RESUMEN
This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.
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Infecciones Comunitarias Adquiridas/diagnóstico , Servicio de Urgencia en Hospital , Neumonía Bacteriana/diagnóstico , Adulto , Antibacterianos/uso terapéutico , Biomarcadores , Reglas de Decisión Clínica , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/mortalidad , Servicio de Urgencia en Hospital/normas , Humanos , Neumonía Bacteriana/tratamiento farmacológico , Neumonía Bacteriana/mortalidad , Pronóstico , Medición de RiesgoRESUMEN
OBJECTIVES: To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time. DESIGN: Before-and-after quasi-experimental study. SETTING: Urban, tertiary care hospital ED. PARTICIPANTS: Consecutive adult patient visits between July 2011 and June 2013. INTERVENTION: A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR. MAIN OUTCOME MEASURES: Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow. RESULTS: About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar. CONCLUSION: The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.
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Registros Electrónicos de Salud/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Triaje/métodos , Adulto , Anciano , Algoritmos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Severe sepsis and septic shock are a major health concern worldwide. The objective of this study is to determine if Severe Sepsis Best Practice Alert (SS-BPA) implementation was associated with improved processes of care and clinical outcomes among patients with severe sepsis or septic shock presenting to the emergency department (ED). METHODS: This is a single-center, before-and-after observational study. The intervention group (n = 103) consisted of adult patients presenting to the ED with severe sepsis or septic shock during a 7-month period after implementation of the SS-BPA. The control group (n = 111) consisted of patients meeting the same criteria over a prior 7-month period. The SS-BPA primarily acts by automated, real-time, algorithm-based detection of severe sepsis or septic shock via the electronic medical record system. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (LOS), time to antibiotic administration, and proportion of patients who received antibiotics within the target 60 minutes. RESULTS: Time to antibiotics was significantly reduced in the SS-BPA cohort (29 vs 61.5 minutes, P < .001). In addition, there was a higher proportion of patients who received antibiotics within 60 minutes (76.7 vs 48.6%; P < .001). On multivariable analysis, in-hospital mortality was not significantly reduced in the intervention group (odds ratio, 0.64; 95% confidence interval, 0.26-1.57). Multivariable analysis of LOS indicated a significant reduction among patients in the SS-BPA cohort (geometric mean ratio, 0.66; 95% confidence interval, 0.53-0.82). CONCLUSION: Implementation of the SS-BPA for severe sepsis or septic shock among ED patients is associated with significantly improved timeliness of antibiotic administration and reduced hospital LOS.
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Protocolos Clínicos , Registros Electrónicos de Salud , Servicio de Urgencia en Hospital , Evaluación de Procesos y Resultados en Atención de Salud , Sepsis/terapia , Anciano , Algoritmos , Antibacterianos/uso terapéutico , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Sepsis/mortalidad , Factores de TiempoRESUMEN
OBJECTIVE: Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. METHODS: A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. RESULTS: A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). CONCLUSION: A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.
