Choosing Wisely and Promoting High-Value Care and Staff Safety During the COVID-19 Pandemic in a Large Safety Net System.

BACKGROUND AND OBJECTIVES: As the COVID-19 pandemic brought surges of hospitalized patients, it was important to focus on reducing overuse of tests and procedures to not only reduce potential harm to patients but also reduce unnecessary exposure to staff. The objective of this study was to create a Choosing Wisely in COVID-19 list to guide clinicians in practicing high-value care at our health system. METHODS: A Choosing Wisely in COVID-19 list was developed in October 2020 by an interdisciplinary High Value Care Council at New York City Health + Hospitals, the largest public health system in the United States. The first phase involved gathering areas of overuse from interdisciplinary staff across the system. The second phase used a modified Delphi scoring process asking participants to rate recommendations on a 5-point Likert scale based on criteria of degree of evidence, potential to prevent patient harm, and potential to prevent staff harm. RESULTS: The top 5 recommendations included avoiding tracheal intubation without trial of noninvasive ventilation (4.4); not placing routine central venous catheters (4.33); avoiding routine daily laboratory tests and batching laboratory draws (4.19); not ordering daily chest radiographs (4.17); and not using bronchodilators in the absence of reactive airway disease (4.13). CONCLUSION: We successfully developed Choosing Wisely in COVID-19 recommendations that focus on evidence and preventing patient and staff harm in a large safety net system to reduce overuse.

Reducing unnecessary routine laboratory testing for noncritically ill patients with COVID-19.

BACKGROUND: Reducing unnecessary routine laboratory testing is a Choosing Wisely® recommendation, and new areas of overuse were noted during the COVID-19 pandemic. OBJECTIVE: To reduce unnecessary repetitive routine laboratory testing for patients with COVID-19 during the pandemic across a large safety net health system. DESIGNS, SETTINGS AND PARTICIPANTS: This quality improvement initiative was initiated by the System High-Value Care Council at New York City Health + Hospitals (H + H), the largest public healthcare system in the United States consisting of 11 acute care hospitals. INTERVENTION: four overused laboratory tests in noncritically ill hospitalized patients with COVID-19 were identified: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. A two-pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. MAIN OUTCOME AND MEASURES: The average of excess tests per encounter days (ETPED) for each of four target laboratory testing only in patients with COVID-19. OBJECTIVE: Interdisciplinary System High-Value Care Council identified four overused laboratory tests (inflammatory markers) in noncritically ill hospitalized patients with COVID-19: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. Within an 11-hospital safety net health system, a two-pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. The preintervention period (March 16, 2020 to January 24, 2021) was compared to the postintervention period (January 25, 2021 to March 22, 2022). RESULTS: Time series linear regression showed decreases in CRP (-17.9%, p < .05), ferritin (-37.6%, p < .001), and LDH (-30.1%, p < .001). Slope differences were significant (CRP, ferritin, and LDH p < 0.001; procalcitonin p < 0.05). Decreases were observed across weekly averages: CRP (-19%, p < .01), ferritin (-37.9%, p < .001), LDH (-28.7%, p < .001), and procalcitonin (-18.4%, p < .05). CONCLUSION: This intervention was associated with reduced routine inflammatory marker testing in non-intensive care unit COVID-19 hospitalized patients across 11 hospitals. Variation was high among individual hospitals.

What strategies are used by clinician champions to reduce low-value care?

Background: Clinician champions are front-line clinicians who advocate for and influence practice change in their local context. The strategies they use when leading efforts to reduce the use of low-value care have not been well described. The purpose of this study is to identify and describe strategies used by six clinician champions who led a low-value care initiative in their clinical setting. Methods: Qualitative data collected during an overuse reduction initiative led by clinician champions were used to identify strategies, guided by the Expert Recommendations for Implementing Change compilation of strategies. Clinician champions were asked to rank the importance of these activities and indicate which one of the six most important activities they would be willing to discuss in an interview. A 30-min semi-structured interview was conducted with each clinician about the activity they selected and thematically analyzed. Results: Twelve Expert Recommendations for Implementing Change strategies were identified. The top six strategies discussed during interviews were: build a coalition, conduct a local needs assessment, develop a formal implementation blueprint, conduct educational meetings, use facilitation, and develop clinical reminders. Common themes that emerged across all interviews were the use of data to engage clinicians in conversations, including the patient's perspective in designing the interventions, and investing the time upfront to plan and launch the initiative because of the inherent challenges of relinquishing a service. Conclusions: Clinician champions identified multiple strategies as important when de-implementing a low-value service. Many were used to engage in conversations with stakeholders, including leadership, providers, and patients, to increase buy-in and support, challenge beliefs, promote behavior change, and gather insights about next steps in their effort. Future work is needed to better understand how prepare clinicians for this role and to understand the mechanisms through which these strategies might be effective.

