Reducing Length of Stay in the ED


The Emergency Department of Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago’s largest pediatric provider, handles 60,000 visits a year. The ED has been open since 2012, when the hospital (formerly known as Children’s Memorial) moved from the residential neighborhood of Lincoln Park to a more central location in Streeterville, adjacent to Northwestern Memorial Hospital and the Feinberg School of Medicine. The new hospital added 90 beds — a 33% increase — with a corresponding increase in ED capacity and resources.

Despite the greater capacity, by December 2016, the pace of ED operation had slowed down, and length of stay had increased 20%, for reasons that were not clear until we analyzed patient flow. The increase in length of stay hindered our ability to serve our patients effectively, and stressed both patients and staff (who either left the department or became disengaged, damaging the collegial culture that had been one of our ED’s most valuable assets). This paper describes the operational and cultural changes we made that have reduced length of stay by 11% and have helped restore our esprit de corps.

Key Takeaways

  1. The triad of leadership between nursing, medical, and operations is critical to success. Each brings skills and relationships that make the team strong. By relinquishing the “fix it all yourself” mentality, the team has been able to make significant strides.

  2. It’s critical to test changes as part of the system. While incremental improvement and marginal gains are pivotal to long-term success, combined efforts and comprehensive testing (versus siloed tests of change) have yielded benefit more rapidly.

  3. Have a system to oversee, modify, and evolve. Entering high season with the flu, our daily volume increased. The ED experienced volume not seen in a month since H1N1 in 2014, averaging 200 patients per day with levels as high as 250. Through weekly EDOC meetings, we have modified several times the hours of operation of our interventions, as well as the staffing and system that surrounds them. Our staff have also become more agile at adapting to fluctuating conditions.

  4. Change systems can be built and driven locally, with structure, transparency, and strong local leadership.

  5. “Just try it” and keep moving. It was scary for many to do something drastically different. We had to move together and take the leap, and now everyone is more comfortable with change.

  6. It is hard to maintain the pace and sense of urgency in the summer “slow” season.

  7. Taking the time to understand how to improve is as important as improving. We are actively working on sharing the process that we used to accomplish these improvements, at the executive level and throughout the hospital.

The Challenge

In January of 2017, our average Emergency Department length of stay was 3:11 hours, above the target for the department at 3:00 hours. While 11 minutes may not sound like a lot, the average masked a wide variability. Daytime patients might move through faster than average, while wait times between 4 p.m. and midnight, when we see 60 to 70% of our patients, could exceed 3 hours. Our resources are particularly stressed during flu season, and we often see 250 patients a day in the winter (compared with about 140 in the summer).

We have 30 ED exam rooms (divided into three 10-bed pods), a procedure room, and two trauma rooms that hold four patients each.

The leadership team agreed to take a comprehensive approach, rather than pursuing fragmented solutions that might increase dysfunction elsewhere, and to involve the entire staff in redesigning care and transforming our culture.

Developing an Infrastructure — Design and Execution

The ED team developed an infrastructure and management system that integrated the Lean management philosophy, focusing on continuous improvement, and a recognition that patients are at the center of all we do and we need to align our goals accordingly, rather than structuring our activities for the convenience of the staff. The system included the following elements:

  • ED Operations Committee (EDOC): A standing multidisciplinary oversight committee with 12 members comprising ED staff and related areas like patient access and registration and environmental services. Meeting weekly, the group guides improvement initiatives, provides resources and team members, manages follow up issues, tracks progress and mitigates barriers, and develops communication points for management bodies in other parts of the organization. An EDOC liaison attends the monthly house-wide throughput and capacity meeting.
  • Project Teams (Front Line) and Shared Responsibility Structure: Frontline team assignments were pre-planned including dedicated off-unit time to work on initiatives. Given a budgeted timeline and resources, project teams with four to six members are responsible for leading project sub-groups and reporting back on progress to the larger EDOC group.
  • Communication Plan: We adopted multi-modal communication plan at the start of the fiscal year, including a quarterly print newsletter, a biweekly communication on updates to the department every pay day, and a 1-hour update for everyone on the ED staff every quarter. We provide six sessions over 3 days to allow staff members to attend this update as their schedules permit.
  • Tests of Change Strategy: Our Lean management approach included the Plan-Do-Study-Act (PDSA) model for testing improvement hypotheses. In accordance with PDSA, we created a schedule at the beginning of the fiscal year that designated specific days to test change. This schedule allowed the department to plan for staffing, and to alert staff that we would be trying something new. It also gave the project teams a deadline for completing the planning on their interventions. Each intervention was tested on both a high-volume day (Tuesday) and a low-volume day (Thursday).
  • Implementation Dates: As with the PDSA tests described above, each intervention had an implementation schedule set in advance to impose discipline on the process and track progress.
  • Education/Hardwiring Strategy: The interventions we tested required changes in our Epic electronic health record system (EHR) to accommodate the new workflows. Our implementation plan included passing EHR change recommendations through the local staff clinical informatics committee, and also through the team handling staff education, so that it could incorporate the changes into its training curricula along with the changes in triage workflow.

