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250: The Utility of Formal Radiology Ultrasonography After Indeterminate Emergency Physician Pelvic Ultrasonography In the Evaluation of Ectopic Pregnancy
Research Forum Abstracts Study Objectives: To evaluate the feasibility and clinical utility of point of care ultrasonography imaging of the IJV collapsibility index in the assessment of hypovolemia in critically ill patients identified by standard hemodynamic variables requiring crystalloid resuscitation. Methods: A prospective observational study conducted in an urban tertiary care teaching hospital intensive care unit. Point-of-care IJV ultrasonography by emergency medicine or critical care physician sonographers were performed on 15 patients who were diagnosed as hypovolemic by the managing critical care physicians using standard hemodynamic assessment and initiated on crystalloid resuscitation. Sonographic measurements were done prior to initiation of resuscitation and IJV collapsibility index was defined as: [(max IJV AP diameter - min IJV AP diameter) / max IJV AP diameter] multiplied by 100%. (Figure 1) Results: 15 hypovolemic critically ill patients identified on admission were 50% male and 71% white with a mean age of 62 (⫾19) years old. Hypovolemia was identified by the critical care physicians using standard hemodynamic parameters with mean (⫾std. dev) as listed: mean arterial pressure 78.8 ⫾16.8 mmHg, pulse rate 99 ⫾18 beats per minute, respiratory rate 23 ⫾7 breaths per minute, central venous pressure (CVP) 6 ⫾4 mmHg. The average IJV collapsibility index was 57 ⫾21%. 5 of the 15 hypovolemic were on mechanical ventilation with positive end-expiratory pressure with a mean CVP of 7 ⫾5 mmHg with an IJV collapsibility index of 52 ⫾25%. Conclusion: IJV collapsibility index can be readily obtained via point of care ultrasonography in critically ill patients. First description to date of an IJV collapsibility index measured in hypovolemic critically ill patients, both on or off mechanical ventilation. Further studies are needed to identify what cut-off parameter for IJV collapsibility index are associated with hypovolemia, euvolemia and hypervolemia.
Methods: This was a structured, explicit, retrospective chart review based at an urban academic ED with an annual census of approximately 160,000 patient visits. Previously published criteria for improving the value of medical record reviews were followed closely. Two investigators, each blinded to the study hypothesis, used a standard data abstraction form to independently review charts. All adult patients (⬎18 years) from July 1, 2009 to January 31, 2010 with a final diagnosis of renal colic were queried. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasonography performed by an emergency physician. Only those patient encounters with both CT proven renal calculi and documented bedside ultrasonography results were included. STATA 10 software (College Station, TX) was used to analyze data. Ordinal logistic regression analysis was performed to evaluate trends in stone size and number. Results: Of the 124 patients who met inclusion criteria, 92% were non-white and 95.2% were uninsured. The overall sensitivity of ultrasonography for detection of hydronephrosis was 78.4% [95% Confidence Interval (CI) ⫽ 70.2-85.3%]. Based on a prior assumption that ultrasonography would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p ⫽ 0.04) difference in detecting hydronephrosis in patients with a stone ⱖ 6mm (sensitivity ⫽ 85% [95% CI ⫽ 73-93%]) compared to a stone ⬍6mm (sensitivity ⫽ 72% [95% CI ⫽ 6083%]). For those with three or more stones, sensitivity was 100% [95% CI ⫽ 63100%]. Sensitivity in patients with two stones was 88% [95% CI ⫽ 64-99%] and 75% [95% CI ⫽ 65-83%] with a single stone. Conclusion: ED bedside ultrasonography sensitivity significantly improved in patients with stones ⱖ 6mm compared to those with smaller stones. It also showed an improving trend for detection of hydronephrosis in patients with multiple stones. In our uninsured, minority population with CT-proven urolithiasis, ED bedside ultrasonography showed similar overall sensitivity for detecting hydronephrosis compared with other populations.
250
The Utility of Formal Radiology Ultrasonography After Indeterminate Emergency Physician Pelvic Ultrasonography In the Evaluation of Ectopic Pregnancy
Stein JC, Lee E, Wang R, Sanford E, Martinez C, Cortez A, McAlpine I, Reynolds T, Jacoby V/University of California, San Francisco, San Francisco, CA; UCSF, San Francisco, CA
249
Trends In Emergency Bedside Ultrasonography for the Detection of Hydronephrosis In a Population With Computed Tomography-Proven Stones
Riddell J, Case A, Wopat R, Beckham S, Lucas M, McClung CD, Swadron S/Keck School of Medicine of the University of Southern California, Los Angeles, CA
Study Objectives: Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasonography is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number; as well as determine if the previously reported sensitivity would be observed in a minority/uninsured population.
