Effect of Automated Real-Time Feedback on Early-Sepsis Care: A Pragmatic Clinical Trial.

OBJECTIVES: To determine if a real-time monitoring system with automated clinician alerts improves 3-hour sepsis bundle adherence. DESIGN: Prospective, pragmatic clinical trial. Allocation alternated every 7 days. SETTING: Quaternary hospital from December 1, 2020 to November 30, 2021. PATIENTS: Adult emergency department or inpatients meeting objective sepsis criteria triggered an electronic medical record (EMR)-embedded best practice advisory. Enrollment occurred when clinicians acknowledged the advisory indicating they felt sepsis was likely. INTERVENTION: Real-time automated EMR monitoring identified suspected sepsis patients with incomplete bundle measures within 1-hour of completion deadlines and generated reminder pages. Clinicians responsible for intervention group patients received reminder pages; no pages were sent for controls. The primary analysis cohort was the subset of enrolled patients at risk of bundle nonadherent care that had reminder pages generated. MEASUREMENTS AND MAIN RESULTS: The primary outcome was orders for all 3-hour bundle elements within guideline time limits. Secondary outcomes included guideline-adherent delivery of all 3-hour bundle elements, 28-day mortality, antibiotic discontinuation within 48-hours, and pathogen recovery from any culture within 7 days of time-zero. Among 3,269 enrolled patients, 1,377 had reminder pages generated and were included in the primary analysis. There were 670 (48.7%) at-risk patients randomized to paging alerts and 707 (51.3%) to control. Bundle-adherent orders were placed for 198 intervention patients (29.6%) versus 149 (21.1%) controls (difference: 8.5%; 95% CI, 3.9-13.1%; p = 0.0003). Bundle-adherent care was delivered for 152 (22.7%) intervention versus 121 (17.1%) control patients (difference: 5.6%; 95% CI, 1.4-9.8%; p = 0.0095). Mortality was similar between groups (8.4% vs 8.3%), as were early antibiotic discontinuation (35.1% vs 33.4%) and pan-culture negativity (69.0% vs 68.2%). CONCLUSIONS: Real-time monitoring and paging alerts significantly increased orders for and delivery of guideline-adherent care for suspected sepsis patients at risk of 3-hour bundle nonadherence. The trial was underpowered to determine whether adherence affected mortality. Despite enrolling patients with clinically suspected sepsis, early antibiotic discontinuation and pan-culture negativity were common, highlighting challenges in identifying appropriate patients for sepsis bundle application.

Measuring Emergency Department Workload Perception Using Electronic Medical Record Measures of Patient Volume and Acuity.

BACKGROUND: Workload in the emergency department (ED) fluctuates and there is no established model for measurement of clinician-level ED workload. OBJECTIVE: The aim of this study was to measure perceived ED workload and assess the relationship between perceived workload and objective measures of workload from the electronic medical record (EMR). METHODS: This study was conducted at a tertiary care, academic ED from July 1, 2020 through April 13, 2021. Attending workload perceptions were collected using a 5-point scale in three care areas with variable acuity. We collected eight EMR measures thought to correlate with perceived workload. EMR values were compared across areas of the department using ANOVA and correlated with attending workload ratings using linear regression. RESULTS: We collected 315 unique workload ratings, which were normally distributed. For the entire department, there was a weak positive correlation between reported workload perception and mean percentage of inpatient admissions (r = 0.23; p < 0.001), intensive care unit admissions (r = 0.2; p < 0.001), patient arrivals per shift (r = 0.14; p = 0.017), critical care billed visits (r = 0.22; p < 0.001), cardiopulmonary resuscitation code activations (r = 0.2; p < 0.001), and level 5 visits (r = 0.13; p = 0.02). There was weak negative correlation for ED discharges (r = -0.23; p < 0.001). Several correlations were stronger in individual care areas, including percent admissions in the lowest-acuity area (r = 0.43; p = 0.033) and patient arrivals in the highest-acuity area (r = 0.44; p < .01). No significant correlation was found in any area for observation admissions or trauma activations. CONCLUSIONS: In this study, EMR measures of workload were not closely correlated with ED attending physician workload perception. Future study should examine additional factors contributing to physician workload outside of the EMR.

An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study.

BACKGROUND: Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations. AIM: To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses. DESIGN: A pre-/post-intervention study. SETTINGS/PARTICIPANTS: In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations. RESULTS: Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit. CONCLUSION: A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.