Reducing thoracic and lumbar radiographs in an urban emergency department through a clinical champion led quality improvement intervention.

BACKGROUND: Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number. METHODS: A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months. RESULTS: The percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame. CONCLUSION: A multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

The impact and efficiency of medical screening exams in forward treatment areas at New York City public hospitals during the initial COVID-19 surge.

BACKGROUND: New York City (NYC) emergency departments (EDs) experienced a surge of patients because of coronavirus disease 2019 (COVID-19) in March 2020. NYC Health and Hospitals established rapid medical screening exams (MSE) and each hospital designated areas to perform their MSE. Five of the 11 hospitals created a forward treatment area (FTA) external to the ED to disposition patients before entering who presented with COVID-like symptoms. Three hospitals used paper-based, and 2 used an electronic medical record (EMR)-based MSE. This study evaluated the effectiveness of safely discharging patients home from the FTA while also evaluating the efficiency of using paper-based versus EMR-based MSEs. METHODS: Charts were reviewed using standardized data extraction templates. Patients discharged from the FTA were contacted by phone, and a structured interview captured additional data regarding subsequent clinical courses. Chi-square tests were used to compare proportions of patients hospitalized, as well as proportions of patients with vital signs recorded. Mortality rates were compared with Fisher exact test. A logistic regression model with fixed effects to account for clustering at hospitals was used to compare the odds of being sent to the ED for further evaluation based on vital signs and adjusted for age and sex. RESULTS: Across 5 EDs, 3335 patients were evaluated in their FTAs from March 17, 2020, to April 27, 2020. A total of 970 (29.1%) patients were referred for further evaluation into the ED, of which 203 (20.9%) were hospitalized and 19 (2.0%) died. Of 2302 patients discharged from the FTA, 182 (7.9%) returned to the ED within 7 days, resulting in 42 (1.8%) hospitalizations and 7 (0.3%) deaths. Facilities using EMR-MSE discharged more patients from their FTA (81.9% vs 65.3%, P < 0.001) and had similar 7-day return (9.3% vs 7.1%, P = 0.055) and mortality rates (0.49% vs 0.20%, P = 0.251). CONCLUSION: MSEs in an FTA are an effective process to disposition patients safely in a high-volume situation. Differences exist in paper- versus EMR-based approaches, suggesting EMR-MSEs provide better data, efficiency, and effectiveness. This suggests prioritizing an EMR-based MSE should be considered in future circumstances.

Intubation outcomes and practice trends during the initial New York SARS-COV-19 surge at an academic, level 1 trauma, urban emergency department.

OBJECTIVES: The goal of this study was to describe outcomes and associated characteristics of patients who were intubated during the initial (3/2020-4/2020) New York City surge of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, during which time we were confronted by an unknown and unprecedented respiratory distress syndrome with extremely high degrees of morbidity and mortality. Our secondary aim was to analyze our physician's rapidly evolving approaches to COVID-19 airway management. METHODS: A retrospective cohort analysis of all patients intubated at two emergency departments (EDs) for COVID-19 suspected respiratory failure. In addition, a survey was done to analyze clinician airway management trends and attitudes as they evolved during that period. RESULTS: Ninety-five patients met inclusion criteria for the study. Primary outcomes looked at the spectrum of mortality outcomes ranging from died on arrival (DOA) to the ED, died in the ED (DED), died an inpatient (DIH), and survival to discharge. Overall mortalitywas 71.6% with an average age of 62.7 years. Female sex, as a demographic, was associated with higher rates of survival to discharge at 42.3% when compared to males at 23.2% (P < 0.001). Mean age was 70.8 years DOA, 65.6 years DED, 62.9 years DIH, and 60.0 years for survivors (P = 0.0037). Initial lactate levels were 8.15 mmol/L DED, 3.56 mmol/L DIH, and 2.61 mmol/L survivors (P < 0.0001). Initial creatinine levels were 3.38 mg/dL DED, 1.94 mg/dL DIH, and 1.77 mg/dL survivors (P = 0.0073). D-dimer levels were 7520.5 ng/mL DED, 5932.4 ng/mL DIH, and 1133.9 ng/mL survivors (P = 0.0045). Physician survey respondents reported high levels (69%) of laryngeal edema and prolonged post intubation hypoxia (>50% of time) and >80% remained concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non-invasive approaches (28% of time) as the first surge of the pandemic evolved. CONCLUSION: Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID-19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D-dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID-19 airway management evolved significantly and rapidly over the initial phase of the pandemic.

