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INTRODUCTION: Triage is critical to mitigating the effect of increased volume by determining patient acuity, need for resources, and establishing acuity-based patient prioritization. The purpose of this retrospective study was to determine whether historical EHR data can be used with clinical natural language processing and machine learning algorithms (KATE) to produce accurate ESI predictive models. METHODS: The KATE triage model was developed using 166,175 patient encounters from two participating hospitals. The model was tested against a random sample of encounters that were correctly assigned an acuity by study clinicians using the Emergency Severity Index (ESI) standard as a guide. RESULTS: At the study sites, KATE predicted accurate ESI acuity assignments 75.7% of the time compared with nurses (59.8%) and the average of individual study clinicians (75.3%). KATE's accuracy was 26.9% higher than the average nurse accuracy (P <.001). On the boundary between ESI 2 and ESI 3 acuity assignments, which relates to the risk of decompensation, KATE's accuracy was 93.2% higher, with 80% accuracy compared with triage nurses 41.4% accuracy (P <.001). DISCUSSION: KATE provides a triage acuity assignment more accurate than the triage nurses in this study sample. KATE operates independently of contextual factors, unaffected by the external pressures that can cause under triage and may mitigate biases that can negatively affect triage accuracy. Future research should focus on the impact of KATE providing feedback to triage nurses in real time, on mortality and morbidity, ED throughput, resource optimization, and nursing outcomes.
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Servicio de Urgencia en Hospital , Aprendizaje Automático , Procesamiento de Lenguaje Natural , Gravedad del Paciente , Mejoramiento de la Calidad , Triaje , Adolescente , Adulto , Anciano , Niño , Registros Electrónicos de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Estados UnidosRESUMEN
PURPOSE: To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. METHODS: This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017-2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. RESULTS: 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%-42.6%) for XR, 19.1% (IQR 11.4%-24.9%) for CT, and 0.09% (IQR 0%-0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%-61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%-81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: -12.7%, -4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: -7.3%, -1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: -5.9%, -0;5%), CT (20.1% vs 17.7%; 95% CI: -5.1%, -0.4%) or MRI (0.8% vs 0.7%, 95% CI: -0.4%, -0.3%). CONCLUSIONS: Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.
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Benchmarking , Diagnóstico por Imagen/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Mejoramiento de la Calidad/organización & administración , Procedimientos Innecesarios/estadística & datos numéricos , Conducta de Elección , Traumatismos Craneocerebrales/diagnóstico por imagen , Bases de Datos Factuales , Humanos , Dolor de la Región Lumbar/diagnóstico por imagen , Pautas de la Práctica en Medicina/estadística & datos numéricos , Síncope/diagnóstico por imagen , Estados Unidos , Procedimientos Innecesarios/economíaRESUMEN
STUDY OBJECTIVE: We examine the effect of the Medicaid expansion in 2014 under in the Patient Protection and Affordable Care Act on emergency department (ED) utilization and ED admission rates (fraction of ED visits that lead to hospital admission) during the first 3 postexpansion years (2014 to 2016). METHODS: We compared ED utilization and ED admission rates in 151 EDs in 14 expansion states with those in 376 EDs in 14 nonexpansion states, using difference-in-differences methods with data from 3 national emergency medicine groups from 2013 to 2016. RESULTS: In expansion states, the volume of Medicaid-paid ED visits increased 49% (95% confidence interval 34% to 65%), and the volume of uninsured visits decreased 44% (95% confidence interval -52% to -34%) relative to that of nonexpansion states. Both effects on payer mix leveled off during 2015. There was no significant relative change in overall ED utilization or overall ED admission rates in expansion versus nonexpansion states during the study. However, relative ED admission rates for uninsured patients declined 8% (95% confidence interval -18% to -2%) in expansion states. CONCLUSION: Large changes in payer mix in expansion versus nonexpansion states were observed but leveled off during 2015, with more Medicaid-paid visits and fewer uninsured visits in expansion states. Despite these large changes, during this 3-year period, there was no evidence that expansion affected either overall ED visit volume or ED admission rates. The relative decline in ED admission rates in expansion states among the uninsured may reflect a selection effect in which, among newly Medicaid-eligible persons, sicker persons were more likely to enroll than healthier ones.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Humanos , Medicaid/legislación & jurisprudencia , Patient Protection and Affordable Care Act , Estados UnidosRESUMEN
PURPOSE: Renal colic is common and CT (computerized tomography) is frequently utilized when the diagnosis of kidney stone is suspected. CT is accurate, but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. MATERIALS AND METHODS: In conjunction with the ACEP (American College of Emergency Physicians®) E-QUAL (Emergency Quality Network) we formed a nine-member panel with three physician representatives each from the ACEP, the ACR® (American College of Radiology) and the AUA (American Urological Association). A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%) and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%) with ultrasound in 9 (31%) and no further imaging needed in 13 (45%). CONCLUSIONS: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.
