An early look at performance on the emergency care measures included in Medicare's hospital inpatient Value-Based Purchasing Program.

STUDY OBJECTIVE: Medicare's new, mandatory Hospital Inpatient Value-Based Purchasing Program introduces financial rewards or penalties to hospitals according to achievement or improvement on several publicly reported quality measures. Our objective was to describe hospital reporting on the 4 emergency department (ED)-related program measures, variation in performance on the ED measures across hospital characteristics, and the characteristics of hospitals that were more likely to receive performance scores based on improvement versus achievement. METHODS: This was an exploratory, descriptive analysis. We merged 2008 to 2010 performance data from Hospital Compare with the 2009 American Hospital Association Annual Survey. We calculated a composite score for the 4 ED measures and used Kruskal-Wallis tests to examine differences in performance across hospital characteristics. We also examined differences in the percentage of scores that were awarded according to improvement versus achievement. RESULTS: There were 2,927 hospitals that qualified for the value-based purchasing program and were included in the analysis. For-profit hospitals received the highest scores; public hospitals and hospitals lacking The Joint Commission (TJC) accreditation received the lowest scores. Public hospitals had the largest share of scores awarded according to improvement (39.8%); for-profit hospitals had the lowest (27.8%). CONCLUSION: We found variation in performance by hospital characteristics on the ED-related program measures. Although public and non-TJC-accredited hospitals trailed in performance, they showed strong signs of improvement, signaling that performance gaps by ownership and accreditation may decrease. Considering the increasing scope of the value-based purchasing program, ED leaders should monitor both achievement and improvement on the 4 ED-related program measures.

Use of risk assessment analysis by failure mode, effects, and criticality to reduce door-to-balloon time.

STUDY OBJECTIVE: The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure. METHODS: We conducted a 2-part study: FMECA of the door-to-balloon time system and process of care, and evaluation of a single institution's door-to-balloon time operational data using a retrospective observational cohort design. A multidisciplinary group of FMECA participants described the door-to-balloon time process to then create a comprehensive map and table listing all process steps and identified process failures, including their frequency, consequence, and causes. Door-to-balloon time operational data were assessed by "on" versus "off" hours. RESULTS: Fifty-one failure points were identified across 4 door-to-balloon time phases. Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. Total door-to-balloon time during on hours had a median time of 55 minutes (95% confidence interval 46 to 60 minutes) compared with 77 minutes (95% confidence interval 68 to 83 minutes) during off hours. CONCLUSION: The FMECA revealed clear areas of potential delay and vulnerability that can be addressed to decrease door-to-balloon time from 90 to 60 minutes. FMECAs can provide a robust assessment of potential risks and can serve as the platform for significant process improvement and system redesign for door-to-balloon time.

The weekend effect for patients with sepsis presenting to the emergency department.

BACKGROUND: Mortality differences in weekend and weekday admissions have been observed for a variety of conditions that require aggressive early intervention. It is unknown if there is a mortality difference that exists for patients presenting to the Emergency Department (ED) with sepsis on the weekend. STUDY OBJECTIVES: We hypothesized that there is an increase in early inpatient mortality (death on day 1 or day 2 of hospitalization) among patients with sepsis who present to the ED on the weekend vs. weekdays. METHODS: We performed a cross-sectional analysis of 114,611 ED admissions with a principal diagnosis consistent with sepsis from 576 hospitals in the 2008 Nationwide Inpatient Sample. Adjusted analyses controlled for patient and hospital characteristics, and examined the likelihood of either early (day 1 or day 2 of hospitalization) or overall inpatient mortality. RESULTS: A greater proportion of patients admitted on the weekend died on day 1 and day 2 of hospitalization (5.4% vs. 4.0%, p < 0.001; and 7.5% vs. 6.9%, p = 0.001), the difference for overall inpatient mortality was not significant (17.9% vs. 17.5%, p = 0.08). The risk-adjusted odds ratio (OR) of day 1 and day 2 early inpatient mortality of weekend vs. weekday admissions was 1.10 (95% confidence interval [CI] 1.04-1.17) and 1.08 (95% CI 1.03-1.14), respectively; the association with overall inpatient mortality was not significant (OR 1.03, 95% CI 1.00-1.07). CONCLUSIONS: Patients admitted through the ED with sepsis on the weekend had a greater likelihood of early mortality, but not overall mortality, when compared to patients admitted on weekdays.