Palliative care in the emergency department: A qualitative study exploring barriers, facilitators, desired clinician qualities, and future directions.

OBJECTIVE: To describe the perceived qualities of successful palliative care (PC) providers in the emergency department (ED), barriers and facilitators to ED-PC, and clinicians' perspectives on the future of ED-PC. METHOD: This qualitative study using semi-structured interviews was conducted in June-August 2020. Interviews were analyzed via a two-phase Rapid Analysis. The study's primary outcomes (innovations in ED-PC during COVID) are published elsewhere. In this secondary analysis, we examine interviewee responses to broader questions about ED-PC currently and in the future. RESULTS: PC providers perceived as successful in their work in the ED were described as autonomous, competent, flexible, fast, and fluent in ED language and culture. Barriers to ED-PC integration included the ED environment, lack of access to PC providers at all times, the ED perception of PC, and the lack of a supporting financial model. Facilitators to ED-PC integration included proactive identification of patients who would benefit from PC, ED-focused PC education and tools, PC presence in the ED, and data supporting ED-PC. Increased primary PC education for ED staff, increased automation, and innovative ED-PC models were seen as areas for future growth. SIGNIFICANCE OF RESULTS: Our findings provide useful information for PC programs considering expanding their ED presence, particularly as this is the first study to our knowledge that examines traits of successful PC providers in the ED environment. Our findings also suggest that, despite growth in the arena of ED-PC, barriers and facilitators remain similar to those identified previously. Future research is needed to evaluate the impact that ED-PC initiatives may have on patient and system outcomes, to identify a financial model to maintain ED-PC integration, and to examine whether perceptions of successful providers align with objective measures of the same.

Design and Implementation of a Real-time Monitoring Platform for Optimal Sepsis Care in an Emergency Department: Observational Cohort Study.

BACKGROUND: Sepsis is the leading cause of death in US hospitals. Compliance with bundled care, specifically serial lactates, blood cultures, and antibiotics, improves outcomes but is often delayed or missed altogether in a busy practice environment. OBJECTIVE: This study aims to design, implement, and validate a novel monitoring and alerting platform that provides real-time feedback to frontline emergency department (ED) providers regarding adherence to bundled care. METHODS: This single-center, prospective, observational study was conducted in three phases: the design and technical development phase to build an initial version of the platform; the pilot phase to test and refine the platform in the clinical setting; and the postpilot rollout phase to fully implement the study intervention. RESULTS: During the design and technical development, study team members and stakeholders identified the criteria for patient inclusion, selected bundle measures from the Center for Medicare and Medicaid Sepsis Core Measure for alerting, and defined alert thresholds, message content, delivery mechanisms, and recipients. Additional refinements were made based on 70 provider survey results during the pilot phase, including removing alerts for vasopressor initiation and modifying text in the pages to facilitate patient identification. During the 48 days of the postpilot rollout phase, 15,770 ED encounters were tracked and 711 patient encounters were included in the active monitoring cohort. In total, 634 pages were sent at a rate of 0.98 per attending physician shift. Overall, 38.3% (272/711) patients had at least one page. The missing bundle elements that triggered alerts included: antibiotics 41.6% (136/327), repeat lactate 32.4% (106/327), blood cultures 20.8% (68/327), and initial lactate 5.2% (17/327). Of the missing Sepsis Core Measures elements for which a page was sent, 38.2% (125/327) were successfully completed on time. CONCLUSIONS: A real-time sepsis care monitoring and alerting platform was created for the ED environment. The high proportion of patients with at least one alert suggested the significant potential for such a platform to improve care, whereas the overall number of alerts per clinician suggested a low risk of alarm fatigue. The study intervention warrants a more rigorous evaluation to ensure that the added alerts lead to better outcomes for patients with sepsis.

Adapting the serious illness conversation guide for use in the emergency department by social workers.

