A National Evaluation of Door-to-Imaging Times among Acute Ischemic Stroke Patients within the Veterans Health Administration.

BACKGROUND: Rapid brain imaging for ischemic stroke is important for patient outcomes. We sought to determine the proportion of ischemic stroke patients receiving brain imaging within the guideline-recommended 24 hours, and predictors of faster imaging among patients with acute symptoms. METHODS: Retrospective analysis of Veterans Health Administration (VHA) Office of Performance Measurement Stroke Special Project data. Of 3000 ischemic stroke patients, secondary samples included 649 presenting within 6 hours of onset, and 217 potentially tissue plasminogen activator (tPA)-eligible patients (onset-to-arrival time <3 hours, National Institutes of Health Stroke Scale >2). Two linear regression models examined the association between door-to-imaging time and predictors among secondary samples, accounting for clustering within hospital. RESULTS: Of the 3000 ischemic stroke patients, 97.1% had brain imaging within 24 hours. Among patients presenting within 6 hours of onset, median door-to-imaging time was 59 minutes (interquartile range [IQR], 33-109). Predictors of faster door-to-imaging time included elevated arrival blood pressure and stroke center presentation. Among the potentially tPA-eligible patients, median door-to-imaging time was 52 minutes (IQR, 31-105); no significant predictors were identified. CONCLUSIONS: Nearly all ischemic stroke patients at VHA hospitals have door-to-imaging time within 24 hours. There remains room for improvement for timely brain imaging among patients with acute symptom onset.

Quality of life assessment for acute heart failure patients from emergency department presentation through 30 days after discharge: A pilot study with the Kansas City Cardiomyopathy Questionnaire.

Background: There are no well validated patient-reported disease status instruments for acute heart failure(HF). We assessed the feasibility of using the Kansas City Cardiomyopathy Questionnaire (KCCQ)during acute heart failure hospitalization, and the association of acute changes with 30-day readmission.Methods and Results: A convenience sample of acute HF patients were administered the KCCQ on presentation,discharge, and 30 days after discharge. We examined mean differences in KCCQ scores overtime, and we stratified by readmission status to examine differences in hospital-based changes with the use of t test and logistic regression. Among 52 patients (mean age 63 ± 15 years, 56.9% male, 46.2% white), discharge and 30-day assessments were each completed by 90%. Scores were lowest at presentation,improved during hospitalization, and were highest at 30 days. The mean change was +11.9 ± 27.0(P 5 .007) between presentation and discharge and +19.8 ± 17.8 (P <. .001) between discharge and 30 days. Within the 30-day follow-up, 10 patients were readmitted, and there were no significant differences in score changes during hospitalization between patients with and without readmission (readmitted patients: +4.8 ± 21.5 vs no readmission +16.2 ± 27.4; P = .32).Conclusions: In this pilot study, the KCCQ is feasible to use during acute HF hospitalizations and demonstrates sensitivity to acute changes, but score changes during hospitalization did not predict 30-day readmission.

Emergency department hospitalization volume and mortality in the United States.

STUDY OBJECTIVE: Although numerous studies have demonstrated a relationship between higher volume and improved outcomes in the delivery of health services, it has not been extensively explored in the emergency department (ED) setting. Therefore, we seek to examine the association between ED hospitalization volume and mortality for common high-risk conditions. METHODS: Using data from the Nationwide Inpatient Sample, a national sample of hospital discharges, we evaluated mortality overall and for 8 different diagnoses between 2005 and 2009 (total admissions 17.55 million). These conditions were chosen because they are frequent (in the top 25 of all ED hospitalizations) and high risk (> 3% observed mortality). EDs were excluded from analysis if they did not have at least 1,000 total annual admissions and 30 disease-specific cases. EDs were then placed into quintiles based on hospitalized volume. Regression techniques were used to describe the relationship between volume (number of hospitalized ED patients per year) and both subsequent early inpatient mortality (within 2 days of admission) and overall mortality, adjusted for patient and hospital characteristics. RESULTS: Mortality decreased as volume increased overall and for all diagnoses, but the relative importance of volume varied, depending on the condition. Absolute differences in adjusted mortality rates between very high-volume EDs and very low-volume EDs ranged from -5.6% for sepsis (95% confidence interval [CI] -6.5% to -4.7%) to -0.2% for pneumonia (95% CI -0.6% to 0.1%). Overall, this difference was -0.4% (95% CI -0.6% to -0.3%). A similar pattern was observed when early hospital deaths were evaluated. CONCLUSION: Patients have a lower likelihood of inhospital death if admitted through high-volume EDs.