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Consenso , Cólico Renal/diagnóstico por imagen , Sociedades Médicas/normas , Tomografía Computarizada por Rayos X/normas , Ultrasonografía/normas , Técnica Delphi , Medicina de Emergencia/normas , Humanos , Comunicación Interdisciplinaria , Radiología/normas , Tomografía Computarizada por Rayos X/efectos adversos , Estados Unidos , Urología/normasRESUMEN
STUDY OBJECTIVE: Renal colic is common and computed tomography (CT) is frequently used when the diagnosis of kidney stone is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multiorganizational transdisciplinary collaboration seeks evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. METHODS: In conjunction with the American College of Emergency Physicians (ACEP) Emergency Quality Network, we formed a 9-member panel with 3 physician representatives each from ACEP, the American College of Radiology, and the American Urology Association. A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, out of the 29 scenarios agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%). There were no scenarios in which at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasonography in 9 (31%) and no further imaging needed in 12 (45%). CONCLUSION: Evidence and multispecialty consensus support ultrasonography or no further imaging in specific clinical scenarios, with reduced-radiation-dose CT to be used when CT is needed for patients with suspected renal colic.
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Cólico Renal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Ultrasonografía , Adulto , Anciano , Consenso , Técnica Delphi , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistemas de Atención de Punto , Tomografía Computarizada por Rayos X/efectos adversosRESUMEN
BACKGROUND: Renal colic is common, and CT is frequently utilized when the diagnosis of kidney stones is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. METHODS: In conjunction with the American College of Emergency Physicians (ACEP) eQual network, we formed a nine-member panel with three physician representatives each from ACEP, the ACR, and the American Urology Association. A systematic literature review was used as the basis for a three-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasound in 9 (31%) and no further imaging needed in 12 (45%). SUMMARY: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.
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Cólico Renal/diagnóstico por imagen , Técnica Delphi , Humanos , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
The unprecedented surge in physician assistants (PAs) and NPs in the ED developed quickly in recent years, but scope of practice and practice patterns are not well described. METHODS: We conducted two cross-sectional electronic surveys of the American College of Emergency Physicians' council. Survey construction was informed by interviews and evaluated with validity and reliability studies. Univariate analyses to establish associations also were performed. RESULTS: Most councilors' departments employ PAs and NPs (72.4% of 163 responses). Supervisory requirements varied greatly among respondents for the same emergency severity index (ESI) level. Regardless of experience level, NPs were reported to use significantly more resources than PAs; chi-square(4) = 105.292, P < .001 for less-experienced PAs or NPs; chi-square(4) = 120.415, P < .001 for more experienced PAs or NPs. CONCLUSION: Councilors reported great variation in PA and NP scope of practice. The results also suggest that new graduate PAs may be more clinically prepared to practice in the ED than new graduate NPs.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Enfermeras Practicantes/provisión & distribución , Asistentes Médicos/provisión & distribución , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermeras Practicantes/educación , Asistentes Médicos/educación , Encuestas y CuestionariosRESUMEN
OBJECTIVE: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus. METHODS: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes. RESULTS: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs. CONCLUSIONS: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.
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Comunicación , Comprensión , Consenso , Cuidados Críticos , Voluntad en Vida , Médicos , Órdenes de Resucitación , Adulto , Enfermedad Crítica , Medicina de Emergencia , Medicina Familiar y Comunitaria , Femenino , Humanos , Medicina Interna , Masculino , Persona de Mediana Edad , Seguridad , Encuestas y Cuestionarios , Grabación en VideoRESUMEN
In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1 percent, decreased uninsured visits by 31.4 percent, and decreased privately insured visits by 6.7 percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3 percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Reembolso de Seguro de Salud/tendencias , Medicaid/economía , Patient Protection and Affordable Care Act/economía , Bases de Datos Factuales , Servicio de Urgencia en Hospital/economía , Femenino , Reforma de la Atención de Salud/economía , Humanos , Cobertura del Seguro/economía , Cobertura del Seguro/estadística & datos numéricos , Reembolso de Seguro de Salud/economía , Masculino , Medicaid/estadística & datos numéricos , Patient Protection and Affordable Care Act/organización & administración , Análisis de Regresión , Estudios Retrospectivos , Estados UnidosRESUMEN
NPs and PAs are increasingly common in US and Canadian EDs. Emergency medicine is a unique specialty with a vast knowledge base performed in a high-risk environment; therefore, supervisory models and regulatory requirements developed for lower-risk settings (e.g., primary care) and more circumscribed practices (e.g., diabetes clinic) are unlikely to be sufficient for EDs. As innovative ED staffing models evolve, specific roles and scopes of practice for midlevel providers should be based on an objective analysis of existing care gaps and system needs, local provider availability, operational efficiency, cost-effectiveness, regulatory compliance, risk management, and quality of care. Although it is tempting to reduce cost by using PAs or NPs, de-emphasis of emergency physician involvement should proceed cautiously to avoid negatively impacting patient care. Variability in midlevel provider use and the relative paucity of evidence describing optimal provider roles, scopes of practice, and care outcomes in different patient populations highlight the need for a measured approach, appropriate supervisory models, effective quality assurance programs, and cost-effectiveness analyses looking at both clinical and economic outcomes of this important health system evolution.