Severe sepsis in do-not-resuscitate patients: intervention and mortality rates.

BACKGROUND: Severe sepsis is a high-mortality disease, and early resuscitation decreases mortality. Do-not-resuscitate (DNR) status may influence physician decisions beyond cardiopulmonary resuscitation, but this has not been investigated in sepsis. OBJECTIVE: Among Emergency Department (ED) severe sepsis patients, define the incidence of DNR status, prevalence of central venous catheter placement, and vasopressor administration (invasive measures), and mortality. METHODS: Retrospective observational cohort of consecutive severe sepsis patients to single ED in 2009-2010. Charts abstracted for DNR status on presentation, demographics, vitals, Sequential Organ Failure Assessment (SOFA) score, inpatient and 60-day mortality, and discharge disposition. Primary outcomes were mortality, discharge to skilled nursing facility (SNF), and invasive measure compliance. Chi-squared test was used for univariate association of DNR status and outcome variables; multivariate logistic regression analyses for outcome variables controlling for age, gender, SOFA score, and DNR status. RESULTS: In 376 severe sepsis patients, 50 (13.3%) had DNR status. DNR patients were older (79.2 vs 60.3 years, p < 0.001) and trended toward higher SOFA scores (7 vs. 6, p = 0.07). DNR inpatient and 60-day mortalities were higher (50.5% vs. 19.6%, 95% confidence interval [CI] 15.9-44.9%; 64.0% vs. 24.9%, 95% CI 25.1-53.3%, respectively), and remained higher in multivariate logistic regression analysis (odds ratio [OR] 3.01, 95% CI 1.48-6.17; OR 3.80, 95% CI 1.88-7.69, respectively). The groups had similar rates of discharge to SNF, and in persistently hypotensive patients (n = 326) had similar rates of invasive measures in univariate and multivariate analyses (OR 1.19, 95% CI 0.45-3.15). CONCLUSION: In this sample, 13.3% of severe sepsis patients had DNR status, and 50% of DNR patients survived to hospital discharge. DNR patients received invasive measures at a rate similar to patients without DNR status.

Lower mortality in sepsis patients admitted through the ED vs direct admission.

PURPOSE: Early aggressive resuscitation in patients with severe sepsis decreases mortality but requires extensive time and resources. This study analyzes if patients with sepsis admitted through the emergency department (ED) have lower inpatient mortality than do patients admitted directly to the hospital. PROCEDURES: We performed a cross-sectional analysis of hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis, using data from the 2008 Nationwide Inpatient Sample. Analyses were controlled for patient and hospital characteristics and examined the likelihood of either early (2-day postadmission) or overall inpatient mortality. FINDINGS: Of 98,896 hospitalizations with a principal diagnosis of sepsis, from 290 hospitals, 80,301 were admitted through the ED and 18,595 directly to the hospital. Overall sepsis inpatient mortality was 17.1% for ED admissions and 19.7% for direct admissions (P<.001). Overall early sepsis mortality was 6.9%: 6.8% for ED admissions and 7.4% for direct admissions (P=.005). Emergency department patients had a greater proportion of comorbid conditions, were more likely to have Medicaid or be uninsured (12.5% vs 8.4%; P<.001), and were more likely to be admitted to urban, large bed-size, or teaching hospitals (P<.001). The risk-adjusted odds ratio for overall mortality for ED admissions was 0.83 (95% confidence interval, 0.80-0.87) and 0.92 for early mortality (95% confidence interval, 0.86-0.98), as compared with direct admissions to the hospital. CONCLUSION: Admission for sepsis through the ED was associated with lower early and overall inpatient mortality in this large national sample.

Cost-effectiveness of influenza vaccination of older adults in the ED setting.