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Corticoesteroides/uso terapéutico , Asma/tratamiento farmacológico , Broncodilatadores/uso terapéutico , Vías Clínicas , Servicio de Urgencia en Hospital/organización & administración , Hospitalización/estadística & datos numéricos , Adolescente , Adulto , California/epidemiología , Niño , Preescolar , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Lactante , Masculino , Cumplimiento de la Medicación/estadística & datos numéricos , Estudios Prospectivos , Adulto JovenRESUMEN
INTRODUCTION: Boarding, especially among psychiatric patients, has been characterized as a significant cause of ED crowding, but no quantitative analysis has described boarding nationally. This study determines the incidence, duration, and factors associated with ED boarding in the United States. METHODS: 2008 National Hospital Ambulatory Medical Care Survey ED data were stratified by visit type (psychiatric vs. non-psychiatric), boarding status, and patient and hospital characteristics. Boarding was defined as a visit with an ED length of stay >6 hours, and boarding time as ED length of stay minus 6 hours. Pearson's chi-square tests describe hospital and patient characteristics stratified by boarding status. Multilevel multivariable logistic and linear regressions determine associations with boarding and boarding time. RESULTS: While 11% of all ED patients boarded, 21.5% of all psychiatric ED patients boarded. Boarding was also more prolonged for psychiatric ED patients. Controlling for confounders, odds of boarding for psychiatric patients were 4.78 (2.63-8.66) times higher than non-psychiatric, and psychiatric patients boarded 2.78 (1.91-3.64) hours longer than non-psychiatric. DISCUSSION: US EDs experienced high proportions and durations of boarding with psychiatric patients disproportionately affected. Additional research concerning mental health care services and legislation may be required to address ED psychiatric patient boarding.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Tiempo de Internación , Trastornos Mentales/terapia , Evaluación de Resultado en la Atención de Salud , Admisión del Paciente/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Anciano , Aglomeración , Servicios Médicos de Urgencia/organización & administración , Femenino , Encuestas de Atención de la Salud , Humanos , Modelos Lineales , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/epidemiología , Enfermos Mentales/estadística & datos numéricos , Persona de Mediana Edad , Análisis Multivariante , Evaluación de Necesidades , Medición de Riesgo , Factores Sexuales , Estados Unidos , Adulto JovenRESUMEN
STUDY OBJECTIVE: Proposed national performance measures for severe sepsis or septic shock include interventions within 3 hours of emergency department (ED) arrival rather than from time of first meeting diagnostic criteria. We aim to determine the percentage of ED patients who first meet criteria greater than 3 hours after arrival. METHODS: We conducted a retrospective analysis of adult patients with severe sepsis or septic shock in 2 EDs (university hospital [September 2012 to June 2013] and public trauma center [December 2012 to May 2013]). Times of ED arrival and first meeting clinical criteria were collected for quality assurance programs, which differed between institutions. At the university hospital, patients with admission diagnoses consistent with infection were included. Clinical presentation was defined as time meeting 2 or more systemic inflammatory response syndrome criteria and evidence of end-organ dysfunction. At the trauma center, only patients with hospital discharge diagnoses consistent with infection were included. Clinical presentation was defined by time of end-organ dysfunction. RESULTS: Three hundred seventy-two patients met inclusion criteria at the university hospital and 133 at the trauma center. Median times from ED arrival to first meeting criteria were 68 minutes (interquartile range 34 to 130 minutes) and 31 minutes (interquartile range 8 to 73 minutes), respectively; 15.3% (95% confidence interval 11.9% to 19.3%) and 9.8% (95% confidence interval 5.5% to 15.7%) first met criteria greater than 3 hours from ED arrival, respectively. CONCLUSION: Compliance with a performance metric for severe sepsis and septic shock within 3 hours of ED arrival would require application of this measure to patients who do not meet diagnostic criteria, potentially resulting in unnecessary interventions. Measure developers should consider these findings.
