Fast does not imply flawed: Analyzing emergency physician productivity and medical errors.

Objective: To determine whether emergency physician productivity is associated with the risk of medical errors. Methods: We retrospectively analyzed quality assurance (QA) and billing data over 3 years at 2 urban emergency departments. Faculty physicians working 400 hours or more at either site were included. We measured physician years of experience, age, gender, patients seen per hour (PPH), and relative value units billed per hour (RVU/h). From an established QA process, we obtained adjudicated medical errors to calculate rates of medical errors per 1000 patients seen as the outcome. We discretized numeric variables and used Kruskal-Wallis testing to examine relationships between independent variables and rates of medical errors. Results: We included data for 39 physicians at site A and 42 at site B. The median rate of errors per 1000 patients was 1.6 (interquartile range [IQR], 1.1-1.9) at site A and 3.3 (IQR, 2.4-3.9) at site B. At site A, RVU/h was associated with error rates (P = 0.03), with medians of 2.0, 1.2, 1.7, and 1.3 errors per 1000 patients, from slowest to fastest quartiles. At site B, PPH was associated with error rates (P < 0.01), with medians of 3.9, 3.7, 2.4, and 2.7 errors per 1000 patients, from slowest to fastest quartiles. There was no significant relationship between error rates and PPH at site A or RVU/h at site B. Conclusions: Rates of medical errors were associated with 1 metric of physician productivity at each site, with higher error rates seen among physicians with slower productivity.

Case Report: Acute Supraglottitis.

This report illustrates a case of acute supraglottitis, a rare condition that can be easily diagnosed, but can quickly be deadly if missed. The patient presented with a sore throat and unilateral neck swelling that progressed to voice changes and difficulty handling secretions. Initially, radiographs were obtained followed by computed tomography. Imaging raised concern for supraglottitis; therefore otolaryngology consult was obtained and flexible laryngoscopy confirmed the diagnosis. The patient received a prophylactic awake fiberoptic intubation at the bedside and was started on intravenous antibiotics and steroids. She quickly improved and is expected to make a full recovery. Trainees and current practicing physicians in today's post-Haemophilus influenza type b vaccination period rarely encounter epiglottitis or supraglottitis. This case reminds us to keep this uncommon but quickly progressive and dangerous condition in mind to avoid a missed diagnosis which can lead to significant morbidity and mortality. Topics: Supraglottitis, acute supraglottitis, adult, intubation, antibiotic, microbiology.

Describing wait time bottlenecks for ED patients undergoing head CT.

STUDY OBJECTIVES: Facing increased utilization and subsequent capacity and budget constraints, ED's must better understand bottlenecks and their effect on process flow to improve process efficiency. The primary objective of this study was to identify bottlenecks in obtaining a head CT and investigate patient waiting time based on those bottlenecks. METHODS: This observational study included all patients undergoing a head CT between July 1, 2013 and June 30, 2014 at a large, urban academic ED with over 100,000 visits per year. The primary study outcome was total cycle time, defined as the elapsed time between patient arrival and head CT preliminary report, divided into four components of workflow. RESULTS: 8312 patients who had a head CT were included in this study. The median cycle time from patient arrival to head CT preliminary report was 3h and 13min with 39min of waiting time resulting from bottlenecks. In the 4-step model (time from patient arrival to head CT order, time from head CT order to head CT scheduled, time from head CT scheduled to head CT completed, and time from head CT completed to head CT preliminary report), each process was the bottleneck 30%, <1%, 27%, and 42% of the time, respectively. CONCLUSION: Demand capacity mismatch in head CT scanning has a significant impact on patient waiting times. This study suggests opportunities to improve wait times through future research to understand the causes of delays in CT ordering, CT completion and timeliness of radiology reports.

A Case of Status-Epilepticus-Associated Transient Hyperammonemia in the Emergency Department.

This report describes a case of transient hyperammonemia following tonic-clonic status epilepticus with an initial ammonia level of 537 Umol/L. This appears to be the highest transient ammonia level reported in the literature in this clinical scenario. This is an affirmation that an initial elevated ammonia level in the absence of hepatic dysfunction should be interpreted with caution when associated with status epilepticus. Repeat levels should be drawn to identify transient hyperammonemia and determine the need for treatment if levels do not decrease.

The frequency and cost of redundant laboratory testing for transferred ED patients.

