Can Asking Emergency Physicians Whether or Not They Would Have Done Something Differently (WYHDSD) be a Useful Screening Tool to Identify Emergency Department Error?

BACKGROUND: Error in emergency medicine remains common and difficult to identify. OBJECTIVE: To evaluate if questioning emergency physician reviewers as to whether or not they would have done something differently (Would you have done something differently? [WYHDSD]) can be a useful marker to identify error. METHODS: Prospective data were collected on all patients presenting to an academic emergency department (ED) between 2017 and 2021. All cases who met the following criteria were identified: 1) returned to ED within 72 h and admitted; 2) transferred to intensive care unit from floor within 24 h of admission; 3) expired within 24 h of arrival; or 4) patient or provider complaint. Cases were randomly assigned to emergency physicians and reviewed using an electronic tool to assess for error and adverse events. Reviewers were then mandated to answer WYHDSD in the management of the case. RESULTS: During the study period, 6672 cases were reviewed. Of the 5857 cases where reviewers would not have done something differently, 5847 cases were found to have no error. The question WYHDSD had a sensitivity of 97.4% in predicting error and a negative predictive value of 99.8%. CONCLUSION: There was a significantly higher rate of near misses, adverse events, and errors attributable to an adverse event in cases where the reviewer would have done something differently (WHDSD) compared with cases where they would not. Therefore, asking reviewers if they WHDSD could potentially be used as a marker to identify error and improve patient care in the ED.

Preference for opioids in emergency department patients with acute musculoskeletal pain.

BACKGROUND: Public awareness of the opioid epidemic is increasing nationally, emphasizing the need to develop methods to reduce opioid use. We determined patient preference for analgesics before and after a brief educational intervention informing them of the risks and benefits of opioids versus non-steroidal anti-inflammatory drugs (NSAID's). We hypothesized 50% of patients would prefer opioids pre-intervention and that this would be reduced by the intervention by at least 15%. METHODS: Study Design-Before and after study. Setting-Suburban ED with annual census of 110,000. Patients-English-speaking adult ED patients with acute musculoskeletal pain. Interventions-An anonymous survey was administered by an investigator not involved in the patient's clinical care prior to physician evaluation, before and after a video describing the risks and benefits of opioids versus NSAID's. Patients were asked if they desired analgesics. Data Analysis-Descriptive statistics were used to summarize the data. Univariate analysis and logistic regression were used to predict patient demographics and pain characteristics associated with desire for analgesics. RESULTS: Of all 94 patients, 48 (51% [95% CI 41-62%]) desired an analgesic pre-intervention. Of these 48 patients, 10 (11% [5-19%]) specifically preferred an opioid. Of the 10 patients who preferred an opioid pre-intervention, one had no preference for analgesic post-intervention. CONCLUSIONS: Many adult ED patients with acute musculoskeletal pain do not desire any analgesics and few specifically prefer opioids. This knowledge can prove helpful to ED physicians across the country in discussing pain management options with patients as we attempt to combat the opioid epidemic.

Does initiating care in alternate care sites decrease time to disposition in the emergency department?

Objectives: During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition. Methods: Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time. Results: The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p < 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p = 0.09). Conclusions: Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.

Comparison of nurse and resident physician paging frequency by sex in the emergency department.

Objectives: The role of biological sex in interprofessional relationships is an important factor in collaborative health care settings such as the emergency department (ED) but one that has been sparsely studied. While there is anecdotal evidence on gender-based differences in communication, little research has focused on this topic. The goal of this study was to determine whether there are differences in paging frequency between nurses and male and female residents. Methods: We conducted a retrospective review of patient visits to our urban, tertiary care academic ED between January 1 and April 1, 2021. Only pages from nurses to emergency medicine (EM) residents were included. Outcome variables included number of pages received by sex, number of unique ED visits, and mean number of pages per unique visit. Pearson's chi-square tests were used to analyze differences between observed and expected results. Results: A total of 15,617 pages from nurses to residents over 6843 unique patient visits to the ED were analyzed. This included 187 nurses, 162 (87%) of whom were female and 25 (13%) were male. Of the 39 residents, 12 (31%) were female and 27 (69%) were male. Female residents received 4500 pages over 2228 unique patient ED visits, or a mean of two pages per patient with a mean of 186 unique ED visits per female resident. Male residents received 11,117 pages over 4615 unique patient ED visits, or a mean of 2.4 pages per patient, with a mean of 171 unique ED visits per male resident. This difference in pages per patient was statistically significant (χ2(1) = 369, p < 0.001). Conclusions: We found that male residents received significantly more pages per patient than their female colleagues. Overall, further research is required to understand the factors, such as characteristics of patients or preferred communication methods of providers, that drive this disparity and what the implications are for patient outcomes.

Does the number of pages received per hour affect resident productivity?

Background: Workflow interruptions are common for emergency physicians and are shown to have downstream consequences such as patient dissatisfaction, delay in clinical response, and increase in medical error. However, the impact of passive interruptions on physician productivity is unclear and has not been well studied. We sought to evaluate if the number of pages received per hour significantly affects the number of patients seen per hour. Methods: Retrospective data was collected on resident physician (RP) emergency department shifts from July 1st, 2021 to June 30th, 2022 at an academic medical center with an annual census of 55,000 patients. A total of 2865 RP shifts were collected among the 26 postgraduate year (PGY) 1 and PGY2 residents. For each RP shift, we identified the number of pages received per hour and the number of new patients seen per hour. Pages consist of any transmitted message that was sent to the RP's personal pager, which includes both automatic (eg, bed assignments, abnormal lab values) and personalized pages from other healthcare practicioners (eg, nursing, consultants). Data were analyzed using Poisson regression controlling for clustering at the physician level to determine if the number of patients seen per hour is significantly affected by the number of pages (divided into quartiles) received. Results: We found the number of pages received per hour did not decrease the number of patients seen per hour. Contrary to our hypothesis, there was a strong positive relationship between the number of pages received per hour and the number of patients seen by RPs in that hour and subsequent hours. During the middle of a shift (hours 3, 4, and 5), RPs receiving pages in the third and fourth quartile (top 50% of pages) saw significantly more patients during that same hour and the next hour (p <0.001). Conclusion: The number of pages received by RPs per hour did not decrease the number of patients seen per hour. When RPs receive a higher number of pages, there is a positive association with the number of patients they see in that hour and subsequent hours. Further studies will be needed to determine whether the content of pages affects resident productivity.