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Servicio de Urgencia en Hospital/normas , Sepsis/diagnóstico , Adulto , California , Registros Electrónicos de Salud , Femenino , Hospitales Universitarios , Humanos , Masculino , Estudios Retrospectivos , Sepsis/terapia , Índice de Severidad de la Enfermedad , Choque Séptico/diagnóstico , Choque Séptico/terapia , Factores de Tiempo , Centros TraumatológicosRESUMEN
BACKGROUND: Pneumonia antibiotic timing performance measures can result in unnecessary antibiotic administration to patients in whom a diagnosis of pneumonia remains possible but has not been confirmed. OBJECTIVE: Our objective was to determine if unnecessary antibiotic administration to admissions with Emergency Department (ED) congestive heart failure (CHF) diagnoses increased as institutional attention to pneumonia antibiotic timing intensified. METHODS: We performed a cross-sectional study in an academic ED with 39,000 annual visits. Our subjects included adult admissions with ED CHF diagnoses between October and March of 2004-2005, 2005-2006, and 2006-2007. We excluded patients with any concomitant infectious diagnosis from primary analysis. We obtained patient age, sex, triage acuity, vital signs, ED diagnoses, and admitting service from electronic databases. Trained abstractors confirmed infectious diagnosis presence and noted if antibiotics were administered. Inter-observer agreement was assessed. Multivariate logistic regression determined association of time period with antibiotic administration. We assessed trends in concomitant infectious diagnoses. RESULTS: Of 778 CHF admissions, 125 had infectious diagnoses, leaving 653 for primary analysis. Inter-observer agreement was good to excellent (κ = 0.71-0.83). Demographic and presenting characteristics did not vary by period. Antibiotics were administered to 18.4% (95% confidence interval [CI] 12.7-23.3), 15.0% (95% CI 9.6-18.5), and 15.1% (95% CI 10.2-19.8), per period, respectively. Time period was not associated with antibiotics, odds ratios were 0.8 (95% CI 0.5-1.4) and 0.9 (95% CI 0.5-1.6) for periods 2 and 3, respectively. Concomitant infectious diagnoses did not increase significantly (from 15.5% to 19.4%). Pneumonia antibiotic timing compliance remained low (50-70%). CONCLUSIONS: Unnecessary antibiotic administration to ED CHF admissions did not increase as institutional scrutiny of pneumonia antibiotic timing intensified, although neither did compliance with pneumonia antibiotic timing.
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Profilaxis Antibiótica/estadística & datos numéricos , Insuficiencia Cardíaca/complicaciones , Neumonía/complicaciones , Neumonía/prevención & control , Anciano , Anciano de 80 o más Años , Estudios Transversales , Servicios Médicos de Urgencia/normas , Servicio de Urgencia en Hospital , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis MultivarianteRESUMEN
OBJECTIVE: This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. METHODS: This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. RESULTS: Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids. CONCLUSIONS: In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.
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Corticoesteroides/uso terapéutico , Antiasmáticos/uso terapéutico , Asma/tratamiento farmacológico , Aglomeración , Servicio de Urgencia en Hospital , Enfermedad Aguda , Adolescente , Corticoesteroides/administración & dosificación , Factores de Edad , Antiasmáticos/administración & dosificación , Asma/sangre , Broncodilatadores/administración & dosificación , Broncodilatadores/uso terapéutico , Niño , Preescolar , Esquema de Medicación , Quimioterapia Combinada , Registros Electrónicos de Salud , Femenino , Adhesión a Directriz , Humanos , Hipoxia/etiología , Lactante , Masculino , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Taquipnea/etiología , Factores de Tiempo , Triaje , Adulto JovenRESUMEN
CONTEXT: Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. OBJECTIVE: To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status. DESIGN, SETTING, AND PARTICIPANTS: The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance. MAIN OUTCOME MEASURES: Emergency Department length-of-stay measure compliance by disposition and safety-net status. RESULTS: Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non-safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non-safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]). CONCLUSION: Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non-safety-net hospitals.
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Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitales/clasificación , Tiempo de Internación , Pacientes no Asegurados , Adulto , Anciano , Economía Hospitalaria , Femenino , Adhesión a Directriz , Humanos , Masculino , Medicaid/estadística & datos numéricos , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Reembolso de Incentivo , Estados Unidos , Adulto JovenRESUMEN
Background: Residency selection in the United States relied on in-person interviews for many decades. The COVID-19 pandemic and recommendations from the Coalition for Physician Accountability (COPA) required programs to implement virtual interviews for the 2020-2021 residency selection cycle. Although virtual interviews may become the norm in the future, there is scant data at the institutional level to inform how to best approach this process. Objective: To describe the perceptions of applicants to several residency programs at one institution on the importance of virtual recruitment features and assess the impact on their overall ranking decisions. Methods: Applicants who interviewed for 12 medical and surgical residency programs during the 2020-2021 cycle at the University of California San Francisco were invited to participate in an anonymous survey in March 2021, after all interviews were completed. A survey consisting of 26 questions was administered to applicants on features that are important during interviews and the impact on their ranking decisions scored on a 5-point Likert scale. Results: Of the 1422 participating applicants, 303 (21%) completed the survey. The most important feature for applicants during the interview day was getting a feel of the program (92%). Conversations with residents (91%) and faculty (79%) were also highly rated. Respondents reported morale and happiness of residents (71%) as an extremely important factor in their overall ranking decision. Conclusion: Programs should consider prioritizing features that aid in alignment with getting to know residents and faculty and provide a sense of morale over emphasis on the institutional and location features. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00004-5.