INTRODUCTION: Health care costs continue to rise; reducing unnecessary laboratory testing may reduce costs. The goal of this study was to calculate the frequency and estimated costs of repeat normal laboratory testing of patients transferred to a tertiary care emergency department (ED). METHODS: This was a retrospective cohort study of patients transferred to a tertiary care, level -one trauma ED with an annual census of 90,000 patients. We defined "repeat normal testing" as laboratory tests repeated within 8 hours that were normal at both the sending hospital and the receiving tertiary care hospital. We estimated the charges associated with repeat normal laboratory testing for 11 common ED tests: basic metabolic panel, calcium, magnesium, phosphorus, lipase, thyroids stimulating hormone, prothrombin time, partial thromboplastin time, complete blood count, liver function test, and urine analysis. RESULTS: Two hundred thirty-two patients were transferred to the receiving tertiary care hospital from within the hospital's network from May 1, 2011, to October 31, 2011. On average, each transferred patient had one repeat normal laboratory test (245/232=1.06). For all laboratory tests, repeat normal testing occurred at least 40% of the time. Extrapolating the data, the total yearly estimated charges of all repeat normal testing was $580,526. CONCLUSION: This study provides the first analysis of the frequency of repeated laboratory testing for all transferred ED patients and indicates that repeat normal testing represents a significant cost. Future research needs to determine if such repeat testing is indeed clinically appropriate or redundant.

A long-term analysis of physician triage screening in the emergency department.

OBJECTIVES: The problem of emergency department (ED) crowding is well recognized; however, little data exist on the sustainability of potential solutions, including physician triage and screening. The authors hypothesized that a physician triage screening program (Supplemented Triage and Rapid Treatment [START]) sustainably improves standard ED performance metrics. METHODS: This retrospective, observational, before-and-after study compared performance measures over 4 years in a tertiary care urban academic medical center with approximately 90,000 annual ED visits. Patients seen between December 2006 and November 2010 were included. Outcome measures included length of stay (LOS) for ED patients, percentage of patients who left without completing assessment (LWCA), percentage of patients treated and dispositioned by START without using monitored beds, and door-to-room time. Descriptive statistics were used. RESULTS: Median LOS for START patients was 56 minutes/patient lower when comparing 2010 to 2007 (p < 0.0001) and for non-START patients 22 minutes/patient lower (p < 0.0001). The percentage of patients who LWCA decreased from 4.8% to 2.9% (p < 0.0001) during the same time period. In START's first half-year, 18% of patients were discharged without using monitored beds. This increased to 29% by year 3. In addition, median door-to-room time decreased from 18.4 to 9.9 minutes during the same 3-year interval. CONCLUSIONS: Physician screening appears to provide sustainable improvements in ED performance metrics including ED LOS, percentage of patients who LWCA, door-to-room time, and percentage of patients treated without using a monitored bed, despite increasing ED volume. Physician screening delivers additional incremental benefits for several years after implementation and can effectively increase ED capacity by allowing emergency physicians to more efficiently use monitored beds.

The triple work-up for emergency department patients with acute chest pain: how often does it occur?

OBJECTIVES: To measure the degree of overlap and diagnostic yield for evaluations of acute coronary syndrome (ACS), pulmonary embolism (PE), and aortic dissection (AD) among Emergency Department (ED) patients. METHODS: We conducted a cross-sectional descriptive study of consecutive adult patients seen in the ED of a 78,000-annual-visit urban academic medical center. Patients who had received at least one of eight of the tests used in our ED to diagnose these three diseases were identified through three methods, and a final study population list was created. Overlap of evaluations and diagnostic yields were calculated by simple descriptive statistics. RESULTS: Over a 2-week period, 626 patient encounters among 622 unique patients were identified. Among these 626 visits, 139 (22%) included diagnostic tests for more than one of the three diagnoses of interest. The majority of these multiple tests were for ACS plus PE (n = 121, 87% of all multiple tests), whereas a minority of patients received tests for ACS plus AD (n = 14, 10% of all multiple tests) or for the "triple work-up" of ACS plus PE plus AD (n = 4, 2.9% of all multiple tests). CONCLUSION: Although the "triple work-up" evaluation for ACS, PE, and AD is relatively uncommon, a significant number of ED patients who are evaluated for at least one of these three major chest pain syndromes receive simultaneous testing for one of the others.