Assessment of dyspnea early in acute heart failure: patient characteristics and response differences between likert and visual analog scales.

BACKGROUND: Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management. OBJECTIVES: The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five-point absolute Likert scale, 10-cm visual analog scale [VAS], or seven-point relative Likert scale). METHODS: This was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement. RESULTS: Of the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five-point Likert scale (c-index ranged from 0.708 to 0.831 for each scale). CONCLUSIONS: Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.

Hospital variation in thrombolysis times among patients with acute ischemic stroke: the contributions of door-to-imaging time and imaging-to-needle time.

IMPORTANCE: Given the limited time window available for treatment with tissue plasminogen activator (tPA) in patients with acute ischemic stroke, guidelines recommend door-to-imaging time (DIT) within 25 minutes of hospital arrival and door-to-needle (DTN) time within 60 minutes for patients with acute ischemic stroke. Despite improvements in DITs, DTN times for tPA treatment in patients with acute ischemic stroke remain suboptimal. OBJECTIVES: To examine the contributions of DIT and imaging-to-needle (ITN) time to delays in timely delivery of tPA to patients with acute ischemic stroke and to assess between-hospital variation in DTN times. DESIGN, SETTING, AND PARTICIPANTS: A cohort analysis of 1193 patients having acute ischemic stroke treated with intravenous tPA between January 2009 and December 2012. Multilevel linear regression models included random effects for 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. MAIN OUTCOMES AND MEASURES: The primary outcome was a continuous measure of DTN time, in minutes, from emergency department arrival to thrombolytic delivery. RESULTS: The mean age was 68.1 years, the median National Institutes of Health Stroke Scale score was 11.0 (interquartile range, 6-17), 51.4% were female, and 37.5% were of nonwhite race/ethnicity.The mean (SD) DTN time was 82.9 (35.4) minutes, the mean (SD) DIT was 22.8 (15.9) minutes, and the mean (SD) ITN time was 60.1 (32.3) minutes. Most patients (68.4%) had DIT within 25 minutes, while 28.7% had DTN time within 60 minutes. Hospital variation accounted for 12.7% of variability in DTN times. Neither annual stroke volume nor primary stroke center designation was a significant predictor of shorter DTN time. Patient factors (age, sex, race/ethnicity, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN times. After adjustment for patient-level factors, DIT explained 10.8% of the variation in hospital risk-adjusted DTN times, while ITN time explained 64.6%. CONCLUSIONS AND RELEVANCE: Compared with DIT, ITN time is a much greater source of variability in hospital DTN times and is a more common contributor to delays in timely tPA therapy for acute ischemic stroke. More attention is needed to determine systems changes that can decrease ITN time for patients with acute ischemic stroke.

Understanding the value of emergency care: a framework incorporating stakeholder perspectives.

BACKGROUND: In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined. OBJECTIVES: To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services. METHODS: A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions. RESULTS: We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition. CONCLUSION: The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care.

A systematic review and critical appraisal of quality measures for the emergency care of acute ischemic stroke.

Acute stroke is an important focus of quality improvement efforts. There are many organizations involved in quality measurement for acute stroke, and a complex landscape of quality measures exists. Our objective is to describe and evaluate existing US quality measures for the emergency care of acute ischemic stroke patients in the emergency department (ED) setting. We performed a systematic review of the literature to identify the existing quality measures for the emergency care of acute ischemic stroke. We then convened a panel of experts to appraise how well the measures satisfy the American College of Cardiology/American Heart Association (ACC/AHA) criteria for performance measure development (strength of the underlying evidence, clinical importance, magnitude of the relationship between performance and outcome, and cost-effectiveness). We identified 7 quality measures relevant to the emergency care of acute ischemic stroke that fall into 4 main categories: brain imaging, thrombolytic administration, dysphagia screening, and mortality. Three of the 7 measures met all 4 of the ACC/AHA evaluation criteria: brain imaging within 24 hours, thrombolytic therapy within 3 hours of symptom onset, and thrombolytic therapy within 60 minutes of hospital arrival. Measures not satisfying all evaluation criteria were brain imaging report within 45 minutes, consideration for thrombolytic therapy, dysphagia screening, and mortality rate. There remains room for improvement in the development and use of measures that reflect high-quality emergency care of acute ischemic stroke patients in the United States.