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Antimicrobial resistance in urinary tract infections (UTIs) is a major public health concern. This study aims to characterize the phenotypic and genetic basis of multidrug resistance (MDR) among expanded-spectrum cephalosporin-resistant (ESCR) uropathogenic Escherichia coli (UPEC) causing UTIs in California patient populations. Between February and October 2019, 577 ESCR UPEC isolates were collected from patients at 6 clinical laboratory sites across California. Lineage and antibiotic resistance genes were determined by analysis of whole-genome sequence data. The lineages ST131, ST1193, ST648, and ST69 were predominant, representing 46%, 5.5%, 4.5%, and 4.5% of the collection, respectively. Overall, 527 (91%) isolates had an expanded-spectrum ß-lactamase (ESBL) phenotype, with blaCTX-M-15, blaCTX-M-27, blaCTX-M-55, and blaCTX-M-14 being the most prevalent ESBL genes. In the 50 non-ESBL phenotype isolates, 40 (62%) contained blaCMY-2, which was the predominant plasmid-mediated AmpC (pAmpC) gene. Narrow-spectrum ß-lactamases, blaTEM-1B and blaOXA-1, were also found in 44.9% and 32.1% of isolates, respectively. Among ESCR UPEC isolates, isolates with an ESBL phenotype had a 1.7-times-greater likelihood of being MDR than non-ESBL phenotype isolates (P < 0.001). The cooccurrence of blaCTX-M-15, blaOXA-1, and aac(6')-Ib-cr within ESCR UPEC isolates was strongly correlated. Cooccurrence of blaCTX-M-15, blaOXA-1, and aac(6')-Ib-cr was associated with an increased risk of nonsusceptibility to piperacillin-tazobactam, cefepime, fluoroquinolones, and amikacin as well as MDR. Multivariate regression revealed the presence of blaCTX-M-55, blaTEM-1B, and the ST131 genotype as predictors of MDR. IMPORTANCE The rising incidence of resistance to expanded-spectrum cephalosporins among Escherichia coli strains, the most common cause of UTIs, is threatening our ability to successfully empirically treat these infections. ESCR E. coli strains are often MDR; therefore, UTI caused by these organisms often leads to treatment failure, increased length of hospital stay, and severe complications (D. G. Mark, Y.-Y. Hung, Z. Salim, N. J. Tarlton, et al., Ann Emerg Med 78:357-369, 2021, https://doi.org/10.1016/j.annemergmed.2021.01.003). Here, we performed an in-depth analysis of genetic factors of ESCR E. coli associated with coresistance and MDR. Such knowledge is critical to advance UTI diagnosis, treatment, and antibiotic stewardship.
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Infecciones por Escherichia coli , Escherichia coli Uropatógena , Humanos , Cefalosporinas/farmacología , Escherichia coli Uropatógena/genética , Infecciones por Escherichia coli/epidemiología , beta-Lactamasas/genética , Fenotipo , Monobactamas , Farmacorresistencia Bacteriana Múltiple/genéticaRESUMEN
OBJECTIVE: The study aimed to determine if emergency department (ED)-administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival. DESIGN: Time series analysis. SETTING: Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). PARTICIPANTS: Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. MAIN OUTCOME: Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering. RESULTS: Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department-administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100 degrees F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007. CONCLUSIONS: Emergency department-administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.
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Antibacterianos/uso terapéutico , Bronquitis/tratamiento farmacológico , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Adolescente , Adulto , Anciano , Antibacterianos/administración & dosificación , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía/tratamiento farmacológico , Calidad de la Atención de Salud , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND: Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. METHODS: An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. RESULTS: Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. CONCLUSIONS: In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.