Value Stream Analysis Event

In February 2017, the Emergency Department hosted a 2-day value stream analysis event to outline and map all the processes and workflows associated with the Emergency Department, along with gaps, barriers to improvement, and possible solutions (prioritized by vote of the attendees). The event included 40+ team members from the ED, patient access center (house managers), registration, critical care, acute care, and environmental services. The event reviewed many observations and time studies, operational data, and surveys from patients, ED staff, and inpatient staff. The meeting gave us a list of priorities on which to focus.

A Comprehensive and Targeted Intervention Plan — Tangible Improvements

The process described above identified two areas for change:

First, the triage process at the front door could be streamlined. We discovered that we were doing the full triage assessment (head to toe) in Triage even when it could be done in an exam room, resulting in a bottleneck at Triage and empty exam rooms. If we moved some steps to the exam room, the triage nurse could continue to triage at the same time the ER physicians saw patients. When rooms are available, the triage nurse could record name and demographics, chief complaint, acuity, and weight, and then move patients to an exam room. At the same time, when the exam rooms are full, some steps usually done in the exam room could be moved to Triage.

Second, especially during the December to March flu season, many patients who didn’t really need a bed were being placed in precious bed space, which increased our door-to-provider time and delayed care for potentially sicker children, especially during our busiest 8 hours, between 4 p.m. and midnight. Pod 3 was nominally allocated to the lowest-acuity patients (Levels 4 and 5), which sometimes caused a shortage of bed space for higher-acuity patients. We needed to be more precise in how we triaged less acute patients and find a more efficient way to care for them, both to reduce their length of stay and to keep bed space for the most acute patients.

The project teams created the following interventions to address these areas:

We placed a provider in Triage specifically to assess and treat low-acuity patients (Levels 4 and 5) during our busiest times. This provider, an APN or MD known as the Provider in ER (PIER), sees potentially 30 patients per day who would otherwise take bed space in the ED. The PIER is generally available December through March, Sunday through Wednesday, 11 a.m. to 11 p.m.

With additional capacity now available in the back, Pod 3 expanded its acuity criteria up to acuity Level 2 to make up for the decrease in volume of lower-acuity patients and relieve the stress on Pods 1 and 2.

Comprehensive Intervention Review at Lurie Childrens Hospital - improving patient flow and length of stay

  Click To Enlarge.

We adjusted our staffing model to better reflect our fluctuations in volume. Previously, we had had a high-season and a low-season staffing plan; now we tier both seasons according to the days of the week, with the highest level for Sunday-Monday-Tuesday, a lower level for Wednesday, and the lowest level for Thursday-Friday-Saturday.

Results

The interventions in concert with one another and with a labor team–approved staffing model to support have, to date, demonstrated valuable metrically driven improvements.

Emergency Department length of stay is down 11%, to 2:50 hours, which is below our goal of 3:00 hours. The PIER provider, using surge bed space for an additional two beds, has seen up to 50 patients in a 12-hour shift. Pod 3, now with increased acuity, has seen an increased volume of Emergency Severity Index (ESI) 2s and 3s (from 0.5% to 6%). Our patient surveys show that we have improved at seeing the lowest-acuity patients in a timely manner and are spending enough time with patients, and our scores now exceed the national average for children’s hospitals.

  Click To Enlarge.

Moreover, our team feels a difference. Seeing 250 patients per day no longer feels unmanageable but rather a routine winter day. We are now thinking as one ED.

Moving beyond the rollout, adjustments and next steps have already been taken. We are expanding the days on which we run the PIER to accommodate the surge in volume from this year’s flu season. We are also beginning the PIER coverage earlier on our busy days. We continue to see such benefit from the PIER that we have also assessed the waiting room at the start of the shift to determine if this provider should see patients in the unused Triage bays or begin immediately in the surge space for the available added capacity.

No matter the adjustment, the takeaway for the entire team is that we can always review on Wednesday, and if it needs to be addressed, it will be. Our new operating principle is active improvement management.

Patient Family Experience Scores: Low-Acuity Patient Population

  • Seen in a timely manner:

    • Before Implementation: 54.8%

    • After Implementation: 60.4%

    • Children’s Hospital Association Average: 59%

  • Provider spent enough time with patient:

    • Before Implementation: 66.3%

    • After Implementation: 70.3%

    • Children’s Hospital Association Average: 68%

    Source: NRC Health / Ann & Robert H. Lurie Children’s Hospital Patient Survey

Pediatric Medication Safety in the Emergency Department


Abstract

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

 

  • Abbreviations:
    AAP
    American Academy of Pediatrics
    ACEP
    American College of Emergency Physicians
    ADE
    adverse drug event
    CDS
    clinical decision support
    CPOE
    computerized physician order entry
    ED
    emergency department
    ENA
    Emergency Nurses Association

 

Background

Despite a national focus on patient safety since the publication of the Institute of Medicine (now the National Academy of Medicine) report “To Err is Human” in 1999, medical errors remain a leading cause of morbidity and mortality across the United States.1 Medication errors are by far the most common type of medical error occurring in hospitalized patients,2 and the medication error rate in pediatric patients has been found to be as much as 3 times the rate in adult patients.3,4 Because many medication errors and adverse drug events (ADEs) are preventable,1 strategies to improve medication safety are an essential component of an overall approach to providing quality care to children.