Impact of a Novel Emergency Department Forward Treatment Area During the New York City COVID-19 Surge.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused a disproportionate number of patients to seek emergency care at hospitals in New York City (NYC) during the initial crisis. Our urban emergency department (ED), a member of the NYC public hospital system had to process the increased volume while also differentiating our patients' critical needs. We established a forward treatment area (FTA) directly in front of the ED to accomplish these goals from March 23-April 16, 2020. METHODS: A clinical greeter evaluated patients 18 years and older who presented to the walk-in entrance of the ED where they were screened for COVID-19-like complaints. If they did not appear critically ill and could ambulate they were directed into the FTA. Clinical and non-clinical staff worked in concert to register, evaluate, and process patients with either a disposition of directly home or into the ED for further care. RESULTS: A total of 634 patients were seen in the FTA from March 23-April 16, 2020. Of the 634 patients evaluated, 135 (21%) were referred into the ED for further evaluation, of whom 81 (12.7% of the total) were admitted. These patients were disproportionately male (91 into the ED and 63 admitted) and tended to have a higher heart rate (105.4 vs 93.7), a higher respiratory rate (21.5 vs 18.1), and lower oxygen saturation (93.9% vs 97.8%). CONCLUSION: A forward treatment area is an effective method to rapidly screen and process an increased volume of COVID-19 patients when resources are limited. This treatment area helped decompress the ED by being rapidly deployable and effectively screening patients for safe discharge home.

Ready or Not, Patients Will Present: Improving Urban Pandemic Preparedness.

Over the past century, society has achieved great gains in medicine, public health, and health-care infrastructure, particularly in the areas of vaccines, antibiotics, sanitation, intensive care and medical technology. Still, despite these developments, infectious diseases are emerging at unprecedented rates around the globe. Large urban centers are particularly vulnerable to communicable disease events, and must have well-prepared response systems, including on the front-line level. In November 2018, the United States' largest municipal health-care delivery system, New York City Health + Hospitals, hosted a half-day executive-level pandemic response workshop, which sought to illustrate the complexity of preparing for, responding to, and recovering from modern-day infectious diseases impacting urban environments. Attendees were subjected to a condensed, plausible, pandemic influenza scenario and asked to simulate the high-level strategic decisions made by leaders by internal (eg, Chief Medical Officer, Chief Nursing Officer, and Legal Affairs) and external (eg, city, state, and federal public health and emergency management entities) partners across an integrated system of acute, postacute, and ambulatory sites, challenging players to question their assumptions about managing the consequences of a highly pathogenic pandemic.

Interfacility ambulance transport of mental health patients.

The transportation of mental health patients between facilities by emergency medical services personnel poses a unique risk to both patients and their providers. Increasingly, common injuries are occurring and difficulties are arising during this transition in care. Proximal causes exist that could be addressed to help mitigate many of the complexities that occur during this shift in care. Patient safety, quality of care, and provider safety are all at risk if improvements are not made and problems not identified or rectified.

Emergency Diagnosis and Management of Genitourinary Trauma.

Genitourinary trauma often occurs concomitantly with other abdominopelvic trauma, but nevertheless is important to master in diagnosis, management, and treatment. There are subtleties to diagnosis and important steps that should not be missed to properly manage patients.

Imaging Modalities in Genitourinary Emergencies.