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Infección Hospitalaria/tratamiento farmacológico , Neumonía/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Centros Médicos Académicos , Antibacterianos/uso terapéutico , HumanosRESUMEN
STUDY OBJECTIVE: We determine the proportion of methicillin-resistant Staphylococcus aureus (MRSA) in adult septic arthritis patients presenting to the emergency department (ED). METHODS: This was a cross-sectional retrospective review in 2 urban academic EDs in northern California, one tertiary care and one public. Subjects included patients who underwent arthrocentesis in the ED from April 2006 through July 2007. We queried the microbiology laboratory databases for synovial fluid cultures sent from the ED. We reviewed synovial fluid culture results and corresponding synovial fluid analyses and then classified positive culture results as true septic arthritis or likely contaminant. For septic arthritis cases, we reviewed medical records and abstracted presenting features. We report our findings with descriptive statistics. RESULTS: One hundred nine synovial fluid cultures were sent from the EDs. Twenty-three results (21%; 95% confidence interval [CI] 14% to 30%) were positive, of which 9 were likely contaminants; 1 was from a soft tissue abscess and 1 was from bursitis. Of 12 septic arthritis cases, 6 cultures (50%; 95% CI 21% to 78%) grew MRSA, 4 (33%; 95% CI 7% to 60%) methicillin-susceptible S aureus, and 1 each (8%; 95% CI 0% to 24%) Streptococcus pneumoniae, Enterococcus faecalis, and Pseudomonas aeruginosa. Of the 6 MRSA cases, 4 were in male patients; median age of patients was 47.5 years, 3 patients had previously diseased joints, 2 patients injected drugs, 2 patients were febrile, 3 patients had previously diseased joints, median synovial fluid leukocyte count was 15,184 cells/microL (range 3,400 to 34,075 cells/microL), and 5 patients received appropriate ED antibiotics. CONCLUSION: In this 2-ED population from a single geographic region, MRSA was the most common cause of community-onset adult septic arthritis. Synovial fluid cell counts were unexpectedly low in MRSA septic arthritis cases.
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Artritis Infecciosa/epidemiología , Artritis Infecciosa/microbiología , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Infecciones Estafilocócicas/epidemiología , Adulto , Antibacterianos/uso terapéutico , Artritis Infecciosa/diagnóstico , Artritis Infecciosa/tratamiento farmacológico , Artroscopía/métodos , California/epidemiología , Estudios Transversales , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Articulación de la Cadera/microbiología , Articulación de la Cadera/fisiopatología , Humanos , Incidencia , Articulación de la Rodilla/microbiología , Articulación de la Rodilla/fisiopatología , Recuento de Leucocitos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Articulación del Hombro/microbiología , Articulación del Hombro/fisiopatología , Infecciones Estafilocócicas/diagnóstico , Líquido Sinovial/microbiologíaRESUMEN
The administration of antibiotics within 4 hours to patients with community-acquired pneumonia has been criticized as a quality standard because it pressures clinicians to rapidly administer antibiotics despite diagnostic uncertainty at the time of patients' initial presentations. The measure was recently revised (to 6 hours) in response to this criticism. On the basis of the experience with the 4-hour rule, the authors make 5 recommendations for the development of future publicly reported quality measures. First, results from samples with known diagnoses should be extrapolated cautiously, if at all, to patients without a diagnosis. Second, for some measures, "bands" of performance may make more sense than "all-or-nothing" expectations. Third, representative end users of quality measures should participate in measure development. Fourth, quality measurement and reporting programs should build in mechanisms to reassess measures over time. Finally, biases, both financial and intellectual, that may influence quality measure development should be minimized. These steps will increase the probability that future quality measures will improve care without creating negative unintended consequences.
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Antibacterianos/administración & dosificación , Evaluación de Resultado en la Atención de Salud/normas , Neumonía Bacteriana/tratamiento farmacológico , Salud Pública/normas , Garantía de la Calidad de Atención de Salud , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Esquema de Medicación , Humanos , Evaluación de Resultado en la Atención de Salud/tendenciasRESUMEN
INTRODUCTION: Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. METHODS: We conducted a national survey at 33 emergency medicine residency programs evaluating residents' perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified. RESULTS: There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity's impact on punitive response to error, the ability to learn from cases, and professional responsibility. CONCLUSION: Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.
