Increased rate of central venous catheterization procedures in community EDs.

OBJECTIVE: Central venous catheterization (CVC) is integral to the emergency department (ED) treatment of critically ill patients, such as those receiving early goal-directed therapy for severe sepsis. No previous studies have described the overall use of CVC in community EDs. The objective of this study was to estimate the overall frequency and temporal trends in CVC use in a sample of patients visiting community EDs. METHODS: This was a retrospective observational study of 2.97 million patient visits at 28 community EDs (range of annual visits, 10 837-110 136) from January 2004 to February 2008. Data were obtained from a community-based research consortium. Central venous catheterization procedures were aggregated at the hospital level for each study year. Trends in CVC use were evaluated using linear regression. RESULTS: Three thousand four hundred eighty-nine patient visits (0.12% of all ED patient visits) had a CVC procedure performed in the ED. The overall rate of CVC procedures per 1000 ED patient visits increased from 0.87 (95% confidence interval [CI(95%)], 0.80-0.95) in 2004 to 1.62 (CI(95%), 1.38-1.91) procedures in 2008 (P value for trend = .003). There was wide variability in the frequency of CVC procedures performed among EDs, ranging from a low of 0.27 (CI(95%), 0.18-0.42) to a high of 7.58 (CI(95%), 6.27-9.17) procedures per 1000 ED visits. The CVC procedure rates were lower in the 8 rural EDs (0.99 CVCs per 1000 ED patient visits [CI(95%), 0.91-1.07] compared with the 20 urban EDs (1.22 CVCs [CI(95%), 1.18-1.27]; P < .001). An increasing rate of CVC procedures during the study period was observed in urban EDs (0.84-1.94 CVCs per 1000 ED patient visits; P value for trend = .005) but not in rural EDs (1.1-0.93; P value for trend = .41) during the study period. CONCLUSION: The overall rate of CVC increased from 2004 to 2008. However, there was a wide variation among Eds, and the CVC rate was lower in rural compared with urban EDs. The increase in CVC use in urban EDs may reflect more intensive therapy in the management of ED patients with acute illness or injury. Future efforts are needed to optimize best practices for the use of CVC in community ED practices and to characterize factors responsible for urban rural differences in the rate of CVC procedures.

Promoting quality: the health-care organization from a management perspective.

BACKGROUND: Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure-process-outcome framework in which to think about quality-improvement efforts. ISSUE: There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement. SOLUTIONS: We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of 'structure' for transforming quality-improvement initiatives.

Healthcare economics for the emergency physician.

Although the principles of healthcare economics are not usually part of the fundamental education of emergency physicians, an understanding of these elements will enhance our ability to contribute to improved health-care value. This article introduces the practical aspects of microeconomics, insurance, the supply-and-demand relationship, competition, and costs as they affect the practice of medicine on a daily basis. Being cognizant of how these elements create a dynamic interplay in the health-care industry will allow physicians to better understand the expanded role they need to assume in the ongoing cost and quality debate.