S82 Annals of Emergency Medicine
Study Objectives: Ectopic pregnancy is a common concern in the emergency department. Pelvic ultrasonography by emergency physicians has been shown to be both an accurate and efficient means of evaluating such patients. Between 50-70% of patients that undergo pelvic ultrasonography by an emergency physician will have a visible intrauterine pregnancy (IUP), thus excluding ectopic pregnancy. However, it is not clear how much additional value formal radiology offers in cases where the emergency physician ultrasonography is non-diagnostic. We sought to evaluate how often formal radiology is diagnostic in the presence of a non-diagnostic initial emergency physician pelvic ultrasonography. Methods: This was a prospective study of consecutive first trimester female ED patients presenting with abdominal pain or vaginal bleeding who had a positive urine pregnancy test. Patients with a diagnosed IUP by previous ultrasonography were excluded. Patients received 1) a pelvic transvaginal ultrasonography performed by the attending emergency physician, 2) serum b-hCG testing, and 3) subsequent radiologist pelvic ultrasonography. Radiologists were blinded to the result of the initial exam. Emergency physicians were credentialed in ultrasonography according to ACEP guidelines. The ED ultrasonography was classified as showing an IUP if a gestational sac and yolk sac was visualized within the uterus. Radiology department studies were classified as “diagnostic” if they met previously defined criteria. Diagnostic IUP scans required: 1) gestational sac with a yolk sac, 2) gestational sac with fetal pole, or 3) fetal pole with heartbeat. Diagnostic ectopic pregnancy scans required: 1) extrauterine gestational sac with or without a yolk sac or fetal pole, 2) a complex mass discrete from the ovary, or 3) a large amount of fluid in the cul-de-sac. All patients were followed up at 8 weeks to determine final outcomes. Results: A total of 296 patients were eligible for the study, and 51 did not consent or were not approached. Thus, 245 patients were enrolled in the study, and thirty-one different physicians performed bedside pelvic ultrasonography exams. 119 (49%) patients had ED ultrasonographys showing IUP and thus were excluded from further analysis. Of the 126 (51%) patients with ED ultrasonographys showing no IUP, 10 did not receive formal ultrasonographys, giving a final study population of 116 patients, and 17 (15%) of these patients were eventually diagnosed with ectopic pregnancy.
Volume , . : September
Research Forum Abstracts 38 of the 116 were categorized as having a diagnostic ultrasonography by radiology (33%, 95% CI 24% - 42%). Included were 11 patients diagnosed with ectopic pregnancy, representing 65% (95% CI 38% - 86%) of the 17 total. In the 59 patients with b-hCG over 2000 mIU/ml, 28 had diagnostic formal ultrasonographys (47%, 95% CI 34% - 61%). In the 57 patients with a b-hCG under 2000 mIU/mL, 10 (18%, 95% CI 9% - 30%) had diagnostic formal ultrasonographys. Conclusions: Formal radiology ultrasonography was diagnostic in one third of symptomatic first trimester patients after an initial indeterminate ED pelvic sonogram. Formal ultrasonography was diagnostic at the time of presentation in two thirds of the patients with ectopic pregnancy who had a non-diagnostic ED ultrasonography. Even for patients with b-hCG below the discriminatory zone who had a negative ED ultrasonography, formal radiology was still diagnostic for one in five patients.