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Medicina de Emergencia/educación , Internado y Residencia , Acreditación , Confidencialidad , Humanos , Morbilidad , Mortalidad , Cultura Organizacional , Seguridad , Estudiantes de Medicina/psicología , Encuestas y Cuestionarios , Estados UnidosRESUMEN
BACKGROUND: Implementation of evidence-based quality improvement (QI) initiatives is not without its challenges. Recent experience in the design, implementation, and evaluation of three QI initiatives at the University of California, San Francisco Medical Center (UCSF) suggests lessons learned that may be generalizable to other QI initiatives. INITIATIVES: Between December 2002 and May 2006, a ventilator bundle of care and a tight glycemic control (TGC) protocol were implemented in the intensive care units (ICUs), and early goal-directed therapy (EGDT) for patients with severe sepsis or septic shock was implemented in the ICUs and emergency department. The initiatives were selected on the basis of the magnitude of the problem, strength of the evidence regarding associated reductions in morbidity and mortality in the critically ill, and cost-effectiveness. LESSONS LEARNED: A number of challenges in QI processes and strategies for success were identified via retrospective analysis within the construct of the Plan-Do-Study-Act model, representing a novel use of the model. Pitfalls most commonly occurred in the planning stage. Suggested strategies for success include using an interdisciplinary team, selecting a champion, securing additional resources, identifying specific goals and providing feedback on progress, using work-flow analyses and stepwise implementation and/or pilot testing, creating standard work, eliciting feedback from staff, and celebrating successes. The knowledge gained from these initiatives has been disseminated at UCSF, and the initiatives have helped to raise general awareness regarding the importance of quality. CONCLUSIONS: The ventilator bundle of care, TGC, and EGDT are still in use at UCSF, with modification of the initiatives occurring as new evidence becomes available.
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Cuidados Críticos/normas , Medicina Basada en la Evidencia , Garantía de la Calidad de Atención de Salud/métodos , Índice Glucémico , Humanos , Comunicación Interdisciplinaria , Respiración Artificial , Estudios Retrospectivos , San FranciscoRESUMEN
PURPOSE: To characterize the Emergency Department (ED) presentation of necrotizing soft tissue infections (NSTI) and identify severity markers. PROCEDURES: Retrospective chart review of pathologically diagnosed NSTIs presenting to an urban ED from 1990-2001. Cases were identified from a surgical database, ICD-9 search and prospectively. Five Emergency Physicians (EPs) abstracted data using a standardized form. Severe NSTI was defined by any of the following: death, amputation, intensive care unit (ICU) stay >24 h, >300 cm(2) debrided. Severe and non-severe cases were compared using chi-square, Fisher's exact, and multivariate logistic regression testing. FINDINGS: The 122 cases were characterized by: injection drug use, 80%; fever, 44%; systolic blood pressure (BP) <100 mm Hg, 21%; white blood cell count (WBC) >20 x 10(9)/L, 43%; median time to operation, 8.4 h; mortality, 16%. The managing EP suspected NSTI in 59%. A systolic BP <100 mm Hg, BUN >18 mg/dL, radiographic soft tissue gas, admission to a non-surgical service and clostridial species were independently associated with severe NSTI. CONCLUSIONS: Pathologically defined NSTIs have a wide spectrum of ED presentations and early diagnosis remains difficult.