OBJECTIVES: Adults older than 50 years are at greater risk for death and severe disability from influenza. Persons in this age group, however, are frequently not vaccinated, despite extensive efforts by physicians to provide this preventive measure in primary care settings. We performed this study to determine if influenza vaccination of older adults in the emergency department (ED) may be cost-effective. METHODS: Using a probabilistic decision model with quasi-Markov modeling of a typical influenza season, we calculated costs and health outcomes for a hypothetical cohort of patients using parameters from the literature. Three ED-based intervention strategies were compared: (1) no vaccination offered, (2) vaccination offered to patients older than 65 years (limited strategy), and (3) vaccination offered to all patients who are 50 years and older (inclusive strategy). Outcomes were measured as costs, lives saved, and incremental costs per life saved. We performed deterministic and probabilistic sensitivity analyses. RESULTS: Vaccination of patients 50 years of age and older results in an incremental cost of $34,610 per life saved when compared with the no-vaccination strategy. Limiting vaccination to only those older than 65 years results in an incremental cost of $13,084 per life saved. Results were sensitive to changes in vaccine cost but were insensitive to changes in other model parameters. CONCLUSIONS: Vaccination of older adults against influenza in the ED setting is cost-effective, especially for those older than 65 years. Emergency departments may be an important setting for providing influenza vaccination to adults who may otherwise have remained unvaccinated.

The relationship between inpatient discharge timing and emergency department boarding.

BACKGROUND: Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling. STUDY OBJECTIVE: Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m. METHODS: A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies. RESULTS: A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0. CONCLUSION: Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.

Volume of emergency department admissions for sepsis is related to inpatient mortality: results of a nationwide cross-sectional analysis.

OBJECTIVES: Emergency department resuscitation plays a significant role in sepsis care, and it is unknown if patient outcomes vary by institution based on the level of sepsis experience of the emergency department. This study examines whether there is an association between the annual volume of patients admitted via the emergency department with sepsis and inpatient mortality. DESIGN: Cross-sectional analysis of the 2007 Nationwide Inpatient Sample. SETTING AND PATIENTS: We included 87,166 adult emergency department sepsis admissions from 551 hospitals. MEASUREMENTS: Hospitals were categorized into quartiles by 2007 emergency department sepsis volume. Univariate associations of patient characteristics, hospital characteristics, and inpatient mortality with sepsis volume level were evaluated by chi-square test. A population-averaged logistic regression model of inpatient mortality was used to estimate the effects of age, gender, comorbid conditions, payer status, median zip code income, hospital bed size, teaching status, and emergency department sepsis volume. MAIN RESULTS: Overall inpatient sepsis mortality was 18.0% and early mortality (2 days after admission) was 6.9%. The risk-adjusted odds ratios of mortality were 0.73 (95% confidence interval, 0.64-0.83; p < .001) in quartile 4 (highest volume), 0.83 in quartile 3 (95% confidence interval, 0.74-0.93; p = .001), and 0.90 in quartile 2 (95% confidence interval, 0.82-0.99; p < .05) when compared to quartile 1 (lowest volume). Adjusted results were similar for early mortality: 0.69 (95% confidence interval, 0.61-0.76; p < .001) in quartile 4, 0.83 in quartile 3 (95% confidence interval, 0.74-0.93; p < .05), and 0.85 in quartile 2 (95% confidence interval, 0.77-0.94; p < .05) when compared to quartile 1. CONCLUSIONS: After adjustment for comorbidity and hospital-level factors, there was a significant relationship between emergency department sepsis case volume and overall and early inpatient mortality among patients admitted through the emergency department with sepsis. Patients admitted to hospitals in the highest-volume quartile had 27% lower odds of inpatient mortality in this large heterogeneous sample.

Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion?

STUDY OBJECTIVE: We evaluate a computer simulation model designed to assess the effect on emergency department (ED) length of stay of varying the number of ED beds or altering the interval of admitted patient departure from the ED. METHODS: We created a computer simulation model (Med Model) based on institutional data and augmented by expert estimates and assumptions. We evaluated simulations of increasing the number of ED beds, increasing the admitted patient departure and increasing ED census, analyzing potential effects on overall ED length of stay. Multiple sensitivity analyses tested the robustness of the results to changes in model assumptions and institutional data. RESULTS: With a constant ED departure rate at the base case and increasing ED beds, there is an increase in mean length of stay from 240 to 247 minutes (95% confidence interval [CI] 0.8 to 12.6 minutes). When keeping the number of beds constant at the base case and increasing the rate at which admitted patients depart the ED to their inpatient bed, the mean overall ED length of stay decreases from 240 to 218 minutes (95% CI 16.8 to 26.2 minutes). With a 15% increase in daily census, the trends are similar to the base case results. The sensitivity analyses reveal that despite a wide range of inputs, there are no differences from the base case. CONCLUSION: Our computer simulation modeled that improving the rate at which admitted patients depart the ED produced an improvement in overall ED length of stay, whereas increasing the number of ED beds did not.