Emergency physicians rely on a multitude of different imaging modalities in the diagnosis of genitourinary emergencies. There are many considerations to be taken into account when deciding which imaging modality should be used first, as oftentimes several diagnostic tools can be used for the same pathologic condition. These factors include radiation exposure, sensitivity, specificity, age of patient, availability of resources, cost, and timeliness of completion. In this review, the strengths and weaknesses of different imaging tools in the evaluation of genitourinary emergencies are discussed.

Cardiogenic Shock.

Cardiogenic shock is the leading cause of morbidity and mortality in patients presenting with acute coronary syndrome. Although early reperfusion strategies are essential to the management of these critically ill patients, additional treatment plans are often needed to stabilize and treat the patient before reperfusion may be possible. This article discusses pharmacologic and surgical interventions, their indications and contraindications, management strategies, and treatment algorithms.

Emergency Department Bouncebacks: Is Lack of Primary Care Access the Primary Cause?

BACKGROUND: National emergency department (ED) bounceback rates within 30 days of previous ED discharge have been found to be as high as 26%. We hypothesize that having a primary care physician (PCP) would prevent bouncebacks to the ED because a patient would have a medical resource for follow-up and continued care. METHODS: We performed a prospective, consecutive, anonymous survey study of adult ED patients at a suburban teaching hospital with 88,000 visits annually, from July 5, 2011 through August 8, 2011. Using chi-squared and Fisher's exact tests, we compared patients with an initial visit to those returning within 30 days of a previous visit to our ED. RESULTS: We collected 1084 surveys. Those in the bounceback group were more likely to have no insurance (10.2% vs. 4.4%) or Medicaid (17.7% vs. 10.8%) and less likely to have a PCP (79% vs. 86%). Of those with a PCP, 9% in both groups had seen their PCP that day, 58% (initial visit) and 49% (bouncebacks) could have been seen that day, and 35% & 36%, respectively, within 1 week. Of those with a PCP, 38% of initial visits and 32% of bouncebacks stated they had already seen their physician at least once. CONCLUSION: Our results suggest that patients who bounce back to the ED might have already contacted their PCP. Although insurance status and the lack thereof predict a higher likelihood to bounce back to the ED, many bouncebacks are insured patients with PCPs able to be seen the same day.

Regional nerve blocks of the face.

Regional nerve blocks of the face are important skills every emergency physician ought to know. Facial anesthesia improves cosmetic outcomes, reduces pain, and improves patient satisfaction. Understanding the anatomy of the head and face is essential to the application of regional anesthesia, and this anatomy will be reviewed in depth. By completion of this article, physicians should appreciate the basics of the various nerve blocks of the head and face to repair any laceration.

Facial wound management.

This article presents an overview of facial wound management, beginning with a brief review of basic anatomy of the head and face as it relates to wound care. Basic wound management is discussed, and techniques for repairing specific cosmetically high-risk areas of the face, particularly the eyes, lips, and ears, are reviewed. Also described are the proper techniques for the management of an auricular hematoma.

Electrocardiographic implications of the prolonged QT interval.

The QT interval measures the time from the start of the QRS complex to the end of the T wave. Prolongation of the QT interval may lead to malignant ventricular tachydysrhythmias, including torsades de pointes. Causes of QT prolongation include congenital abnormalities of the sodium or potassium channel, electrolyte abnormalities, and medications; idiopathic causes have also been identified. Patients can be asymptomatic or present with syncope, palpitations, seizure-like activity, or sudden cardiac death. Management involves looking for and treating reversible causes. For patients with congenital or idiopathic QT interval prolongation, the use of beta-blockers can be considered. Certain subsets of patients benefit from implantation of a cardioverter-defibrillator. Clinicians must remain vigilant for QT interval prolongation when interpreting electrocardiograms, especially in patients presenting with syncope or ventricular arrhythmias.

Hypertension and pregnancy.

Hypertension in pregnancy is increasing in prevalence and incidence and its treatment becoming more commonplace. Associated complications of pregnancy, including end-organ damage, preeclampsia, eclampsia, and postpartum eclampsia, are leading sources of maternal and fetal morbidity and mortality, requiring an emergency physician to become proficient with their identification and treatment. This article reviews hypertension in pregnancy as it relates to outcomes, with special emphasis on preeclampsia, eclampsia, and postpartum eclampsia.