The pediatric emergency care setting is recognized as a high-risk environment for medication errors because of a number of factors, including medically complex patients with multiple medications who are unknown to emergency department (ED) staff, a lack of standard pediatric drug dosing and formulations,5 weight-based dosing,6,7 verbal orders, a hectic environment with frequent interruptions,8 a lack of clinical pharmacists on the ED care team,9,10 inpatient boarding status,11 the use of information technology systems that lack pediatric safety features,12 and numerous transitions in care. In addition, the vast majority of pediatric patients seeking care in EDs are not seen in pediatric hospitals but rather in community hospitals, which may treat a low number of pediatric patients.13 Studies also outline the problem of medication errors in children in the prehospital setting. A study of 8 Michigan emergency medical services agencies revealed errors for commonly used medications, with up to one-third of medications being dosed incorrectly.14 Medication error rates reported from single institutions with dedicated pediatric EDs range from 10% to 31%,15,16 and in a study from a pediatric tertiary care center network, Shaw et al6 showed that medication errors accounted for almost 20% of all incident reports, with 13% of the medication errors causing patient harm. The authors of another study examined medication errors in children at 4 rural EDs in northern California and found an error rate of 39%, with 16% of these errors having the potential to cause harm.17 The following discussion adds to the broad topic of medication safety by introducing specific opportunities unique to pediatric patients within EDs to facilitate local intervention on the basis of institutional experience and resources.

Strategies for Improvement

A multidisciplinary expert panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics (AAP), through its Committee on Pediatric Emergency Medicine, to discuss challenges related to pediatric medication safety in the emergency setting. The panel included emergency care providers, nurses, pharmacists, electronic health record industry representatives, patient safety organization leaders, hospital accreditation organizations, and parents of children who suffered ADEs. The panel outlined numerous opportunities for improvement, including raising awareness of risks for emergency care providers, trainees, children, and their families; developing policies and processes that support improved pediatric medication safety; and implementing best practices to reduce pediatric ADEs. Specific strategies discussed by the panel, as well as recent advances in improving pediatric medication safety, are described.

Decreasing Pediatric Medication Prescribing Errors in the ED

Computerized Physician Order Entry

Historically, the majority of pediatric medication errors were associated with the ordering phase of the medication process. Specific risks related to pediatric weight-based dosing include not using the appropriate weight,6 performing medication calculations based on pounds instead of the recognized standard of kilograms,6 and making inappropriate calculations, including tenfold dosing errors.1820 Childhood obesity introduces further opportunity for dosing error. In addition to the lack of science to guide medication dosing in patients with obesity,21 frequent underdosing22 is reported, and currently available resuscitation tools are commonly imprecise.23 Furthermore, there are limited opportunities for prescription monitoring or double-checking in the ED setting, and many times calculations are performed in the clinical area without input from a pharmacist.9 The implementation of computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing have reduced many of these errors, because most CPOE systems obviate the need for simple dose calculation. However, CPOE systems have not fully eliminated medication errors. Commercial or independently developed CPOE systems may fail to address critical unique pediatric dosing requirements.12,24 Kilogram-only scales are recommended for obtaining weights, yet conversion to pounds either by the operator or electronic health record may introduce opportunity for error into the system. In addition, providers may override CDS, despite its proven success in reducing errors.16,25 Prescribers frequently choose to ignore or override CDS prescribing alerts, with reported override rates as high as 96%.26 Allowing for free text justification to override alerts for nonformulary drugs may introduce errors. The development of an override algorithm can help reduce user variability.27 As the use of CPOE increases, one can expect that millions of medication errors will be prevented.28 For EDs that do not use CPOE, preprinted medication order forms have been shown to significantly reduce medication errors in a variety of settings and serve as a low-cost substitute for CPOE.2932

Standardized Formulary

The Institute of Medicine (now the National Academy of Medicine) recommends development of medication dosage guidelines, formulations, labeling, and administration techniques for the pediatric emergency care setting.5 Unfortunately, there are currently no universally accepted, pediatric-specific standards with regard to dose suggestion and limits, and dosing guidelines and alerts found in CPOE are commonly provided by third-party vendors that supply platforms to both children’s and general hospitals. The development of a standard pediatric formulary, independent of an adult-focused system, can reduce opportunities for error by specifying limited concentrations and standard dosage of high-risk and frequently used medications, such as resuscitation medications, vasoactive infusions, narcotics, and antibiotics, as well as look-alike and sound-alike medications.33 A standard formulary will allow for consistent education during initial training and continuing medical education for emergency care providers, creating a consistent measure of provider competency. At least 1 large hospital organization has successfully implemented this type of change.34 In addition, the American Society of Health-System Pharmacists is working with the Food and Drug Administration to develop and implement national standardized concentrations for both intravenous and oral liquid medications.35