Sixty-four-slice computed tomography of the coronary arteries: cost-effectiveness analysis of patients presenting to the emergency department with low-risk chest pain.

OBJECTIVES: The aim was to use a computer model to estimate the cost-effectiveness of 64-slice multidetector computed tomography (MDCT) of the coronary arteries in the emergency department (ED) compared to an observation unit (OU) stay plus stress electrocardiogram (ECG) or stress echocardiography for the evaluation of low-risk chest pain patients presenting to the ED. METHODS: A decision analytic model was developed to compare health outcomes and costs that result from three different risk stratification strategies for low-risk chest pain patients in the ED: stress ECG testing after OU care, stress echocardiography after OU care, and MDCT with no OU care. Three patient populations were modeled with the prevalence of symptomatic coronary artery disease (CAD) being very low risk, 2%; low risk, 6% (base case); and moderate risk, 10%. Outcomes were measured as quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs), the ratio of change in costs of one test over another to the change in QALY, were calculated for comparisons between each strategy. Sensitivity analyses were conducted to test the robustness of the results to assumptions regarding the characteristics of the risk stratification strategies, costs, utility weights, and likelihood of events. RESULTS: In the base case, the mean (+/- standard deviation [SD]) costs and QALYs for each risk stratification strategy were MDCT arm $2,684 (+/- $1,773 to $4,418) and 24.69 (+/- 24.54 to 24.76) QALYs, stress echocardiography arm $3,265 (+/- $2,383 to $4,836) and 24.63 (+/- 24.28 to 24.74) QALYs, and stress ECG arm $3,461 (+/- $2,533 to $4,996) and 24.59 (+/- 24.21 to 24.75) QALYs. The MDCT dominated (less costly and more effective) both OU plus stress echocardiography and OU plus stress ECG. This resulted in an ICER where the MDCT arm dominated the stress echocardiography arm (95% confidence interval [CI] = dominant to $29,738) and where MDCT dominated the ECG arm (95% CI = dominant to $7,332). The MDCT risk stratification arm also dominated stress echocardiography and stress ECG in the 2 and 10% prevalence scenarios, which demonstrated the same ICER trends as the 6% prevalence CAD base case. The thresholds where the MDCT arm remained a cost-saving strategy compared to the other risk stratification strategies were cost of MDCT, < $2,097; cost of OU care, > $1,092; prevalence of CAD, < 70%; MDCT specificity, > 65%; and a MDCT indeterminate rate, < 30%. CONCLUSIONS: In this computer-based model analysis, the MDCT risk stratification strategy is less costly and more effective than both OU-based stress echocardiography and stress ECG risk stratification strategies in chest pain patients presenting to the ED with low to moderate prevalence of CAD.

Workplace violence: a survey of emergency physicians in the state of Michigan.