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Servicio de Urgencia en Hospital , Fascitis Necrotizante/diagnóstico , Infecciones de los Tejidos Blandos/diagnóstico , Adulto , California/epidemiología , Cuidados Críticos , Desbridamiento , Fascitis Necrotizante/etiología , Fascitis Necrotizante/mortalidad , Femenino , Hospitalización , Hospitales Urbanos/normas , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Infecciones de los Tejidos Blandos/etiología , Infecciones de los Tejidos Blandos/mortalidad , Abuso de Sustancias por Vía Intravenosa/complicacionesRESUMEN
STUDY OBJECTIVE: We determine whether it is feasible to identify 90% of emergency department (ED) patients who subsequently receive a hospital discharge diagnosis of community-acquired pneumonia using the current Joint Commission on Accreditation of Healthcare Organizations (JCAHO)/Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures criteria. METHODS: This was a retrospective case series in a university tertiary care ED. From a random sample of patients discharged from the hospital between January and December 2005 who were eligible for JCAHO/CMS community-acquired pneumonia antibiotic timing measure PN-5b, we identified the proportion of patients admitted through the ED who received antibiotics more than 4 hours after hospital arrival (outliers). Medical records of outliers were reviewed to determine whether they received a final ED community-acquired pneumonia diagnosis. Presenting characteristics of outliers with and without final ED community-acquired pneumonia diagnoses were compared to determine feature(s) that might explain failure to diagnose community-acquired pneumonia in the ED. RESULTS: Of 152 eligible ED community-acquired pneumonia patients, 53 (34.9%) were identified as outliers. Thirty-one of the outliers did not have a final ED community-acquired pneumonia diagnosis. Thus, at least 20.4% (95% confidence interval [CI] 14.3% to 27.7%) of all ED community-acquired pneumonia patients did not have an ED community-acquired pneumonia diagnosis. Of outliers without an ED community-acquired pneumonia diagnosis, 43.3% had an abnormal chest radiograph compared with 95% with an ED community-acquired pneumonia diagnosis (odds ratio 24.8; 95% CI 3.63 to infinity). CONCLUSION: It may not be possible to identify 90% of hospitalized patients with a discharge diagnosis of community-acquired pneumonia during their ED assessment by using the current JCAHO/CMS criteria. It may therefore be unrealistic to expect that 90% of such patients will have antibiotics delivered within 4 hours of hospital presentation. A more realistic performance standard for antibiotic administration should be established or case definitions modified to include only patients with a final ED community-acquired pneumonia diagnosis or objective clinical and radiographic evidence.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Neumonía/diagnóstico , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Antibacterianos/uso terapéutico , California , Infecciones Comunitarias Adquiridas/diagnóstico , Diagnóstico Precoz , Medicina de Emergencia/normas , Servicio de Urgencia en Hospital/normas , Humanos , Evaluación de Procesos y Resultados en Atención de Salud , Neumonía/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Factores de TiempoRESUMEN
STUDY OBJECTIVE: We hypothesize that emergency department (ED) volume and increased patient complexity are associated with lower quality of care, as measured by time to antibiotics for patients being admitted with community-acquired pneumonia. METHODS: This was a cross-sectional study at a university tertiary care hospital ED. Community-acquired pneumonia patients admitted from the ED and discharged between January 2004 and June 2005 were reviewed by our institution for The Joint Commission's antibiotic timing core measure. Medical records were abstracted for patient age, sex, race, mode of transport, arrival time, triage acuity, inpatient level of care, and arrival-to-antibiotic-administration times. Controlling for patient characteristics, multivariate logistic regression determined association of antibiotic administration within 4 hours of arrival, with total ED volume at the time of the community-acquired pneumonia patient's arrival, and with number of ED patients requiring admission at the time of arrival. RESULTS: Four hundred eighty-six patients were eligible for the study; antibiotic administration time was available for 405. Sixty-one percent of patients received antibiotics within 4 hours. Antibiotic administration within 4 hours was less likely with a greater number of patients (odds ratio 0.96 per additional patient; 95% confidence interval 0.93 to 0.99) and a greater number of patients ultimately admitted (odds ratio 0.93 per patient; 95% confidence interval 0.88 to 0.99) in the ED. The effect of additional patients was present below total ED capacity. CONCLUSION: As ED volume increases, ED patients with community-acquired pneumonia are less likely to receive timely antibiotic therapy. The effect of additional patients appears to occur even at volumes below the maximum bed capacity. Measures to ensure that quality targets are met in the ED should consider the impact of ED volume.