251
Correlation of Previous Ultrasonography Experience to Interpretation of Core Ultrasonography Scans by Emergency Medicine Residents
Bahl A, Chinwala A/William Beaumont Hospital, Royal Oak, MI
Study Objectives: This study investigated the correlation between the number of previously performed ultrasonography scans completed by emergency medicine (EM) residents and their subsequent interpretation of standardized ultrasonography scans. The motivation of this study was to evaluate the utility of the current numbers-based guidelines for EM resident training in emergency ultrasonography. Methods: A single-site prospective study was completed evaluating EM residents’ ability to interpret ultrasonography images. Data was collected via a standardized multiple-choice annual examination of 90 randomized ultrasonography video clips given in 2009 and 2010. Video clips focused on five core ultrasonography applications, including right upper quadrant (RUQ), cardiac, first trimester pregnancy (FTP), abdominal aorta (AA), and focused abdominal sonography in trauma (FAST). Statistical analysis utilizing Kruskal-Wallis tests and logistic regression was then performed to determine the relationship between examination scores and the number of previously-completed scans at time of test. Results: Thirty-six EM residents were enrolled in the study. Post-graduate level (PGY) ranged from PGY1-3 (n⫽ 15, 8, and 13 respectively). Every resident included in this study took the test only once throughout his/her residency. On average, residents had previously completed 16 RUQ scans, 11 cardiac scans, 4 FTP scans, 13 AA scans, and 23 FAST scans. Residents accurately interpreted 71% of RUQ scans, 71% of Cardiac scans, 52% of FTP scans, 68% of AA scans, and 87% of FAST scans. There was a statistically significant linear relationship between number of scans performed and interpretation accuracy on the RUQ and AA portions of the test (pvalue less than 0.0001). The odds ratio of a RUQ score greater than 71% increased by a factor of 5 for residents who performed greater than 25 RUQ scans when compared to those that performed less than or equal to 25 scans while this odds ratio increased by a factor of 13 for residents who performed greater than 16 RUQ scans when compared to those that performed less than or equal to 16 such scans. The odds ratio of an AA score greater than 68% increased by a factor of 11 for residents who performed greater than 25 AA scans compared to those who performed less than or equal to 25 such scans while this odds ratio increased by a factor of 13 for residents who performed greater than 13 AA scans when compared to those who performed less than or equal to 13 such scans. No clear significant relationship was evident between number of scans performed and the cardiac, FTP, or FAST exam scores. Conclusions: This data supports a relationship between number of scans performed and interpretation accuracy on core emergency ultrasonography applications. Specifically, a strong association was identified between number of previously performed scans and interpretation of RUQ and AA scans. Our data suggests, however, that adequate resident training for interpretation may be achievable using smaller than the generally accepted guideline of 25 scans per application. Furthermore, the number of scans needed may be variable dependent on the specific application. Further research is necessary to identify the optimal numeric guidelines for each ultrasonography application.
252
Perceptions of Emergency Department Staff Concerning Adverse Events and Near Misses
Kellogg KM, Fairbanks RJ, Clark LN, Shah MN/University of Rochester, Rochester, NY
Study Objectives: The Institute of Medicine reported that the emergency department (ED) has the highest amount of preventable adverse events, and a systems
Volume , . : September
approach has been cited as an important solution. Few studies since have prospectively collected staff perceptions of events in real time. The objectives of this study were to better understand the perceptions of staff regarding causality and reporting of adverse events (AE) and near misses (NM) that occur in an academic medical center ED and to describe the nature of these events. Methods: As this study was intended to be hypothesis generating, qualitative methods were used. A trained research assistant conducted real time interviews with ED staff during their shifts. Staff members were approached individually, consented, and asked to share recent experiences involving AE, NM, or other patient safety concerns. Responses were transcribed, coded, and thematically analyzed using rigorous qualitative analysis methods. Emerging themes were identified. As tests for significance are not applicable in qualitative research, none were performed. However, descriptive statistics were calculated for reference. Results: 143 interviews were conducted with 134 unique participants, including 55 nurses (41%), 33 attendings (23%), 25 residents (19%), 11 non-ED staff (8%), 6 physician assistants or nurse practitioners (5%), and 4 ED technicians (3%). 18 AE were reported by 12 participants and 48 NM were reported by 37 participants. 9 (50%) AE and 34 (71%) NM reported were medication-related. Pharmacotherapyrelated factors were the most frequently cited as contributing to AE and NM (50% and 70.8%, respectively), and problems reported included incorrect ordering of dose, medication order being carried out incorrectly, and an inappropriate medication being ordered. The medication classes most commonly reported as involved in any event were narcotic analgesics, antibiotics, anticoagulants, and beta-blockers. Device problems were the second most common factor cited as a cause of AE and NM (11.1% and 18.8%, respectively). Personal blame was commonly sited as a cause (38.9% in AE and 29.9% in NM). Very few participants reported system problems (5.6% in AE and 2.1% in NM). Staff rarely reported they had entered or intended to enter the events in the hospital’s event reporting system. Conclusions: AE and NM are common in the ED, but staff rarely report to the hospital’s event reporting system. Physicians reported more adverse events while nurses reported more near misses. One of the most concerning emerging themes we identified was that of a culture of blame. ED staff in our study did not tend to report a system-based perspective when considering adverse events and near misses that they witness. Future efforts to encourage systems-based thinking are essential to improving patient safety.