Quality of life assessment for acute heart failure patients from emergency department presentation through 30 days after discharge: a pilot study with the Kansas City Cardiomyopathy Questionnaire.

BACKGROUND: There are no well validated patient-reported disease status instruments for acute heart failure (HF). We assessed the feasibility of using the Kansas City Cardiomyopathy Questionnaire (KCCQ) during acute heart failure hospitalization, and the association of acute changes with 30-day readmission. METHODS AND RESULTS: A convenience sample of acute HF patients were administered the KCCQ on presentation, discharge, and 30 days after discharge. We examined mean differences in KCCQ scores over time, and we stratified by readmission status to examine differences in hospital-based changes with the use of t test and logistic regression. Among 52 patients (mean age 63 ± 35 years, 56.9% male, 46.2% white), discharge and 30-day assessments were each completed by 90%. Scores were lowest at presentation, improved during hospitalization, and were highest at 30 days. The mean change was +11.9 ± 97.0 (P = .007) between presentation and discharge and +19.8 ± 87.8 (P < .001) between discharge and 30 days. Within the 30-day follow-up, 10 patients were readmitted, and there were no significant differences in score changes during hospitalization between patients with and without readmission (readmitted patients: +4.8 ± 81.5 vs no readmission +16.2 ± 27.4; P = .32). CONCLUSIONS: In this pilot study, the KCCQ is feasible to use during acute HF hospitalizations and demonstrates sensitivity to acute changes, but score changes during hospitalization did not predict 30-day readmission.

Time to brain imaging in acute stroke is improving: secondary analysis of the INSTINCT trial.

BACKGROUND AND PURPOSE: Patients with acute ischemic stroke benefit from rapid evaluation and treatment, and timely brain imaging is a necessary component. We determined the effect of a targeted behavioral intervention on door-to-imaging time (DIT) among patients with ischemic stroke treated with tissue-type plasminogen activator. Second, we examined the variation in DIT accounted for by patient-level and hospital-level factors. METHODS: The Increasing Stroke Treatment through Interventional behavioral Change Tactics (INSTINCT) trial was a cluster-randomized, controlled trial involving 24 Michigan hospitals. The intervention aimed to increase tissue-type plasminogen activator utilization. Detailed chart abstractions collected data for 557 patients with ischemic stroke. We used a series of hierarchical linear mixed-effects models to evaluate the effect of the intervention on DIT (difference-in-differences analysis) and used patient-level and hospital-level explanatory variables to decompose variation in DIT. RESULTS: DIT improved over time, without a difference between intervention and control hospitals (intervention: 23.7-19.3 minutes, control: 28.9-19.2 minutes; P=0.56). Adjusted DIT was faster in patients who arrived by ambulance (7.2 minutes; 95% confidence interval, 4.1-10.2), had severe strokes (1.0 minute per +5-point National Institutes of Health Stroke Scale; 95% confidence interval, 0.1-2.0), and presented in the postintervention period (4.9 minutes; 95% confidence interval, 2.3-7.4). After accounting for these factors, 13.8% of variation in DIT was attributable to hospital. Neither hospital stroke volume nor stroke center status was associated with DIT. CONCLUSIONS: Performance on DIT improved similarly in intervention and control hospitals, suggesting that nonintervention factors explain the improvement. Hospital-level factors explain a modest proportion of variation in DIT, but further research is needed to identify the hospital-level factors responsible.

Severe sepsis in do-not-resuscitate patients: intervention and mortality rates.