STUDY OBJECTIVE: We seek to determine the amount and type of work-related violence experienced by Michigan attending emergency physicians. METHODS: A mail survey of self-reported work-related violence exposure during the preceding 12 months was sent to randomly selected emergency physician members of the Michigan College of Emergency Physicians. Work-related violence was defined as verbal, physical, confrontation outside of the emergency department (ED), or stalking. RESULTS: Of 250 surveys sent, 177 (70.8%) were returned. Six were blank (3 were from retired emergency physicians), leaving 171 (68.4%) for analysis. Verbal threats were the most common form of work-related violence, with 74.9% (95% confidence interval [CI] 68.4% to 81.4%) of emergency physicians indicating at least 1 verbal threat in the previous 12 months. Of the emergency physicians responding, 28.1% (95% CI 21.3% to 34.8%) indicated that they were victims of a physical assault, 11.7% (95% CI 6.9% to 16.5%) indicated that they were confronted outside of the ED, and 3.5% (95% CI 0.8% to 6.3%) experienced a stalking event. Emergency physicians who were verbally threatened tended to be less experienced (11.1 versus 15.1 years in practice; mean difference -4.0 years [95% CI -6.4 to -1.6 years]), as were those who were physically assaulted (9.5 versus 13.1 years; mean difference -3.6 years [95% CI -5.9 to -1.3 years]). Urban hospital location, emergency medicine board certification, or on-site emergency medicine residency program were not significantly associated with any type of work-related violence. Female emergency physicians were more likely to have experienced physical violence (95% CI 1.4 to 5.8) but not other types of violence. Most (81.9%; 95% CI 76.1% to 87.6%) emergency physicians were occasionally fearful of workplace violence, whereas 9.4% (95% CI 5.0% to 13.7%) were frequently fearful. Forty-two percent of emergency physicians sought various forms of protection as a result of the direct or perceived violence, including obtaining a gun (18%), knife (20%), concealed weapon license (13%), mace (7%), club (4%), or a security escort (31%). CONCLUSION: Work-related violence exposure is not uncommon in EDs. Many emergency physicians are concerned about the violence and are taking measures, including personal protection, in response to the fear.

Capturing more emergency department errors via an anonymous web-based reporting system.

OBJECTIVES: It is generally understood that errors occur during patient care in the emergency department (ED). However, the errors that are reported likely represent a fraction of those that occur. Increasing the error reporting rate would allow for more opportunities to investigate the root causes of errors and improve systems design as part of a continuous quality improvement (CQI) process. We present a model Web-based system for reporting of errors that occur in patient care in the ED. METHODS: We propose a Web-based system of error reporting. Utilizing Web technology permits secure, timely, and, optionally, anonymous reporting of errors. The Web page is readily accessible to users within the medical center. Reporting may be anonymous or the reporters may identify themselves. The reports are sorted by the user and entered based on the type of error and sent to a secure database. The database can be regularly reviewed by a designated person as part of an ongoing CQI process. CQI committees should then have more useful data to reference when designing system improvements. CONCLUSIONS: A Web-based error reporting implemented in this manner may improve error reporting because of the convenience it offers and the option of anonymity. More reporting should create more opportunities for system improvement.

Resident perceptions of medical errors in the emergency department.

OBJECTIVES: To evaluate resident experience and perceptions of medical error associated with emergency department (ED) care. METHODS: Using a semistructured interview protocol, three researchers interviewed 26 randomly selected medical, surgical, and obstetrics residents regarding medical error. The authors chose a 16-case subset of incidents involving ED care for initial review. Interview transcripts were reviewed iteratively to draw out recurrent categories and themes. Two investigators separately analyzed all cases to ensure common understanding and agreement. RESULTS: Most cases involved misdiagnosis, misread radiographs, or inappropriate disposition. Two thirds of the case patients died or experienced delays in care. Residents felt that the complexity of the patients, as well as the complexity of their own jobs, contributed to error. Attending supervision, nurse evaluation, and additional physician involvement all were noted to be important checks within the hospital system. Residents most often held the ED responsible for error. In addition, they deemed themselves, their teams, and their lack of training responsible. Though residents often discussed events with their admitting teams, follow-up with the ED or other associated individuals was uncommon. The findings revealed seven common themes that include factors contributing to errors, checks and adaptations, and follow-up of the event. CONCLUSIONS: Residents are aware of medical error and able to recall events in detail. Whereas events are discussed among inpatient teams, little information finds its way back to the ED, potentially resulting in misunderstandings between departments and hindering learning from events. In-depth interviewing allows a nuanced and detailed approach to error analysis.

Minimizing transfer time to an ST segment elevation myocardial infarction-receiving center: a modified Delphi consensus.