253
Computerized Prescriber Order Entry Decreases Patient Satisfaction and Emergency Physician Productivity
Bastani A, Walch R, Todd B, Dimsdale S, Donaldson D, Dennis B, Bonanno D, Anderson W/William Beaumont Hospital Troy, Troy, MI
Study Objective: Current literature has demonstrated a reduction in medication errors with the implementation of computerized prescriber order entry (CPOE) in academic centers, especially in the pediatric population. Due to its fast-paced environment, high patient turnover and the broad age of patients, many hospitals are moving towards CPOE beginning with their emergency departments (EDs). With ED crowding reaching epidemic proportions, the indirect effects of CPOE in ED must be evaluated alongside the purported advantages. The indirect effect of CPOE on ED throughput and patient satisfaction has not yet been described in a community hospital setting. Our objective was to evaluate the impact of CPOE on these ED metrics. Methods: We conducted a before and after study of ED patient data at our 320 bed suburban community hospital with an ED census of 70,000 visits annually. The before study cohort was comprised of 60 days of data from August 28, 2009 through October 27, 2009. On October 28th, 2009 CPOE began in the ED at our institution. We then allowed a one-month adjustment period, and collected data in the after cohort from December 1, 2009 through Jan 31, 2010. Our primary outcome measure was the effect of CPOE on ED throughput as measure by the effect on: 1) Door to Room time, 2) Room to Doc time, 3) Door to Doc time, 4) Length of Stay for both admitted and discharged patients, 5) % of patients who left without being seeing and 6) % of time spent on diversion. Our secondary outcome measure was patient satisfaction as provided by Press Ganey surveys. Data was analyzed using descriptive statistics, and means were compared using a standard t-test. Results: A total of 10,578 patients were evaluated in the before group compared with 11,483 patients in the after group. All primary outcome measures are displayed in Table #1. There was a 10-minute, 34.2% increase (p ⬍0.0001), in Room to Doc time from the before to the after cohort. This increase made up the majority of 14 minute, 23.1% increase, (p ⬍0.0001) in Door to Doc time that also occurred after CPOE initiation. Admitted patients length of stay decreased 7 minutes (p ⬍0.0001)
Annals of Emergency Medicine S83
Methods: This was a structured, explicit, retrospective chart review based at an urban academic ED with an annual census of approximately 160,000 patient visits. Previously published criteria for improving the value of medical record reviews were followed closely. Two investigators, each blinded to the study hypothesis, used a standard data abstraction form to independently review charts. All adult patients (⬎18 years) from July 1, 2009 to January 31, 2010 with a final diagnosis of renal colic were queried. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasonography performed by an emergency physician. Only those patient encounters with both CT proven renal calculi and documented bedside ultrasonography results were included. STATA 10 software (College Station, TX) was used to analyze data. Ordinal logistic regression analysis was performed to evaluate trends in stone size and number. Results: Of the 124 patients who met inclusion criteria, 92% were non-white and 95.2% were uninsured. The overall sensitivity of ultrasonography for detection of hydronephrosis was 78.4% [95% Confidence Interval (CI) ⫽ 70.2-85.3%]. Based on a prior assumption that ultrasonography would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p ⫽ 0.04) difference in detecting hydronephrosis in patients with a stone ⱖ 6mm (sensitivity ⫽ 85% [95% CI ⫽ 73-93%]) compared to a stone ⬍6mm (sensitivity ⫽ 72% [95% CI ⫽ 6083%]). For those with three or more stones, sensitivity was 100% [95% CI ⫽ 63100%]. Sensitivity in patients with two stones was 88% [95% CI ⫽ 64-99%] and 75% [95% CI ⫽ 65-83%] with a single stone. Conclusion: ED bedside ultrasonography sensitivity significantly improved in patients with stones ⱖ 6mm compared to those with smaller stones. It also showed an improving trend for detection of hydronephrosis in patients with multiple stones. In our uninsured, minority population with CT-proven urolithiasis, ED bedside ultrasonography showed similar overall sensitivity for detecting hydronephrosis compared with other populations.