ED Pharmacists

Currently, many medications are prepared and dispensed in the ED without pharmacist verification or preparation because many EDs lack consistent on-site pharmacist coverage.9,36 In a survey of pharmacists, 68% reported at least 8 hours of ED coverage on weekdays, but fewer than half of EDs see this support on weekends, with a drastic reduction in coverage during overnight and morning hours.37 The American College of Emergency Physicians (ACEP) supports the integration of pharmacists within the ED team, specifically recognizing the pediatric population as a high-risk group that may benefit from pharmacist presence.38 The Emergency Nurses Association (ENA) supports the role of the emergency nurse as well as pharmacy staff to efficiently complete the best possible medication history and reduce medication discrepencies.39,40 The American Society of Health-System Pharmacists suggests that ED pharmacists may help verify and prepare high-risk medications, be available to prepare and double-check dosing of medications during resuscitation, and provide valuable input in medication reconciliation, especially of medically complex children whose medications and dosing may be unknown to ED staff and who present without a medication list or portable emergency information form.41 Medically complex patients typify the difficulty with medication reconciliation, with an error rate of 21% in a tertiary care facility.42 In this study, no 1 source from the parent, pharmacy, and primary provider group was both available and appropriately sensitive or specific in completing medication reconciliation. Pharmacist-managed reconciliation has had a positive impact for admitted pediatric patients and may translate to the emergency setting.43,44 ED pharmacists can also help monitor for ADEs, provide drug information, and provide information regarding medication ingestions to both providers and patients and/or families.45

Dedicated pharmacists can be integrated through various methods, such as hiring dedicated pharmacy staff for the ED,7 having these staff immediately available when consulted, or having remote telepharmacy review of medication orders by a central pharmacist.46,47 Although further research is needed on the potential outcomes on medication safety and return on investment when a pharmacist is placed in the ED, current experience reveals improvements in medication safety when a pharmacist is present.48 Studies from general EDs reveal significant cost savings as well,49 with the authors of 1 study in a single urban adult ED identifying more than $1 million dollars of cost avoidance in only 4 months.50

Training in Pediatric Medication Safety

Dedicated training in pediatric medication safety is highly variable in the curricula of professional training programs in medical, nursing, and pharmacy schools.51 Although national guidelines support the training of prehospital personnel with specific pediatric content and safety and error-reduction training,52 a nearly 35% prehospital medication error rate for critical medications for pediatric patients remains.14 At the graduate medical education level, the curricula of pediatric and emergency medicine residency programs and pediatric emergency medicine fellowship programs do not define specific requirements for pediatric medication safety training.5355 The same is true for pharmacy programs.56 Although schools of pharmacy include pediatric topics in their core curricula, pediatric safety advocates believe there is an opportunity for enhanced and improved training.57

Experts in pediatric emergency care from the multidisciplinary panel recommend development of a curriculum on pediatric medication safety that could be offered to all caregivers of children in emergency settings. A standard curriculum may include content such as common medication errors in children, systems-improvement tools to avoid or abate errors, and the effects of developmental differences in pediatric patients. Demonstrating competency on the basis of this curriculum is 1 means by which institutions may reduce risks of medication errors.

Decreasing Pediatric Medication Administration Errors in the ED

The dispensing and administration phases serve as final opportunities to optimize medication safety. Strategies to reduce errors include standardizing the concentrations available for a given drug, having readily available and up-to-date medication reference materials, using premixed intravenous preparations when possible, having automated dispensing cabinets with appropriate pediatric dosage formulations, using barcoded medication administration,58 having pharmacists and ED care providers work effectively as a team, and having policies to guide medication use.59,60 Although yet to be studied in the ED environment, smart infusion pumps have shown promise in other arenas in reducing administration errors for infusions.61

Nurses are held accountable by each state’s nurse practice act for the appropriateness of all medications given. Nursing schools teach the 5 rights of medication administration: the right patient, the right medication, the right dose, the right time, and the right route.62 Elliott and Liu63 expand the 5 rights to include right documentation, right action, right form, and right response to further improve medication safety. Simulated medication administration addresses opportunities beyond those captured within these rights and may have implications within the ED.64 Additionally, given the association of medication preparation interruptions and administration errors,65 the use of a distraction-free medication safety zone has been shown to enhance medication safety.66,67 Implementation of an independent 2-provider check process for high-alert medications, as suggested by The Joint Commission, also reduces administration errors.68 Both the Institute for Safe Medication Practices and The Joint Commission provide excellent guidance on these topics.69

Decreasing Pediatric Medication Errors in the Home

Recognizing and addressing language barriers and health literacy variability in the ED can affect medication safety in the home. Nonstandardized delivery devices continue to be used in the home, and dosing error rates of greater than 40% are reported.70 Advanced counseling and instrument provision in the ED are proven to decrease dosing errors at home.71 Pictograms provided to aide in medication measurement have also been shown to decrease errors and may be considered as part of discharge instructions.72 The AAP supports policy on the use of milliliter-only dosing for liquid medications used in the home and suggests that standardized delivery devices be distributed from the ED for use with these medications.73 As the body of literature regarding health literacy evolves, further addressing these issues in real time may influence out-of-hospital care.