Of patients with ST segment elevation myocardial infarction (STEMI), approximately two thirds present to a hospital not capable of percutaneous coronary intervention. Transfer to a STEMI-receiving center delays time to reperfusion in patients with STEMI, but factors that affect this delay have not been well studied. We performed a 3-round modified Delphi study to identify system practices that minimize transfer time to a STEMI-receiving center. A comprehensive literature review was used to identify candidate system practices. Emergency medical services, emergency medicine, and cardiology experts were invited to participate. Consensus was defined as 80% agreement that a variable was "very important (5)" or "important (4)" with a mean score ≥ 4.25 or 80% agreement that a variable was "not important (1)" or "somewhat important (2)" with a mean score ≤ 1.75. In round 1, participants rated the candidate items and suggested additional items. Individual feedback was provided, and participants discussed items via conference calls before rating them again in round 2. In round 3, participants ranked the consensus items from rounds 1-2 from most to least important, and the mean score for each item was calculated. Of the 98 experts invited, 29 participated in round 1, 22 in round 2, and 14 in round 3. Participants identified 18 system practices that they agree are critical in minimizing transfer time to STEMI-receiving centers, with the most important being performance of a prehospital electrocardiogram and having established transfer protocols. These factors should be considered in the development of STEMI systems of care.

Is emergency department quality related to other hospital quality domains?

OBJECTIVES: Systems theory suggests that there should be relatively high correlations among quality measures within an organization. This was an examination of hospital performance across three types of quality measures included in Medicare's Hospital Inpatient Value-Based Purchasing (HVBP) program: emergency department (ED)-related clinical process measures, inpatient clinical process measures, and patient experience measures. The purpose of this analysis was to determine whether hospital achievement and improvement on the ED quality measures represent a distinct domain of quality. METHODS: This was an exploratory, descriptive analysis using publicly available data. Composite scores for the ED, inpatient, and patient experience measures included in the HVBP program were calculated. Correlations and frequencies were run to examine the extent to which achievement and improvement were related across the three quality domains and the number of hospitals that were in the top quartile for performance across multiple quality domains. RESULTS: Achievement scores were calculated for 2,927 hospitals, and improvement scores were calculated for 2,842 hospitals. There was a positive, moderate correlation between ED and inpatient achievement scores (correlation coefficient of 0.50, 95% confidence interval [CI] = 0.47 to 0.53), but all other correlations were weak (0.16 or less). Only 96 hospitals (3.3%) scored in the top quartile for achievement across the three quality domains; 73 (2.6%) scored in the top quartile for improvement across all three quality domains. CONCLUSIONS: Little consistency was found in achievement or improvement across the three quality domains, suggesting that the ED performance represents a distinct domain of quality. Implications include the following: 1) there are broad opportunities for hospitals to improve, 2) patients may not experience consistent quality levels throughout their hospital visit, 3) quality improvement interventions may need to be tailored specifically to the department, and 4) consumers and policy-makers may not be able to draw conclusions on overall facility quality based on information about one domain.

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

BACKGROUND: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. METHODS: We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. RESULTS: Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. DISCUSSION: Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States.

OBJECTIVES: Patient acuity triage systems can play an important role in supporting patient safety and emergency department (ED) operations. In 2003, the boards of the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) approved a joint statement calling for hospitals to adopt a reliable, valid, five-level triage scale such as the Emergency Severity Index (ESI). Still, there appears to be considerable variation in use of triage acuity systems in the United States, with many hospitals using three- and four-level systems that have not been validated. The purpose of this effort was to measure the use of various triage acuity systems in U.S. hospitals. METHODS: The authors conducted a cross-sectional analysis of secondary data. Data were obtained from the 2009 American Hospital Association (AHA) Annual Survey--an intensive questionnaire mailed to all U.S. general medical and surgical hospitals. In 2009, a question was added to the survey about hospitals' use of triage systems in EDs. Descriptive statistics were used to explore various triage acuity systems used by different types of hospitals. RESULTS: Of the 4,897 hospitals surveyed, 82% responded, and 62% (3,024 hospitals) provided information on their ED triage system. The 2009 data revealed that the most commonly used triage system types were the five-level ESI (56.9% of responding hospitals) and three-level triage systems (25.2%). More than 70% of large hospitals and teaching hospitals use the ESI, and the unvalidated three-level systems were more common in small hospitals, public hospitals, nonteaching hospitals, and hospitals in the Midwest. The majority (72.1%) of all ED patient visits to hospitals in our sample were assessed using ESI; only 13.1% of visits were assessed using a three-level system. CONCLUSIONS: Among our sample of more than 3,000 hospitals, the ESI was the most commonly used triage system, and more patients were triaged using the ESI than any other triage acuity system. Still, there is an opportunity to further promote the adoption of validated, reliable triage systems.