250
The Utility of Formal Radiology Ultrasonography After Indeterminate Emergency Physician Pelvic Ultrasonography In the Evaluation of Ectopic Pregnancy
Stein JC, Lee E, Wang R, Sanford E, Martinez C, Cortez A, McAlpine I, Reynolds T, Jacoby V/University of California, San Francisco, San Francisco, CA; UCSF, San Francisco, CA
249
Trends In Emergency Bedside Ultrasonography for the Detection of Hydronephrosis In a Population With Computed Tomography-Proven Stones
Riddell J, Case A, Wopat R, Beckham S, Lucas M, McClung CD, Swadron S/Keck School of Medicine of the University of Southern California, Los Angeles, CA
Study Objectives: Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasonography is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number; as well as determine if the previously reported sensitivity would be observed in a minority/uninsured population.
S82 Annals of Emergency Medicine
Study Objectives: Ectopic pregnancy is a common concern in the emergency department. Pelvic ultrasonography by emergency physicians has been shown to be both an accurate and efficient means of evaluating such patients. Between 50-70% of patients that undergo pelvic ultrasonography by an emergency physician will have a visible intrauterine pregnancy (IUP), thus excluding ectopic pregnancy. However, it is not clear how much additional value formal radiology offers in cases where the emergency physician ultrasonography is non-diagnostic. We sought to evaluate how often formal radiology is diagnostic in the presence of a non-diagnostic initial emergency physician pelvic ultrasonography. Methods: This was a prospective study of consecutive first trimester female ED patients presenting with abdominal pain or vaginal bleeding who had a positive urine pregnancy test. Patients with a diagnosed IUP by previous ultrasonography were excluded. Patients received 1) a pelvic transvaginal ultrasonography performed by the attending emergency physician, 2) serum b-hCG testing, and 3) subsequent radiologist pelvic ultrasonography. Radiologists were blinded to the result of the initial exam. Emergency physicians were credentialed in ultrasonography according to ACEP guidelines. The ED ultrasonography was classified as showing an IUP if a gestational sac and yolk sac was visualized within the uterus. Radiology department studies were classified as “diagnostic” if they met previously defined criteria. Diagnostic IUP scans required: 1) gestational sac with a yolk sac, 2) gestational sac with fetal pole, or 3) fetal pole with heartbeat. Diagnostic ectopic pregnancy scans required: 1) extrauterine gestational sac with or without a yolk sac or fetal pole, 2) a complex mass discrete from the ovary, or 3) a large amount of fluid in the cul-de-sac. All patients were followed up at 8 weeks to determine final outcomes. Results: A total of 296 patients were eligible for the study, and 51 did not consent or were not approached. Thus, 245 patients were enrolled in the study, and thirty-one different physicians performed bedside pelvic ultrasonography exams. 119 (49%) patients had ED ultrasonographys showing IUP and thus were excluded from further analysis. Of the 126 (51%) patients with ED ultrasonographys showing no IUP, 10 did not receive formal ultrasonographys, giving a final study population of 116 patients, and 17 (15%) of these patients were eventually diagnosed with ectopic pregnancy.
Volume , . : September
Research Forum Abstracts 38 of the 116 were categorized as having a diagnostic ultrasonography by radiology (33%, 95% CI 24% - 42%). Included were 11 patients diagnosed with ectopic pregnancy, representing 65% (95% CI 38% - 86%) of the 17 total. In the 59 patients with b-hCG over 2000 mIU/ml, 28 had diagnostic formal ultrasonographys (47%, 95% CI 34% - 61%). In the 57 patients with a b-hCG under 2000 mIU/mL, 10 (18%, 95% CI 9% - 30%) had diagnostic formal ultrasonographys. Conclusions: Formal radiology ultrasonography was diagnostic in one third of symptomatic first trimester patients after an initial indeterminate ED pelvic sonogram. Formal ultrasonography was diagnostic at the time of presentation in two thirds of the patients with ectopic pregnancy who had a non-diagnostic ED ultrasonography. Even for patients with b-hCG below the discriminatory zone who had a negative ED ultrasonography, formal radiology was still diagnostic for one in five patients.