Summary

Pediatric medication safety requires a multidisciplinary approach across the continuum of emergency care, starting in the prehospital setting, during emergency care, and beyond. Key areas for medication safety specific to pediatric care in the ED include the creation of standardized medication dosing guidelines, better integration and use of information technology to support patient safety, and increased education standards across health care disciplines. The following is a list of specific recommendations that can lead to improved pediatric medication safety in the emergency care setting.

Recommendations

  1. Create a standard formulary for pediatric high-risk and commonly used medications;

  2. standardize concentrations of high-risk medications;

  3. reduce the number of available concentrations to the smallest possible number;

  4. provide recommended precalculated doses;

  5. measure and record weight in kilograms only;

  6. use length-based dosing tools when a scale is unavailable or use is not feasible;

  7. implement and support the availability of pharmacists in the ED;

  8. use standardized order sets with embedded best practice prescribing and dosing range maximums;

  9. promote the development of distraction-free medication safety zones for medication preparation;

  10. implement process screening, such as a 2-provider independent check for high-alert medications;

  11. implement and use CPOE and CDS with pediatric-specific kilogram-only dosing rules, including upper dosing limits within ED information systems;

  12. encourage community providers of children with medical complexity to maintain a current medication list and an emergency information form to be available for emergency care;

  13. create and integrate a dedicated pediatric medication safety curriculum into training programs for nurses, physicians, respiratory therapists, nurse practitioners, physician assistants, prehospital providers, and pharmacists;

  14. develop tools for competency assessment;

  15. dispense standardized delivery devices for home administration of liquid medications;

  16. dispense milliliter-only dosing for liquid medications used in the home;

  17. employ advanced counseling such as teach-back when sharing medication instructions for home use; and

  18. use pictogram-based dosing instruction sheets for use of home medications.

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Individual Docs Underestimate Their Opioid Prescribing Habits


Most emergency department (ED) physicians underestimated the number of opioid prescriptions they wrote, but began prescribing fewer upon learning of their behavior, according to results of a study published in Academic Emergency Medicine.

Most ED physicians lack data on their opioid prescribing habits, and there are few benchmarks that would allow them to compare their habits with an accepted norm. In fact, only 17 states have published guidelines for opioid prescribing in the ED, and most that do rely on a physician’s knowledge of the opioid crisis and common sense to minimize prescribing rather than assess the behavior of individual clinicians.

In this prospective, multicenter, randomized trial, Sean S. Michael, MD, MBA, from the department of emergency medicine, University of Colorado School of Medicine, in Aurora, and colleagues investigated how providers perceive their opioid prescribing habits and assessed clinicians’ response to learning how their actual prescribing practices compared with group tendencies. The participants were then monitored for self-correction over the course of a year.

The goal of the strategy, which the researchers term “query-reveal intervention,” was to personalize how practitioners view the opioid crisis in their own workplaces. The researchers surveyed attending physicians, residents, and advanced practice providers (APPs) at four hospital EDs: an urban tertiary academic center, an urban acute care hospital/nonprimary teaching site, a small suburban community hospital, and a small rural community hospital.

The investigators randomly assigned 51 clinicians (34 attendings, 15 residents, and 2 APPs) to the intervention arm and 58 (31 attendings, 21 residents, and 6 APPs) to the control arm.

To estimate degree of opioid prescribing, a member of the study team showed each participant in the intervention group bar graphs representing all providers at their ED and asking “Each of these bars represents one provider in the group, including you. Which do you think is you?” Immediately after that, each clinician was provided with his/her true prescribing profile in absolute and relative to peers. Physicians in the control arm did not receive information on individual or group prescribing habits.

The primary outcome was change in percentage of patients discharged with an opioid prescription at 6 and 12 months.

During the year of the study, the 109 practitioners altogether discharged 119,428 patients and wrote 75,203 total prescriptions, including 15,124 (20.1%) for opioids.

Of the participants receiving the intervention, 73% of the attending physicians and advanced practice providers and 27% of the residents underestimated their prescribing rank compared with their peers by more than one decile in one metric or more. Just five providers (three residents and two attendings) overestimated their opioid prescribing rank.

Clinicians in the intervention group who had underestimated their prescribing showed larger declines in the number of patients discharged with an opioid prescription compared with clinicians in the control group. Specifically, compared with the control group, they had a median of 2.1 (95% confidence interval [CI], 0.5 – 3.9; P = .007) fewer opioid prescriptions per 100 patients at 6 months and 2.2 (95% CI, 0.01 – 4.8; P = .05) fewer prescriptions per 100 patients at 12 months.