OBJECTIVE: Although important treatment decisions are made in the Emergency Department (ED), conversations about patients' goals and values and priorities often do not occur. There is a critical need to improve the frequency of these conversations, so that ED providers can align treatment plans with these goals, values, and priorities. The Serious Illness Conversation Guide has been used in other care settings and has been demonstrated to improve the frequency, quality, and timing of conversations, but it has not been used in the ED setting. Additionally, ED social workers, although integrated into hospital and home-based palliative care, have not been engaged in programs to advance serious illness conversations in the ED. We set out to adapt the Serious Illness Conversation Guide for use in the ED by social workers. METHODS: We undertook a four-phase process for the adaptation of the Serious Illness Conversation Guide for use in the ED by social workers. This included simulated testing exercises, pilot testing, and deployment with patients in the ED. RESULTS: During each phase of the Guide's adaptation, changes were made to reflect both the environment of care (ED) and the clinicians (social workers) that would be using the Guide. A final guide is presented. SIGNIFICANCE OF RESULTS: This report presents an adapted Serious Illness Conversation Guide for use in the ED by social workers. This Guide may provide a tool that can be used to increase the frequency and quality of serious illness conversations in the ED.

Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error.

BACKGROUND: It is believed that patients who return to the Emergency Department (ED) and require admission are thought to represent failures in diagnosis, treatment or discharge planning. Screening readmission rates or patients who return within 72 h have been used in ED Quality Assurance efforts. These metrics require significant effort in chart review and only rarely identify care deviations. OBJECTIVE: This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. We planned to assess if the return visits with ICU admission were associated with deviations in care, and secondarily, to understand the common causes of error in this group. METHODS: Retrospective review of patients presenting to a university affiliated ED between January 1, 2005 and December 31, 2015 and returned within 14 days requiring ICU admission. RESULTS: From 1,106,606 ED visits, 511 patients returned within 14 days and were admitted to an ICU. 223 patients returned for a reason related to the index visit (43.6%). Of these related returns, 31 (13.9%) had a deviation in care on the index visit. When a standard diagnostic process of care framework was applied to these 31 cases, 47.3% represented failures in the initial diagnostic pathway. CONCLUSION: Reviewing 14-day returns leading to ICU admission, while an uncommon event, has a higher yield in the understanding of quality issues involving diagnostic as well as systems errors.

Utilization of a multidisciplinary emergency department sepsis huddle to reduce time to antibiotics and improve SEP-1 compliance.

Sepsis is a significant public health crisis in the United States, contributing to 50% of inpatient hospital deaths. Given its dramatic health effects and implications in the setting of new CMS care guidelines, ED leaders have renewed focus on appropriate and timely sepsis care, including timely administration of antibiotics in patients at risk for sepsis. Modeling the success of multidisciplinary bedside huddles in improving compliance with appropriate care in other healthcare settings, a Sepsis Huddle was implemented in a large, academic ED, with the goal of driving compliance with standardized sepsis care as described in the CMS SEP-1 measure. A retrospective cohort analysis was performed, with the primary finding that utilization of the Sepsis Huddle resulted in antibiotics being administered on average 41 min sooner than when the Sepsis Huddle was not performed. Given that literature suggests that early administration of appropriate antibiotic therapy is a major driver of mortality reduction in patients with sepsis, this study represents a proof of concept that utilization of a Sepsis Huddle may serve to improve outcomes among ED patients at risk for sepsis.

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities.

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

Reduction in pediatric gastroenterology ED visits can be sustained through physician accountability and financial incentives.

OBJECTIVE: There have been various interventions to reduce ED utilization. Little is known about the sustainability of outcomes of interventions to reduce ED overcrowding. We sought to investigate whether the outcomes from one of successful interventions to reduce ED utilization, specialist physician level reporting were sustained over time and how this practice change was sustained over time. METHOD: This study is a longitudinal analysis of the pre and post intervention ED utilization data collected on ED pediatric patients who were followed by pediatric gastroenterologists in an urban, academic hospital. The primary outcome was the mean rate of ED visits per 1000 office visits from January, 2013 to June, 2017 using a u control chart with three sigma limits. RESULTS: There were continuous leadership's support, physicians' engagement and communications among different members involved in the intervention. The rate of gastrointestinal (GI)-related ED visits after an intervention decreased by 54% from 4.89 to 2.23 during all hours and by 59% from 2.19 to 0.91 during office hours. DISCUSSION: Physician-level reporting reduced ED utilization over a four year period. The outcomes could be sustained over time with sustained leadership and physicians' engagement.

Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL).

