A Realist Evaluation of a 72-Hour Readmission Audit and Feedback (A&F) Intervention in Emergency Medicine.

Introduction Audit and feedback (A&F) interventions are intended to increase accountability and improve the quality of care; however, their impact can vary significantly. As performance feedback is implemented in healthcare, there is a growing need to determine how users interact with the data and how systems can achieve more consistent performance outcomes. This study aimed to understand the contexts, mechanisms, and outcomes of an emergency department 72-hour readmission A&F intervention. Methods Semi-structured interviews with key stakeholders were conducted and analyzed using thematic and template analysis techniques specifically aimed at identifying context, mechanism, and outcome configurations. Results Seventeen (17) physician interviews were conducted. We identified five outcomes of the intervention and the contexts and mechanisms contributing to them. Importantly, we identified that this A&F strategy could potentially have positive (improved follow-up of cases, improved discharge communication) and negative impacts (increased physician anxiety, potentially increased resource use) on physicians and departmental efficiency. Conclusion The 72-hour readmission alert A&F intervention generates a number of distinct outcome patterns that result from a variety of mechanisms acting in different contexts. Knowledge of these context-mechanism-outcome relationships may help implementers design and tailor performance feedback strategies.

Optimizing standard patient management through order sets - impact on care (blood cultures).

We show that order set design and support must be thoughtful to result in improved quality of care and reduced waste and that order set use should be monitored to confirm expected impact and detect unanticipated consequences.

Computer order entry systems in the emergency department significantly reduce the time to medication delivery for high acuity patients.

BACKGROUND: Computerized physician order entry (CPOE) systems are designed to increase safety and improve quality of care; however, their impact on efficiency in the ED has not yet been validated. This study examined the impact of CPOE on process times for medication delivery, laboratory utilization and diagnostic imaging in the early, late and control phases of a regional ED-CPOE implementation. SETTING: Three tertiary care hospitals serving a population in excess of 1 million inhabitants that initiated the same CPOE system during the same 3-week time window. Patients were stratified into three groupings: Control, Early CPOE and Late CPOE (n = 200 patients per group/hospital site). Eligible patients consisted of a stratified (40% CTAS 2 and 60% CTAS 3) random sample of all patients seen 30 days preceding CPOE implementation (Control), 30 days immediately after CPOE implementation (Early CPOE) and 5-6 months after CPOE implementation (Late CPOE). Primary outcomes were time to (TT) from physician assignment (MD-sign) up to MD-order completion. An ANOVA and t-test were employed for statistical analysis. RESULTS: In comparison with control, TT 1st MD-Ordered Medication decreased in both the Early and Late CPOE groups (102.6 min control, 62.8 Early and 65.7 late, p < 0.001). TT 1st MD-ordered laboratory results increased in both the Early and Late CPOE groups compared to Control (76.4, 85.3 and 73.8 min, respectively, p < 0.001). TT 1st X-Ray also significantly increased in both the Early and Late CPOE groups (80.4, 84.8 min, respectively, compared to 68.1, p < 0.001). Given that CT and ultrasound imaging inherently takes increased time, these imaging studies were not included, and only X-ray was examined. There was no statistical difference found between TT discharge and consult request. CONCLUSIONS: Regional implementation of CPOE afforded important efficiencies in time to medication delivery for high acuity ED patients. Increased times observed for laboratory and radiology results may reflect system issues outside of the emergency department and as a result of potential confounding may not be a reflection of CPOE impact.

Effect of an emergency department sepsis protocol on time to antibiotics in severe sepsis.

OBJECTIVE: We sought to evaluate the time to antibiotics for emergency department (ED) patients meeting criteria for severe sepsis before and after the implementation of an ED sepsis protocol. Compliance with published guidelines for time to antibiotics and initial empiric therapy in sepsis was also assessed. METHODS: A retrospective chart review was conducted. Emergency department patient encounters with International Classification of Diseases codes related to severe infections were screened during a 3-month period before and after the implementation of a sepsis protocol. Encounters meeting criteria for severe sepsis were further assessed. The time to initiation of antibiotics was determined as well as the initial choice of antimicrobial therapy based on the presumed source of infection. RESULTS: We reviewed 213 unique ED patient encounters meeting criteria for severe sepsis. Analysis of the period before implementation showed a median time from the time criteria for severe sepsis were met to delivery of antibiotics of 163 minutes (95% confidence interval [CI] 124 to 210 min). Analysis of the period after implementation of the protocol revealed a median time of 79 minutes (95% CI 64 to 94 min), representing an overall reduction of 84 minutes (95% CI 42 to 126 min). Before the implementation of the protocol, 47% of patients received correct antibiotic coverage for the presumed source of infection in compliance with locally published guidelines. After the initiation of the protocol, 73% received appropriate initial antibiotics, for an overall improvement of 26%. CONCLUSION: A guideline-based ED sepsis protocol for the evaluation and treatment of the septic patient appears to improve the time to administration of antibiotics as well as the appropriateness of initial antibiotic therapy in patients with severe sepsis.

A southern tyrant reptile.

Tyrannosaurids monopolized the apex predator niche in latest Cretaceous Laurasia. Unfortunately, the preceding 100-million-year tyrannosauroid lineage is poorly documented, and its fossil record is restricted to the northern continents. We report an Australian tyrannosauroid, represented by a pubis from the late Early Cretaceous of Victoria. This demonstrates that these extraordinarily successful predators were not restricted to Laurasia. The advanced morphology and small size of the specimen shows that tyrannosauroids with the characteristic short arms and robust skulls probably had a global distribution in the Early Cretaceous. Thus, a potentially cosmopolitan grade of small tyrannosauroids with a tyrannosaurid-like body plan preceded the Late Cretaceous rise of the colossal tyrannosaurids.

A large Cretaceous theropod from Patagonia, Argentina, and the evolution of carcharodontosaurids.

The Cretaceous Carcharodontosauridae is the latest clade of carnosaurs, including the largest predatory dinosaurs yet recorded. Albeit spectacular for their size, the skeletal anatomy of these theropods remains poorly-known, and their diversity was until recently restricted to two Cenomanian species: the highly derived Giganotosaurus carolinii, from southern South America, and the incompletely known Carcharodontosaurus saharicus, from northern Africa. Here we describe an older and basal member of the group, Tyrannotitan chubutensis gen. et sp. nov., from Aptian strata of Patagonia, Argentina. The new taxon gives new insights into the systematics and evolution of carcharodontosaurids and offers a better understanding of the evolution of Southern theropod faunas. We suggest that carcharodontosaurids radiated in Gondwana sharing with spinosaurids the role of top-predators until their extinction in Cenomanian-Turonian times. During this interval, the diplodocoid sauropods and giant titanosaurians went extinct (probably as part of a global-scale crisis), and the smaller abelisaurid theropods took dominance, reigning until the end of the Cretaceous. Electronic Supplementary Material is available.