Meanwhile, those in the intervention group who had not underestimated their prescribing at baseline prescribed 1.3 more prescriptions per 100 patients at 6 months compared with controls, and 1.2 more per 100 patients at 12 months.

“In the multivariable mixed-effects model, intervention allocation with underestimation of one’s prescribing relative to peers, physician level of training (compared to APP), and fewer years of experience were significant predictors of larger-magnitude six and twelve-month decreases in the proportion of patients discharged with an opioid prescription,” the authors write.

Providers with accurate self-perception or who overestimated their opioid prescribing practices didn’t decrease opioid prescribing compared with controls.

The four EDs served different communities but were part of the same healthcare system. Prescribing behavior did not significantly differ among them.

The researchers compare the lack of self-awareness about opioid prescribing to the observation that a majority of drivers think they are above average. They suggest that the disconnect between perceived behavior and being confronted with a different reality creates cognitive dissonance that drives behavior change.

“This randomized trial exposes important gaps in providers’ self-perceptions of opioid prescribing and demonstrates that a simple, data-driven intervention using query-reveal methodology may decrease future prescribing, particularly among providers who underestimate their own prescribing practices,” the researchers conclude.

Limitations of the study include the fact that only 5% to 10% of opioid prescriptions come from EDs, lack of information on the indications for which opioids were prescribed or whether alternative treatments were suggested, and implementation of a state law limiting opioid prescription during the eighth month of the investigation.

Delivering Safe and Effective Analgesia for Management of Renal Colic in the Emergency Department


TAKE-HOME MESSAGE

 The searing pain of renal colic is unforgettable to those who experience it. This well designed study demonstrated that the intramuscular administration of diclofenac, an NSAID, produced better and more durable analgesia than morphine delivered intravenously with a superior side effect profile.  While the intravenous administration of paracetamol (acetaminophen) produced a similar rapid reduction in pain intensity, analgesic rescue was needed more frequently.  Thus, an NSAID shot appears to be the preferred initial management for those experiencing renal colic.

Abstract

Instead of the ER: Paramedics making house calls to chronic patients.


Emergency rooms — which can cost patients thousands of dollars each visit — have become the primary source of medical care for the uninsured and people with chronic illnesses.

A Minnesota health care provider is testing a new program in the hopes of reducing ER admissions and keeping people healthier: they’re sending paramedics on house calls to some of the area’s sickest patients who might otherwise end up in the ER.

The need for such out-of-the-box solutions is clear. In the last year, one in five Americans went to the ER at least once for an estimated 130 million visits. The cost of all those ER visits is staggering, considering that the price for treating some of the most common conditions can range from an average of $750 all the way up to $73,000.

“We don’t screen for insurance at the door,” said Dr. Joey Duren, an emergency physician with North Memorial Healthcare System in Minnesota. “So in our country now, a big thing is that the emergency department is a safety net for people who don’t have insurance.”

Patients with chronic conditions like asthma and diabetes can spiral out of control without regular monitoring and land in the ER multiple times in a single year. The number of repeat patients is often staggering; some of whom visit dozens of times each month, according to North Memorial’s chief medical officer, Dr. Kevin Croston.

“What’s really the biggest cost in health care are the chronic conditions where there are readmissions to the emergency department,” Duren said. “We realized we needed to create care that stopped that.”

That’s where house calls from the community paramedics came in. Since the program began last October paramedics have made more than 1,000 home visits, at a fraction of the cost for a trip to the ER. Although North Memorial doesn’t have data yet on the savings, officials believe the program will help reduce admissions.

“The role of this community paramedic is helping people get on top of their chronic disease processes so they aren’t getting so sick that they need to come to us in the emergency department,” Duren explained. “We’re controlling their diseases so they can be handled in an outpatient setting versus having to come here or be admitted to the hospital for multiple days because they’ve gotten so far behind in their insulin for their diabetes or their COPD has gotten out of control.”

Chris Anderson is among the first group of paramedics who were specially trained to make house calls. He quickly recognized the value of those home visits.

“It’s when you get to spend more time with [patients], you get to find out what’s going on, what’s truly bothering them, what they need the most help with,” Anderson said.

The house calls have been a life-saver for folks like 65-year-old Victoria Denbleyker, who suffers from multiple, hard-to-manage chronic conditions, like diabetes, congestive heart failure, and rheumatoid arthritis—problems that used to routinely send her to the ER.

With doctors, Denbleyker said, “you don’t have that much time to really talk to them, even if you get the maximum amount of time, which is half an hour. Sometimes there are too many things going on. “

Without consistent monitoring, Denbleyker’s condition can rapidly descend into the danger zone.

“My system can change in a heartbeat,” she said. “I never know what is coming next. So the fact that they know what is going on with me means a lot.”

The Minnesota project started last October. To figure out which patients might benefit from the program, the hospital searched for anyone who had used the ER nine or more times in a year.

Nine was “the number we had to land on for our own survival mode,” said North Memorial’s Croston.

Think that’s a lot?

“We’ve had some patients that were here 23 times in a month,” he said.