STUDY OBJECTIVE: We describe current hospital-level performance for the Centers for Medicare & Medicaid Services' Severe Sepsis/Septic Shock Early Management Bundle (SEP-1) quality measure and qualitatively assess emergency department (ED) sepsis quality improvement best practice implementation. METHODS: Using a standardized Web-based submission portal, we surveyed quality improvement data from volunteer hospital-based EDs participating in the Emergency Quality Network Sepsis Initiative. Each hospital submitted preliminary SEP-1 local chart review data, using existing Centers for Medicare & Medicaid Services definitions. We report descriptive statistics of SEP-1 data availability and performance. The primary outcome for this study was SEP-1 bundle compliance, defined as the proportion of all severe sepsis and septic shock cases receiving all required bundle elements, and secondary outcomes included conditional compliance on reported SEP-1 numerator components and ED implementation of sepsis quality improvement best practices. RESULTS: A total of 50 EDs participated in the survey; 74% were nonteaching sites and 26% were affiliated with academic centers. Of all participating EDs, 80% were in regions with relatively high population density. The mean hospital SEP-1 bundle compliance was 54% (interquartile range 30% to 75%). Bundle compliance improved during fiscal year 2016 from 39% to 57%. Broad variation existed for each bundle component, with intravenous fluid resuscitation and repeated lactate bundle elements having the widest variation and largest gaps in quality. At least one consensus sepsis quality improvement best practice implementation occurred in 92% of participating sites. CONCLUSION: Preliminary data on SEP-1 performance suggest wide hospital-level variation in performance, with modest improvement during the first year of data collection.

72h returns: A trigger tool for diagnostic error.

BACKGROUND: Patients who return to the Emergency Department (ED) within 72h of discharge are often used for ED Quality Assurance efforts, however little is known about the yield of this kind of review and the types of errors it identifies. Our objective was to identify the prevalence, types and severity of errors in these cases. METHODS: Retrospective review of patients who presented to an urban, university affiliated ED between 10/1/2012-9/30/2015 who returned within 72 h requiring hospital admission. RESULTS: There were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72h and were admitted to the hospital. An event requiring further investigation was identified in 59 (2.95%) of these patients and 50 (2.49%) of them were deemed to represent a deviation from optimal care. Of these, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%). When Error Severity Codes were applied, 16 (32%) resulted in minor harm and 34 (68%) resulted in major harm or death. CONCLUSION: Screening of 72h ED returns has low yield in identifying suboptimal care, with less than 3% of cases representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. These reviews may be useful as a tool for Ongoing Professional Practice Evaluation of individual clinicians, however likely serve less value in identifying systems issues contributing to unsafe care.

New Mandated Centers for Medicare and Medicaid Services Requirements for Sepsis Reporting: Caution from the Field.

BACKGROUND: The release of the Center for Medicare and Medicaid Service's (CMS) latest quality measure, Severe Sepsis/Septic Shock Early Management Bundle (SEP-1), has intensified the long-standing debate over optimal care for severe sepsis and septic shock. Although the last decade of research has demonstrated the importance of comprehensive bundled care in conjunction with compliance mechanisms to reduce patient mortality, it is not clear that SEP-1 achieves this aim. The heterogeneous and often cryptic presentation of severe sepsis and septic shock, along with the multifaceted criteria for the definition of this clinical syndrome, pose a particular challenge for fitting requirements to this disease, and implementation could have unintended consequences. OBJECTIVE: Following a simulated reporting exercise, in which 50 charts underwent expert review, we aimed to detail the challenges of, and offer suggestions on how to rethink, measuring performance in severe sepsis and septic shock care. DISCUSSION: There were several challenges associated with the design and implementation of this measure. The ambiguous definition of severe sepsis and septic shock, prescriptive fluid volume requirements, rigid reassessment, and complex abstraction logic all raise significant concern. CONCLUSIONS: Although SEP-1 represents an important first step in requiring hospitals to improve outcomes for patients with severe sepsis and septic shock, the current approach must be revisited. The volume and complexity of the currently required SEP-1 reporting elements deserve serious consideration and revision before they are used as measures of accountability and tied to reimbursement.

Association of magnetic resonance imaging for back pain on seven-day return visit to the Emergency Department.

