Correlations among common emergency medicine physician performance measures: Mixed messages or balancing forces?

The increasing complexity of ED physician performance measures has resulted in significant challenges, including duplicative and conflicting measures that fail to account for different ED settings. We performed a cross sectional analysis of correlations between measures to characterize their relationships and determine if differences exist between academic versus non-academic ED settings. Pearson correlations were calculated for 12 measures among 220 ED physicians at 11 EDs. Higher admission rate was strongly correlated with higher CT utilization rate (R = 0.7, p < 0.01) and longer room to discharge time (R = 0.7, p < 0.01). Higher patients per hour was strongly correlated with shorter room to doctor time (R = -0.7, p < 0.01). Stronger measure correlations were found in the academic setting compared to the non-academic setting. Strong correlations between ED measures imply opportunities to reduce competing performance demands on clinicians. Differences in correlations at academic versus non-academic settings suggest that it may be inappropriate to apply the same performance standards across settings.

Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions.

BACKGROUND/OBJECTIVE: Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. METHODS: We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement. RESULTS: This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival). CONCLUSIONS: Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.

Identification of Patients with Nontraumatic Intracranial Hemorrhage Using Administrative Claims Data.

INTRODUCTION: Nontraumatic intracranial hemorrhage (ICH) is a neurological emergency of research interest; however, unlike ischemic stroke, has not been well studied in large datasets due to the lack of an established administrative claims-based definition. We aimed to evaluate both explicit diagnosis codes and machine learning methods to create a claims-based definition for this clinical phenotype. METHODS: We examined all patients admitted to our tertiary medical center with a primary or secondary International Classification of Disease version 9 (ICD-9) or 10 (ICD-10) code for ICH in claims from any portion of the hospitalization in 2014-2015. As a gold standard, we defined the nontraumatic ICH phenotype based on manual chart review. We tested explicit definitions based on ICD-9 and ICD-10 that had been previously published in the literature as well as four machine learning classifiers including support vector machine (SVM), logistic regression with LASSO, random forest and xgboost. We report five standard measures of model performance for each approach. RESULTS: A total of 1830 patients with 2145 unique ICD-10 codes were included in the initial dataset, of which 437 (24%) were true positive based on manual review. The explicit ICD-10 definition performed best (Sensitivity = 0.89 (95% CI 0.85-0.92), Specificity = 0.83 (0.81-0.85), F-score = 0.73 (0.69-0.77)) and improves on an explicit ICD-9 definition (Sensitivity = 0.87 (0.83-0.90), Specificity = 0.77 (0.74-0.79), F-score = 0.67 (0.63-0.71). Among machine learning classifiers, SVM performed best (Sensitivity = 0.78 (0.75-0.82), Specificity = 0.84 (0.81-0.87), AUC = 0.89 (0.87-0.92), F-score = 0.66 (0.62-0.69)). CONCLUSIONS: An explicit ICD-10 definition can be used to accurately identify patients with a nontraumatic ICH phenotype with substantially better performance than ICD-9. An explicit ICD-10 based definition is easier to implement and quantitatively not appreciably improved with the additional application of machine learning classifiers. Future research utilizing large datasets should utilize this definition to address important research gaps.

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage.

GOAL: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. MATERIALS AND METHODS: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. FINDINGS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. CONCLUSIONS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

A review of micronutrients in sepsis: the role of thiamine, l-carnitine, vitamin C, selenium and vitamin D.

Sepsis is defined as the dysregulated host response to an infection resulting in life-threatening organ dysfunction. The metabolic demand from inefficiencies in anaerobic metabolism, mitochondrial and cellular dysfunction, increased cellular turnover, and free-radical damage result in the increased focus of micronutrients in sepsis as they play a pivotal role in these processes. In the present review, we will evaluate the potential role of micronutrients in sepsis, specifically, thiamine, l-carnitine, vitamin C, Se and vitamin D. Each micronutrient will be reviewed in a similar fashion, discussing its major role in normal physiology, suspected role in sepsis, use as a biomarker, discussion of the major basic science and human studies, and conclusion statement. Based on the current available data, we conclude that thiamine may be considered in all septic patients at risk for thiamine deficiency and l-carnitine and vitamin C to those in septic shock. Clinical trials are currently underway which may provide greater insight into the role of micronutrients in sepsis and validate standard utilisation.

The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest.

Non-traumatic cardiac arrest is a major public health problem that carries an extremely high mortality rate. If we hope to increase the survivability of this condition, it is imperative that alternative methods of treatment are given due consideration. Balloon occlusion of the aorta can be used as a method of circulatory support in the critically ill patient. Intra-aortic balloon pumps have been used to temporize patients in cardiogenic shock for decades. More recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized in the patient in hemorrhagic shock or cardiac arrest secondary to trauma. Aortic occlusion in non-traumatic cardiac arrest has the effect of reducing the vascular volume that the generated cardiac output is distributed across. This augments myocardial and cerebral perfusion, increasing the probability of a return to a good quality of life for the patient. This phenomenon has been the subject of numerous animal studies dating back to the early 1980s; however, the human evidence is limited to several small case series. Animal research has demonstrated improvements in cerebral and coronary perfusion pressure during ACLS that lead to statistically significant differences in mortality. Several case series in humans have replicated these findings, suggesting the efficacy of this procedure. The objectives of this review are to: 1) introduce the reader to REBOA 2) review the physiology of NTCA and examine the current limitations of traditional ACLS 3) summarize the literature regarding the efficacy and feasibility of aortic balloon occlusion to support traditional ACLS.

Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program.

BACKGROUND: The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies. METHODS: This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data. RESULTS: We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs. CONCLUSIONS: We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

Emergency department initiated resuscitative endovascular balloon occlusion of the aorta (REBOA) for out-of-hospital cardiac arrest is feasible and associated with improvements in end-tidal carbon dioxide.

Objectives: Out-of-hospital cardiac arrest (OHCA) claims the lives of approximately 350,000 people in the United States each year. Resuscitative endovascular balloon occlusion of the aorta (REBOA) when used as an adjunct to advanced cardiac life support may improve cardio-cerebral perfusion. Our primary research objective was to determine the feasibility of emergency department (ED)-initiated REBOA for OHCA patients in an academic urban ED. Methods: This was a single-center, single-arm, early feasibility trial that used REBOA as an adjunct to advanced cardiac life support (ACLS) in OHCA. Subjects under 80 years with witnessed OHCA and who received cardiopulmonary rescuitation (CPR) within 6 minutes were eligible. Results: Five patients were enrolled between February 2020 and April 2021. The procedure was successful in all patients and 4 of 5 (80%) patients had transient return of spontaneous circulation (ROSC) after aortic occlusion. Unfortunately, all patients re-arrested soon after intra-aortic balloon deflation and none survived to hospital admission. At 30 seconds post-aortic occlusion, investigators noted a statistically significant increase in end tidal carbon dioxide of 26% (95% confidence interval, 10%, 44%). Conclusion: Initiating REBOA for OHCA patients in an academic urban ED setting is feasible. Aortic occlusion during chest compressions is temporally associated with improvements in end tidal carbon dioxide 30 seconds after aortic occlusion. Four of 5 patients achieved ROSC after aortic occlusion; however, deflation of the intra-aortic balloon quickly led to re-arrest and death in all patients. Future research should focus on the utilization of partial-REBOA to prevent re-arrest after ROSC, as well as the optimal way to incorporate this technique with other endovascular reperfusion strategies.

A Multimodal Intervention to Improve the Quality and Safety of Interhospital Care Transitions for Nontraumatic Intracerebral and Subarachnoid Hemorrhage.

BACKGROUND: Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. The researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT. METHODS: Pre and post analyses of timeliness, effectiveness, and communication outcome measures were performed for patients transferred to an urban, academic center with nontraumatic ICH/SAH following implementation of a multimodal intervention. Intervention components included clinical practice guideline dissemination, IHT process redesign, electronic patient arrival notification, electronic imaging exchange, and electronic health record improvements. Three months of preintervention outcomes were compared to six months of postintervention outcomes to assess impact and sustainability of the intervention; t-tests and chi-square tests were used to compare continuous and proportional outcomes, respectively. RESULTS: The IHT study population included 106 patients (37 preintervention, 69 postintervention). Significant improvements were observed in timeliness outcomes, including emergency department (ED) time to admission order (preintervention median: 66 minutes vs. postintervention: 33 minutes, p = 0.008), ED boarding time (preintervention median: 223 minutes vs. postintervention: 93 minutes, p = 0.001), and ED length of stay (preintervention median: 300 minutes vs. postintervention: 150 minutes, p ≤ 0.0001). Verbal communication between ED and neurocritical care clinicians prior to IHT improved from 40.0% preintervention to 90.9% postintervention. CONCLUSION: Application of scripted quality improvement interventions as part of the IHT process is feasible and effective at improving the timeliness of care and communication of critical information in patients with nontraumatic ICH/SAH.

Description and Yield of Current Quality and Safety Review in Selected US Academic Emergency Departments.

OBJECTIVES: Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement. We hypothesized that decades-old approaches used in many academic EDs are inefficient and low yield for identifying patient harm. METHODS: We conducted a prospective observational study to evaluate the efficiency and yield of current quality review processes at five academic EDs for a 12-month period. Sites provided descriptions of their current practice and collected summary data on the number and severity of events identified in their reviews and the referral sources that led to their capture. Categories of common referral sources were established at the beginning of the study. Sites used the Institute for Healthcare Improvement's definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for grading severity of events. RESULTS: Participating sites had similar processes for quality review, including a two-level review process, monthly reviews and conferences, similar screening criteria, and a grading system for evaluating cases. In 60 months of data collection, we reviewed a total of 4735 cases and identified 381 events. This included 287 near-misses, errors/events (MERP A-I) and 94 adverse events (AEs) (MERP E-I). The overall AE rate (event rate with harm) was 1.99 (95% confidence interval = 1.62%-2.43%), ranging from 1.24% to 3.47% across sites. The overall rate of quality concerns (events without harm) was 6.06% (5.42%-6.78%), ranging from 2.96% to 10.95% across sites. Seventy-two-hour returns were the most frequent referral source used, accounting for 47% of the cases reviewed but with a yield of only 0.81% in identifying harm. Other referral sources similarly had very low yields. External referrals were the highest yield referral source, with 14.34% (10.64%-19.03%) identifying AEs. As a percentage of the 94 AEs identified, external referrals also accounted for 41.49% of cases. CONCLUSIONS: With an overall adverse event rate of 1.99%, commonly used referral sources seem to be low yield and inefficient for detecting patient harm. Approximately 6% of the cases identified by these criteria yielded a near miss or quality concern. New approaches to quality and safety review in the ED are needed to optimize their yield and efficiency for identifying harm and areas for improvement.

Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies.

Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate. Risks to patient safety during the transfer process were reported by 1 in 3 of respondents. Perceived risks were reported more frequently by nurses (44%) than physicians/advanced practice providers (28%). Real-time survey methodology appears to be a feasible and valuable, albeit resource intensive, tool to identify safety risks, expose barriers to communication, and reveal challenges not captured by traditional approaches to inform multidisciplinary quality improvement efforts.

Clinical risk stratification for gastrointestinal hemorrhage: still no consensus.

A lack of consensus exists in the pre-endoscopic risk stratification of patients with upper or lower gastrointestinal hemorrhage. The work by Das and colleagues in the previous issue of Critical Care serves to externally validate the BLEED criteria. Their results suggest that hemodynamically stable patients without evidence of ongoing bleeding or unstable comorbidities may be at lower risk for hospital complications. While their results reinforce previous studies, further investigation is needed before comprehensive practice guidelines can be established.

Emergency medicine training programs' educational requirements in the management of psychiatric emergencies: current perspective.

OBJECTIVE: The purpose of this study was to determine the extent of training in clinical psychiatry that is provided and/or required by emergency medicine (EM) residency training programs and pediatric emergency medicine (PEM) subspecialty residency training programs. DESIGN/METHODS: A questionnaire was mailed to 114 EM residency directors and to all 50 PEM fellowship directors. Each director was asked to indicate the amount of psychiatric training that was required of residents or fellows in his or her program. Details concerning the exact structure of psychiatric training were solicited from those offering such training. RESULTS: There was a 76% response rate (n = 88) among EM programs, and 76% (n = 59) of the respondents reported no formal training in the management of acute psychiatric emergencies. Only 14% (12 programs) provide a 1-month rotation in psychiatry. Of the 3-year programs, 14% (n = 11) offer 2-week psychiatric electives, and 9% (n = 8) offer some training. There was a 72% response rate among the PEM training programs. Only one of the 36 respondents provided a required 1-month rotation in psychiatry. Six programs stated the availability of a 1-month elective in psychiatry. Two programs reported 2 to 3 hours per year of core lecture time dedicated to psychiatric emergencies. CONCLUSIONS: Standardized psychiatric training is not required of most trainees in EM and PEM. Few (24%) training programs provide formal psychiatric training for their EM residents, and even fewer (< 3%) provide such training for their PEM fellows.

Meta-analysis of protocolized goal-directed hemodynamic optimization for the management of severe sepsis and septic shock in the Emergency Department.

INTRODUCTION: To perform a meta-analysis identifying studies instituting protocolized hemodynamic optimization in the emergency department (ED) for patients with severe sepsis and septic shock. METHODS: We modeled the structure of this analysis after the QUORUM and MOOSE published recommendations for scientific reviews. A computer search to identify articles was performed from 1980 to present. Studies included for analysis were adult controlled trials implementing protocolized hemodynamic optimization in the ED for patients with severe sepsis and septic shock. Primary outcome data was extracted and analyzed by 2 reviewers with the primary endpoint being short-term mortality reported either as 28-day or in-hospital mortality. RESULTS: We identified 1,323 articles with 65 retrieved for review. After application of inclusion and exclusion criteria 25 studies (15 manuscripts, 10 abstracts) were included for analysis (n=9597). The mortality rate for patients receiving protocolized hemodynamic optimization (n=6031) was 25.8% contrasted to 41.6% in control groups (n=3566, p<0.0001). CONCLUSION: Protocolized hemodynamic optimization in the ED for patients with severe sepsis and septic shock appears to reduce mortality.

Toxins.

Exposures to toxins are prevalent, frequently complicate surgical emergencies, and impact critical care. A fundamental understanding of pathophysiologic principles and management strategies is essential for the anesthesiologist frequently responsible for the acute care of patients who have toxicologic exposures. Given their pervasiveness and ability to confound the clinical presentations in the perioperative or intensive care setting, substances of abuse and asphyxiants warrant particular attention and a high degree of vigilance.

Malpractice issues and contrast use.

As the cost of nonionic lower-osmolality contrast media decreases, the standard of practice for using such agents changes, and the implications of informed consent increase. Failure to use specific contrast agents appropriately or failure to respond correctly to a contrast reaction can lead to the claim of malpractice. These topics are reviewed in the context of current practice guidelines.