BACKGROUND: Severe sepsis is a high-mortality disease, and early resuscitation decreases mortality. Do-not-resuscitate (DNR) status may influence physician decisions beyond cardiopulmonary resuscitation, but this has not been investigated in sepsis. OBJECTIVE: Among Emergency Department (ED) severe sepsis patients, define the incidence of DNR status, prevalence of central venous catheter placement, and vasopressor administration (invasive measures), and mortality. METHODS: Retrospective observational cohort of consecutive severe sepsis patients to single ED in 2009-2010. Charts abstracted for DNR status on presentation, demographics, vitals, Sequential Organ Failure Assessment (SOFA) score, inpatient and 60-day mortality, and discharge disposition. Primary outcomes were mortality, discharge to skilled nursing facility (SNF), and invasive measure compliance. Chi-squared test was used for univariate association of DNR status and outcome variables; multivariate logistic regression analyses for outcome variables controlling for age, gender, SOFA score, and DNR status. RESULTS: In 376 severe sepsis patients, 50 (13.3%) had DNR status. DNR patients were older (79.2 vs 60.3 years, p < 0.001) and trended toward higher SOFA scores (7 vs. 6, p = 0.07). DNR inpatient and 60-day mortalities were higher (50.5% vs. 19.6%, 95% confidence interval [CI] 15.9-44.9%; 64.0% vs. 24.9%, 95% CI 25.1-53.3%, respectively), and remained higher in multivariate logistic regression analysis (odds ratio [OR] 3.01, 95% CI 1.48-6.17; OR 3.80, 95% CI 1.88-7.69, respectively). The groups had similar rates of discharge to SNF, and in persistently hypotensive patients (n = 326) had similar rates of invasive measures in univariate and multivariate analyses (OR 1.19, 95% CI 0.45-3.15). CONCLUSION: In this sample, 13.3% of severe sepsis patients had DNR status, and 50% of DNR patients survived to hospital discharge. DNR patients received invasive measures at a rate similar to patients without DNR status.

Hospital-reported data on the pneumonia quality measure "Time to First Antibiotic Dose" are not associated with inpatient mortality: results of a nationwide cross-sectional analysis.

OBJECTIVES: Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality. METHODS: This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance. RESULTS: Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05). CONCLUSIONS: In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.

Disaster preparedness among medical students: a survey assessment.

OBJECTIVE: To describe the level of preparedness in performing medical procedures of medical students at one allopathic medical school and to determine the level of willingness to perform these procedures in the event of a disaster. DESIGN: Cross-sectional survey. SETTING: US allopathic medical school associated with a county hospital. PARTICIPANTS: All third- and fourth-year medical students (344) in the 2007-2008 academic year were invited to participate. One hundred ninety-five students participated in this study (response rate = 57.6 percent). MAIN OUTCOME MEASURES: Information on demographic characteristics, personal disaster experience, personal disaster preparedness, and overall preparedness level and willingness to perform various medical procedures was collected. Multiple regression analysis was used to identify the factors predicting procedural willingness during a disaster. RESULTS: Demographics and personal disaster preparedness were not statistically significant between third-year medical students (M3) and fourth-year medical students (M4). Although procedural preparedness was significantly higher in M4 than M3, willingness to perform these procedures in a disaster was not different. Fourth-year students, first receivers (students' anticipated field is in emergency medicine or surgery), not having had a personal disaster experience, and increased procedural preparedness independently impact procedural willingness in a disaster However, when controlled for the covariate effects in the regression model, only first receivers, no past personal disaster experience, and increased procedural preparedness predicted willingness to perform medical procedures during a disaster. CONCLUSIONS: Third- and fourth-year students possess skills that may prove useful in a disaster response. Further investigations are necessary to determine how medical students may be utilized during these events.

Emergency drills and exercises in healthcare organizations: assessment of pediatric population involvement using after-action reports.

BACKGROUND: Although the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires healthcare organizations to demonstrate disaster preparedness through the use of disaster exercises, the evaluation of pediatric preparations is often lacking. Our investigation identified, described, and assessed pediatric victim involvement in healthcare organizations' disaster drills and exercises using data from after-action reports. METHODS: Following the IRB approval, the authors reviewed the after-action reports generated by healthcare organizations after a disaster drill and exercise, as a self-assessed reporting tool for JCAHO regulations. Forty-nine of these reports that were voluntarily supplied to the emergency medical services agency were collected. The authors analyzed the data using quantitative and qualitative analytic approaches. RESULTS: Only nine reports suggested pediatric involvement. Hospitals with large bed capacity (M = 465.6) tended to include children in exercises compared with smaller facilities (M = 350.8). Qualitative content analysis revealed themes such as lack of parent-child identification and family reunification systems, ineffective communication strategies, lack of pediatric resources and specific training, and unfamiliarity with altering standards of pediatric care during a disaster. CONCLUSIONS: Although many organizations are performing disaster exercises, most are not including pediatric concerns. Further work is needed to understand the basis for this gap in emergency preparedness. Overall, pediatric emergency planning should be a high priority for this vulnerable population.