BACKGROUND: The prevalence of back pain is rising, as is the use of high-cost imaging in the ED. The objective of our study was to determine if an MRI in the ED for patients with back pain resulted in a lower incidence of ED return visit and to determine if these patients had longer ED length of stay (LOS) and use of ED observation. METHODS: A retrospective cohort study of consecutive patients seen with back pain was conducted at an urban, university-affiliated ED between 1 January 2012 and 11 July 2014. The association of MRI on return within 7 days was assessed using a χ2 test and a multivariable logistic regression model and the difference in median ED LOS was compared using a Wilcoxon rank-sum test. RESULTS: During the study period, 6094 patients were evaluated in the ED with back pain as the primary diagnosis. Of these, 797 (13%) received an MRI. Among all patients with back pain, 277 (4.5%) returned within 7 days. Univariate analysis found that patients who received an MRI were no less likely to return within 7 days than patients who did not (4.3% vs 4.6%; p=0.68). Patients who had an MRI were more likely to be admitted to observation (74.2% vs 10.8%; p<0.0001) and had a longer ED LOS (median 4.8 hours vs 2.7; p<0.0001). Multivariable regression confirmed that MRI did not decrease the rate of a 7-day return visit (OR=0.98; 95% CI 0.68 to 1.42). CONCLUSIONS: In patients with uncomplicated back pain, performing an MRI will not mitigate their likelihood of return; however, it leads to a longer ED LOS and more ED observation admissions.

A prediction model to identify patients without a concerning intraabdominal diagnosis.

OBJECTIVE: Patients with abdominal diagnoses constitute 5% to 10% of all emergency department (ED) presentations. The goal of this study is to identify which of these patients will have a nonconcerning diagnosis based on demographic, physical examination, and basic laboratory testing. METHODS: Consecutive patients from July 2013 to March 2014 discharged with a gastrointestinal (GI) diagnosis who presented to an urban, university-affiliated ED were identified. The cohort was split into a derivation set and a validation set. Using univariate and multivariable logistic regression analysis, a risk score was created based on the deviation data and then tested on the validation data. RESULTS: There were 8852 patients with a GI diagnosis during the study period. A total of 7747 (87.5%) of them had a nonconcerning diagnosis. The logistic regression model identified 13 variables that predict a concerning GI diagnosis and created a scoring system ranging from 0 to 20. The area under the receiver operating characteristic was 0.81. When dichotomized at greater than or equal to 7 vs less than 7, the risk score has a sensitivity of 91% (95% confidence interval [CI], 88-94), specificity of 46% (95% CI, 44-48), positive predictive value of 17% (95% CI, 15-19) and negative predictive value of 98% (95% CI, 97-99). CONCLUSION: One can determine with a high degree of certainty, based only on an initial evaluation and screening laboratory work (excluding radiology) whether a patient who presents with a GI-related complaint has a nonconcerning diagnosis. This model could be used as a tool to aid in quality assurance when reviewing patients discharged with GI complaints and with future study, as a secondary triage instrument in a crowded ED environment, and aid in resource allocation.

Seventy-Two-Hour Returns Are Not Useful in Identifying Emergency Department Patients With a Concerning Intra-Abdominal Process.

BACKGROUND: Seventy-two-hour returns to the emergency department (ED) have been used to identify patients who are believed to have been more likely to have suffered medical errors, missed diagnoses, or failure or inadequacy of previous treatment or discharge planning. This approach has been criticized as arbitrary, however, citing the lack of evidence to support its homogenous application to all organ system-based complaints and the unclear implication of returns. OBJECTIVE: Given the significant burden of gastrointestinal (GI)-related illness, our objective was to determine if an audit of 72-hour returns of GI-related diagnoses appropriately captures patients who return with a concerning diagnosis (CD) on their second visit. METHODS: Ten emergency physicians were surveyed and a list of concerning, "not to be missed" diagnoses were generated. The demographic and clinical variables were collected and analyzed on all patients with a GI International Classification of Diseases, 9th revision code presenting to an urban, university-affiliated ED between July 2013 and March 2014. RESULTS: There were 10,012 patient visits during the study period, including 1006 patients (10%) with ≥ 1 return visits. One hundred forty-seven patients (15%) returned within 72 hours, and 859 patients (85%) returned in > 72 hours. Patients that returned within 72 hours were no more likely to have a CD than those that returned at a later time (13.6% vs. 14.4%; p = 0.79). CONCLUSION: An audit of 72-hour returns only captures a small percentage of patients that return with a CD, and these patients are at no greater risk of harboring a CD than those that return at a later date.