Cost-effectiveness of a novel indication of computed tomography of the coronary arteries.

OBJECTIVE: A common strategy for excluding coronary artery disease among patients presenting with low-risk chest pain is observation unit (OU) admission with serial cardiac biomarkers and stress testing for cardiac risk stratification. Patients with positive- or indeterminate-stress tests are often admitted for cardiac catheterization despite a low likelihood of disease. The aim of this study is to estimate the cost-effectiveness of computed tomography of the coronary arteries (CTCA) in the OU for the evaluation of low-risk chest pain patients with indeterminate- or positive-stress test results. METHODS: We conducted a decision analytic study to compare health outcomes and costs between 3 cardiac risk-stratification strategies in a population of patients at low cardiac risk admitted to the OU, who later had indeterminate- or abnormal-stress tests. Our population and test characteristics were based on data obtained both from the published literature and from a retrospective cohort review previously performed at our institution. The 3 strategies compared were (1) A CTCA strategy in which patients with positive- or indeterminate-stress tests subsequently underwent CTCA, and only received catheterization if results were positive, (2) A standard-of-care arm in which all patients with positive- or indeterminate-stress tests were admitted for catheterization, and (3) A do-nothing strategy in which all patients were discharged home after stress testing regardless of outcome. Outcomes measured were cost of care and life expectancy. Sensitivity analysis was performed with a multivariate Monte Carlo methodology. RESULTS: Both the CTCA and standard-of-care strategies dominated the do-nothing strategy in the base case. When comparing the standard-of-care with the CTCA strategy, the incremental cost-effectiveness ratio was $3,423,309 per additional year of life gained. Sensitivity analysis showed that below a willingness to pay of $600,000 per additional year of life, CTCA was the most likely strategy to be cost-effective. CONCLUSIONS: In this computer-modeled analysis, the addition of CTCA following positive- or indeterminate-stress tests to an OU cardiac risk-stratification pathway for low-risk chest pain patients achieved significant cost savings with a small decrease in life expectancy per patient. Adding CTCA after indeterminate- or positive-stress test results is a cost-effective intervention for further risk-stratifying low-risk chest pain patients in the OU setting before proceeding to traditional coronary angiography.

Interventions to improve patient-centered care during times of emergency department crowding.

Patient-centered care is defined by the Institute of Medicine (IOM) as care that is responsive to individual patient needs and values and that guides treatment decisions. This article is the result of a breakout session of the 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" and focuses on three broad domains of patient-centered care: patient satisfaction, patient involvement, and care related to patient needs.The working group provided background information and an overview of interventions that have been conducted in the domains of patient satisfaction, patient involvement (patients' preferences and values in decision-making), and patient needs (e.g., comfort, information, education). Participants in the breakout session discussed interventions reported in the medical literature as well as initiated at their institutions, discussed the effect of crowding on patient-centered care, and prioritized, in a two-step voting process, five areas of focus for establishing a research agenda for studying patient-centered care during times of crowding. The research priorities for enhancing patient-centered care in all three domains during periods of crowding are discussed. These include assessing the effect of other quality domains on patient satisfaction and determining the effects of changes in ED operations on patient satisfaction; enhancing patient involvement by determining the effect of digital records and health information technology (HIT); rapid assessment areas with focused patient-provider communication; and meeting patients' needs through flexible staffing, use of HIT to enhance patient communication, discharge instructions, and postdischarge telephone calls.

Achieving efficiency in crowded emergency departments: a research agenda.

In 2011, Academic Emergency Medicine convened a consensus conference entitled "Interventions to Assure Quality in the Crowded Emergency Department." This article, a product of the breakout session on "interventions to safeguard efficiency of care," explores various elements of the research agenda on efficiency and quality in crowded emergency departments (EDs). The authors discuss four areas identified as critical to achieving progress in the research agenda for improving ED efficiency: 1) What measures can be used to understand and improve the efficiency and quality of interventions in the ED? 2) Which factors outside of the ED's control affect ED efficiency? 3) How do workforce factors affect ED efficiency? 4) How do ED design, patient flow structures, and use of technology affect efficiency? Filling these knowledge gaps is vital to identifying interventions that improve the delivery of emergency care in all EDs.