Croston said, “readmission rates are down for us as a health system, and that’s largely due to the fact that we’re intervening once they leave the hospital or once they leave the emergency department.”

Barb Andrews, who runs the program, says it’s a new way of thinking about health care.

“It gives us, as paramedics, an opportunity to be proactive rather than reactive,” she said. “The community paramedics empower [patients] to be able to manage their own health better in the home.”

And ultimately, she said, that can “keep them out of the hospital, keep them out of the nursing home.”

Choosing Wisely: ACEP Lists 5 Tests to Question


The American College of Emergency Physicians (ACEP) issued a list of 5 tests and procedures that may not be cost-effective in some situations. The ACEP announced this list, which reflects its participation in the ABIM Foundation‘s Choosing Wisely campaign, at the opening session of their annual meeting in Seattle, Washington.

To lower healthcare costs and improve patient care, ACEP recommends that clinicians avoid these interventions when appropriate, after discussing that decision with patients and educating them regarding the rationale.

“ACEP needed a strategy to determine what emergency physicians could do to improve efficiency and reduce cost without affecting the quality of care we deliver,” ACEP Cost Effectiveness Task Force Chair David Ross, MD, an emergency physician in Colorado and medical director for more than 50 emergency medical services agencies in Colorado Springs, said in a news release. “The challenge also was to identify real cost savings, but also to develop consensus among emergency physicians.”

The ACEP board of directors approved the following 5 Choosing Wisely recommendations for patients seen in the emergency department:

1.      For patients with minor head injury who are deemed to be at low risk for skull fractures or hemorrhage, based on validated decision rules, clinicians should avoid head computed tomography scans. The majority of minor head injuries do not result in brain hemorrhage.

2.      For stable patients who can urinate on their own, clinicians should avoid placing indwelling urinary catheters for either urine output monitoring or patient or staff convenience.

3.      For patients likely to benefit from palliative and hospice care services, clinicians should not delay in engaging such services when available. Early referral from the emergency department can improve quality, as well as quantity, of life.

4.      For patients with uncomplicated skin and soft tissue abscesses successfully treated with incision and drainage, clinicians should provide adequate medical follow-up but avoid antibiotics and wound cultures.

5.      For children with mild to moderate, uncomplicated dehydration, clinicians should avoid giving intravenous fluids before a trial of oral rehydration therapy.

“Emergency physicians are dedicated to improving emergency care and to reducing health care costs,” ACEP President Alex Rosenau, DO, said in a news release. “These recommendations are evidence-based and developed with significant input from experts.”

An expert panel of emergency physicians and the ACEP board of directors reviewed pertinent research and input, including a survey of all ACEP members, before developing the recommendations.

In its Choosing Wisely campaign, the ABIM Foundation aims to facilitate discussion among physicians and patients about appropriate use of tests and treatments and avoidance of these interventions when the harms may outweigh the benefits.

More than 80 national, regional, and state medical specialty societies and consumer groups have joined Choosing Wisely since the campaign began in April 2012, but ACEP held off until February 2013. The delay resulted from potential conflicts of the Choosing Wisely strategy with the unique goals of emergency medicine and from concerns that the campaign does not advocate for medical liability reform.

“Overuse of medical tests is a serious problem, and health care reform is incomplete without medical liability reform,” said Dr. Rosenau. “Millions of dollars in defensive medicine are driving up the costs of health care for everyone. We will continue to encourage the ABIM Foundation and its many partners in this campaign to lend their influential voices to the need for medical liability reform.”

Source: American College of Emergency Physicians.

Risks for Peri-Intubation Cardiac Arrest.


In a retrospective analysis, patients in shock were at higher risk for peri-intubation cardiac arrest, which usually had an initial rhythm of pulseless electrical activity.
Peri-intubation hypotension and even cardiac arrest are concerns in patients undergoing emergency resuscitation. To determine the incidence of peri-intubation cardiac arrest and factors associated with it, researchers retrospectively analyzed records for 410 adult patients who underwent rapid sequence intubation (RSI) at a single urban emergency department during 2007.

Peri-intubation cardiac arrest (defined as occurring within 60 minutes after initiation of airway management) was documented on the standardized data collection tool in 17 patients (4.2%), at a median 6 minutes after intubation. Nearly two thirds of cardiac arrests occurred within 10 minutes. Pulseless electrical activity was the initial arrest rhythm in most cases. Arrest was more common in patients with pre-intubation hypotension (12% vs. 3%) and in those with pre-intubation oxygen saturation (<92%).

In multivariate logistic regression analysis, higher pre-RSI shock index and body weight were independently associated with peri-intubation cardiac arrest. Although more than half of patients were initially resuscitated, peri-intubation cardiac arrest portended a 14-fold increase in the odds of in-hospital death.

