter aims to (1) support the dialogue on near-misses and adverse events as a learning opportunity and (2) to provide insights on applications of multiteam systems (MTSs).

To offer discussion on near-misses and adverse events and knowledge on how MTSs are applicable to emergency medical care, we review and dissect a complex patient case.

Throughout this case discussion, we uncover seven pertinent issues specific to this particular MTS: (1) misunderstanding with number of patients and their locations, (2a) lack of context to build a mental model, (2b) no time or resources to think, (3) expertise-facilitated diagnosis, (4) lack of communication contributing to a medication error, (5) treatment plan selection, (6) extended time on scene, and (7) organizational culture impacting treatment plan decisions.

By dissecting a patient case within the prehospital setting, we can highlight the value in engaging in dialogue regarding near-misses and adverse events. Further, we can demonstrate the need to expand the focus from simply teams to MTSs.

Purpose – Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000–2010 to ascertain whether they have become more centralized or decentralized.

Design/Methodology/Approach – We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different “clusters” defined by the American Hospital Association.

Findings – There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital.

Research Limitations – Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization.

Research Implications – Systems that appear to be able to centrally coordinate their services are those that operate in local or regional markets. Larger systems that span several states are likely to decentralize or fragment.

Practical Implications – System fragmentation may thwart policy aims pursued in health care reform. The potential of Accountable Care Organizations rests on their ability to coordinate multiple providers via centralized governance. Hospitals systems are likely to be central players in many ACOs, but may lack the necessary coherence to effectively play this governance role.

Originality/Value – Not all hospital systems act in a systemic manner. Those systems that are centralized (and presumably capable of acting in concerted fashion) are in the minority and have declined in prevalence over most of the past decade.

This paper examines how cultural holes that exist at the intersection of institutional fields influence the exploitation of entrepreneurial opportunities. Through an exploration of physician-founded ambulatory surgery centers in the United States, we examine how the presence of cultural holes presented doctors with alternative beliefs, values, and practices to overcome the cultural constraints around entrepreneurship within the medical profession. In doing so, this study extends cultural entrepreneurship research by bringing cultural holes to the forefront, empirically showing how they facilitate entrepreneurial action and proposing other contexts where cultural holes may affect entrepreneurial actions and outcomes.

Purpose – Policymakers hope that comparative effectiveness research will identify examples of widely used therapies that are no better than less expensive alternatives and, consequently, reduce health care spending. Comparative effectiveness research is unlikely to reduce spending if physicians are quick to adopt effective treatments but slow to abandon ineffective ones.

Methodology/approach – We present a theoretical model that shows how physicians will adopt new treatments in response to positive evidence more readily than they abandon existing treatments in response to negative evidence if the marginal costs of production decline post-adoption. We report trends in the use of two common procedures, percutaneous coronary intervention (PCI) for patients with stable angina and routine episiotomy in vaginal childbirth, where comparative effectiveness research studies have failed to find evidence of a benefit.

Findings – Use of PCI and episiotomy have declined over time but are still excessive based on the standards implied by comparative effectiveness research.

Practical implications (if applicable) – The findings suggest that comparative effectiveness research has the potential to reduce costs but additional efforts are necessary to fully realize savings from abandonment.

Originality/value of chapter – There is a large literature on technological adoption in health care, but few studies address technological abandonment. Understanding abandonment is important for efforts to decrease health care costs by reducing use of ineffective but costly treatments.

In this paper, I review the concept of “institutional voids” that provides a way to understand the structure of emerging markets. These voids impede would-be buyers from getting together with would-be sellers, and hence compromise the functioning of markets. Entrepreneurs must respond to these voids. Their endeavors, however, are also the means through which the voids are progressively removed. I review my work on the contours of such entrepreneurship in many emerging markets, with the greatest research emphasis on China and India. I conclude with a focus on attempts to circumvent a particularly insidious class of institutional voids, those that prevent the marginalized two-thirds of the world’s population from participating in the economic mainstream. Cumulatively, my work calls for our profession to think more creatively and eclectically about our research and teaching in a way that displays greater contextual intelligence toward ubiquitous and socially costly voids.

In a pandemic framework (COVID-19), this chapter explores the impact of the global economy and socio-cultures concerning three axes: recreational, tourism, and hospitality. Although we slowly see an economic revival, it is well known that this sector of study is very susceptible to being affected by the context of nations. Following restrictions and measures taken by governments around the world to reduce the number of cases of coronavirus infections, many nations closed their borders, affecting international travel and by 2020 tourism had been reduced to the near cessation of operations due to the imminent fear of this poorly studied disease, and the service sector was negatively affected. It should be added that, according to the World Tourism Organization's projections, a decrease of between 20 and 30% is forecast for 2020 compared to the previous year.