Hospital Costs and Reimbursement Model for a Geriatric Emergency Department.

OBJECTIVES: The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED. METHODS: Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED. RESULTS: A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328. CONCLUSION: The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.

A Randomized Comparison of In-hospital Rescuer Positions for Endotracheal Intubation in a Difficult Airway.

INTRODUCTION: Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees' performance on ETI delivered from both the seated and standing positions. METHODS: EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests. RESULTS: Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training. CONCLUSION: The position of the in-hospital provider, whether seated or standing, had no effect on the provider's ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.

Airway Management Proficiency Checklist for Assessing Paramedic Performance.

OBJECTIVE: To develop and derive an instrument for assessing airway management proficiency for paramedics. METHODS: Using a validated difficult airway model simulation, we recorded responses to a standard traumatic brain injury scenario requiring airway management in 197 certified paramedics. Discrete items (N = 131) were developed by an expert panel, and referenced to three performance standard subscales (i.e., intubation, ventilation, and backup airway). Responses were scored and subjected to an iterative process to create a more practical number of items for the final Airway Management Proficiency Checklist (AMPC). Tetrachoric correlations were used to evaluate items for relevance. Kuder-Richardson Formula 20 reliabilities were used to assess internal consistency among checklist items. Finally, a Rasch analysis on each subscale was performed to evaluate items for measurement quality. Items were retained if they were determined to fit the Rasch Model. RESULTS: Items were deleted from the final AMPC for lack of simulation fidelity (26 items), duplicity (15 items), and poor psychometric quality (39 items). In four additional iterations, items were dropped for lack of equipment options (e.g., single mask), lack of instructional clarity (e.g., calculation of GCS score), high inference on the part of the evaluator (6 items), or inadequate measurement of behavioral performance (e.g., passes blade through lips without contacting mouth or teeth). Thirty seven items and three outcome standards (first pass success of the endotracheal tube; assisted ventilation with no interruption of 30 seconds or greater; successful placement of a backup airway device within one attempt) were retained to form three hypothesized subscales. CONCLUSIONS: The AMPC represents a psychometrically derived instrument that identified important tasks required for comprehensive airway management. The 37-item instrument will contribute to improving training and measuring the performance of paramedic's airway management skills.

Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation.

UNLABELLED: Introduction Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI. Hypothesis/Problem The availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance. METHODS: The MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis. RESULTS: Nineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts. CONCLUSIONS: The MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers. Bischof JJ , Panchal AR , Finnegan GI , Terndrup TE . Creation and validation of a novel mobile simulation laboratory for high fidelity, prehospital, difficult airway simulation. Prehosp Disaster Med. 2016;31(5):465-470.