COMMENT

The association of peri-intubation cardiac arrest with higher pre-intubation shock index, and the finding that nearly all cardiac arrest patients had pulseless electrical activity, highlights the precarious state of hypotensive critically ill patients, especially those with higher body mass index. We are subjecting these fragile patients to a combination of induction agents, airway manipulation, and, especially, positive pressure ventilation. The take-home message? Intubate earlier, if possible, before the patient deteriorates; optimize hemodynamic parameters with pressors, fluids, or blood; and carefully control mechanical ventilation to minimize ventilation pressures.

Source: NEJM.

Use of ‘Low-Risk Ankle Rule’ May Limit X-Rays in Children.


Using the “low-risk ankle rule” to assess children’s ankle injuries in emergency departments significantly reduces X-ray imaging, according to aCanadian Medical Association Journal study.

Nearly 2200 patients aged 3 to 16 years presented with acute ankle injuries to emergency departments designated as either intervention or control sites. Intervention sites applied the rule, which says that radiography may not be necessary when tenderness and swelling is isolated to the distal fibula and the adjacent lateral ligaments distal to the tibial anterior joint line. At control sites, procedures for ankle injuries were unchanged.

After implementation of the rule, intervention sites saw a 22-percentage-point reduction in weekly ankle radiography, compared with controls. Application of the ankle rule was not associated with an increase in significant fractures being missed or a decrease in physician or patient satisfaction.

The authors conclude: “Widespread implementation of this rule could safely lead to reduction of unnecessary radiography in this radiosensitive population and a more efficient use of healthcare resources.”

Source: CMAJ

Brief Emergency Department Intervention to Reduce Teen Dating Violence.


Among teens with a history of dating violence, effectiveness of the intervention depended on the baseline level of violence.
Investigators evaluated the effectiveness of the SafERteens intervention for reducing dating violence among adolescents presenting to an emergency department (ED). The 35-minute bedside intervention involves goal setting, feedback, decision-balancing exercises, and role-playing scenarios. In the SafERteens study, 726 patients aged 14 to 18 years with a history of aggression or violence and alcohol use in the previous year were randomized to one of three groups: intervention delivered by computer, intervention delivered by a therapist with computer assistance, or a standard brochure about resources (control). Participants were followed up with self-assessments 3, 6, and 12 months after the ED visit.

This secondary analysis included 397 adolescents (36% male) with a history of dating violence. The computer-only group, compared to controls, had a reduction in moderate dating violence (e.g., slapped, hair pulled, shoved) at 3 months and 6 months, but not at 12 months. Neither intervention had an effect on severe dating violence (e.g., punched, choked, knife or gun used). Adolescents with a baseline moderate level and high frequency (>8 times per year) of dating violence had a decrease in moderate dating violence at 6 and 12 months; those with a baseline severe level and high frequency had a decrease in severe violence at 3 months.

COMMENT

Emergency physicians are in a unique position to capitalize on many “teachable moments.” While much remains to be learned as to the best interventions for reducing teen dating violence, we should not miss these opportunities — such as when caring for a beaten teen — to help our patients make wiser choices.

Source: NEJM

Copeptin Helps “Copeptin Helps in the Early Detection Of Patients with Acute Myocardial Infarction”: the primary results of the CHOPIN Trial ONLINE FIRST.


“Copeptin Helps in the Early Detection Of Patients with Acute Myocardial Infarction”: the primary results of the CHOPIN Trial ONLINE FIRST

Objectives  Demonstrate that copeptin level <14 pmol/L allows ruling out AMI when used in combination with cardiac troponin I (cTnI) <99th percentile and a non-diagnostic ECG at the time of presentation to the emergency department (ED).

Background  Copeptin is secreted from the pituitary early in the course of acute myocardial infarction (AMI).

Methods  This was a 16-site study in 1967 chest pain patients presenting to an ED within 6 hours of the onset of chest pain. Baseline demographics and clinical data were collected prospectively. Copeptin and a contemporary sensitive cTnI (99th percentile 40 ng/L; 10% coefficient of variation (CV) 0.03 μg/L) were measured in a core laboratory. Patients were followed for 180 days. The primary outcome was diagnosis of AMI. Final diagnoses were adjudicated by two independent cardiologists blinded to copeptin results.

Results  AMI was the final diagnosis in 156 patients (7.9%). A negative copeptin and cTnI at baseline ruled out AMI for 58% of patients, with a NPV of 99.2% (95% CI 98.5-99.6). AMIs not detected by the initial cTnI alone were picked up with copeptin >14 pmol/L in 23/32 patients (72%). NSTEMIs undetected by cTnI at 0h were detected with Copeptin >14 pmol/L in 10/19 patients (53%). Projected average time-to-decision could be reduced by 43% (from 3.0 hours to 1.8 hours) by the early rule out of 58% of patients. Both abnormal copeptin and cTnI were predictors of death at 180 days (p<0.0001 for both, c index 0.784 and 0.800, respectively). Both were independent of age and each other and provided additional predictive value (all p<0.0001).

Conclusion  Adding copeptin to cTnI allowed safe rule out of AMI with a NPV >99% in patients presenting with suspected ACS. It has the potential to rule out AMI in 58% of patients without serial blood draws.

Source: JACC