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Servicio de Urgencia en Hospital , Modelos Organizacionales , Enfermeras Practicantes/provisión & distribución , Admisión y Programación de Personal , Asistentes Médicos/provisión & distribución , Canadá , Servicio de Urgencia en Hospital/legislación & jurisprudencia , Servicio de Urgencia en Hospital/normas , Humanos , Enfermeras Practicantes/legislación & jurisprudencia , Enfermeras Practicantes/normas , Innovación Organizacional , Asistentes Médicos/legislación & jurisprudencia , Asistentes Médicos/normas , Estados Unidos , Recursos HumanosAsunto(s)
Servicio de Urgencia en Hospital/organización & administración , Seguridad del Paciente/normas , Evaluación de Procesos, Atención de Salud/normas , Administración de la Seguridad/organización & administración , Servicio de Urgencia en Hospital/normas , Humanos , Modelos Organizacionales , Evaluación de Procesos, Atención de Salud/métodos , Medición de Riesgo/métodos , Administración de la Seguridad/métodos , Estados Unidos , Organización Mundial de la SaludRESUMEN
STUDY OBJECTIVE: Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging efficiency measure (Outpatient Measure 15 [OP-15]) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15. METHODS: This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measure's validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Association's Physician Consortium for Performance Improvement. RESULTS: On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval [CI] 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measure's validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measure's accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication (r=-0.11; P=.63). CONCLUSION: The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.
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Servicio de Urgencia en Hospital/normas , Cefalea/diagnóstico por imagen , Medicare/normas , Anciano , Encéfalo/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neuroimagen/normas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/normas , Estados UnidosRESUMEN
With a persistent trend of increasing emergency department (ED) volumes every year, services are intensifying. Thus, improving the timeliness of delivering emergency care should be a primary focus, both from an operational and from a research perspective. Much has been published on factors associated with delays in emergency care, and the next phase in this area of research will focus on exploring interventions to improve the timeliness of care. On June 1, 2011, Academic Emergency Medicine held a consensus conference titled "Interventions to Assure Quality in the Emergency Department." This article summarizes the findings of the breakout session that investigated interventions to improve the timeliness of emergency care. This article will explore the background on the concept of timeliness of emergency care, the current state of interventions that have been implemented to improve timeliness, and specific questions as a framework for a future research agenda.
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Medicina de Emergencia/organización & administración , Servicio de Urgencia en Hospital/organización & administración , Mejoramiento de la Calidad/organización & administración , Administración del Tiempo , Triaje , Aglomeración , Difusión de Innovaciones , Femenino , Humanos , Masculino , Grupo de Atención al Paciente/organización & administración , Garantía de la Calidad de Atención de Salud , Estados Unidos , Flujo de TrabajoRESUMEN
BACKGROUND: Time-outs, as one of the elements of the Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery has been in effect since July 1, 2004. Time-outs are required by The Joint Commission for all hospital procedures regardless of location, including emergency departments (EDs). Attitudes about ED time-outs were assessed for a sample of senior emergency physicians serving in leadership roles for a national professional society. METHODS: A survey questionnaire was administered to members of the American College of Emergency Physicians (ACEP) Council at the October 2009 ACEP Council meeting on the use of time-outs in the ED. A total of 225 (72%) of the 331 councilors present filled out the survey. RESULTS: Twenty-nine (13%) of respondents were unaware of a formal time-out policy in their ED, 79 (35%) reported that ED time-outs were warranted, and 5 (2%) reported they knew of an instance where a time-out may have prevented an error. Chest tubes (167 respondents [74%]) and the use of sedation (142 respondents [63%]) were most commonly identified as ED procedures that necessitated a time-out. Episodes of any wrong-site error in their EDs were reported by 16 (7%) of the respondents. Wrong patient (9 respondents [4%]) and wrong procedure (2 respondents [1%]) errors were less common. CONCLUSIONS: Although the time-out requirement has been in effect since 2004, more than 1 in 10 of ED physicians in this sample ofED physician leaders were unaware of it. According to the respondents, medical errors preventable by time-outs were rare; however, time-outs may be useful for certain procedures, particularly when there is a risk of wrong-site, wrong-patient, or wrong-procedure medical errors.
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Medicina de Emergencia/normas , Servicio de Urgencia en Hospital/normas , Errores Médicos/prevención & control , Administración de la Seguridad/normas , Protocolos Clínicos/normas , Medicina de Emergencia/métodos , Servicio de Urgencia en Hospital/organización & administración , Encuestas de Atención de la Salud , Humanos , Administración de la Seguridad/métodosRESUMEN
Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.