251
Correlation of Previous Ultrasonography Experience to Interpretation of Core Ultrasonography Scans by Emergency Medicine Residents
Bahl A, Chinwala A/William Beaumont Hospital, Royal Oak, MI
Study Objectives: This study investigated the correlation between the number of previously performed ultrasonography scans completed by emergency medicine (EM) residents and their subsequent interpretation of standardized ultrasonography scans. The motivation of this study was to evaluate the utility of the current numbers-based guidelines for EM resident training in emergency ultrasonography. Methods: A single-site prospective study was completed evaluating EM residents’ ability to interpret ultrasonography images. Data was collected via a standardized multiple-choice annual examination of 90 randomized ultrasonography video clips given in 2009 and 2010. Video clips focused on five core ultrasonography applications, including right upper quadrant (RUQ), cardiac, first trimester pregnancy (FTP), abdominal aorta (AA), and focused abdominal sonography in trauma (FAST). Statistical analysis utilizing Kruskal-Wallis tests and logistic regression was then performed to determine the relationship between examination scores and the number of previously-completed scans at time of test. Results: Thirty-six EM residents were enrolled in the study. Post-graduate level (PGY) ranged from PGY1-3 (n⫽ 15, 8, and 13 respectively). Every resident included in this study took the test only once throughout his/her residency. On average, residents had previously completed 16 RUQ scans, 11 cardiac scans, 4 FTP scans, 13 AA scans, and 23 FAST scans. Residents accurately interpreted 71% of RUQ scans, 71% of Cardiac scans, 52% of FTP scans, 68% of AA scans, and 87% of FAST scans. There was a statistically significant linear relationship between number of scans performed and interpretation accuracy on the RUQ and AA portions of the test (pvalue less than 0.0001). The odds ratio of a RUQ score greater than 71% increased by a factor of 5 for residents who performed greater than 25 RUQ scans when compared to those that performed less than or equal to 25 scans while this odds ratio increased by a factor of 13 for residents who performed greater than 16 RUQ scans when compared to those that performed less than or equal to 16 such scans. The odds ratio of an AA score greater than 68% increased by a factor of 11 for residents who performed greater than 25 AA scans compared to those who performed less than or equal to 25 such scans while this odds ratio increased by a factor of 13 for residents who performed greater than 13 AA scans when compared to those who performed less than or equal to 13 such scans. No clear significant relationship was evident between number of scans performed and the cardiac, FTP, or FAST exam scores. Conclusions: This data supports a relationship between number of scans performed and interpretation accuracy on core emergency ultrasonography applications. Specifically, a strong association was identified between number of previously performed scans and interpretation of RUQ and AA scans. Our data suggests, however, that adequate resident training for interpretation may be achievable using smaller than the generally accepted guideline of 25 scans per application. Furthermore, the number of scans needed may be variable dependent on the specific application. Further research is necessary to identify the optimal numeric guidelines for each ultrasonography application.
252
Perceptions of Emergency Department Staff Concerning Adverse Events and Near Misses
Kellogg KM, Fairbanks RJ, Clark LN, Shah MN/University of Rochester, Rochester, NY
Study Objectives: The Institute of Medicine reported that the emergency department (ED) has the highest amount of preventable adverse events, and a systems
Volume , . : September
approach has been cited as an important solution. Few studies since have prospectively collected staff perceptions of events in real time. The objectives of this study were to better understand the perceptions of staff regarding causality and reporting of adverse events (AE) and near misses (NM) that occur in an academic medical center ED and to describe the nature of these events. Methods: As this study was intended to be hypothesis generating, qualitative methods were used. A trained research assistant conducted real time interviews with ED staff during their shifts. Staff members were approached individually, consented, and asked to share recent experiences involving AE, NM, or other patient safety concerns. Responses were transcribed, coded, and thematically analyzed using rigorous qualitative analysis methods. Emerging themes were identified. As tests for significance are not applicable in qualitative research, none were performed. However, descriptive statistics were calculated for reference. Results: 143 interviews were conducted with 134 unique participants, including 55 nurses (41%), 33 attendings (23%), 25 residents (19%), 11 non-ED staff (8%), 6 physician assistants or nurse practitioners (5%), and 4 ED technicians (3%). 18 AE were reported by 12 participants and 48 NM were reported by 37 participants. 9 (50%) AE and 34 (71%) NM reported were medication-related. Pharmacotherapyrelated factors were the most frequently cited as contributing to AE and NM (50% and 70.8%, respectively), and problems reported included incorrect ordering of dose, medication order being carried out incorrectly, and an inappropriate medication being ordered. The medication classes most commonly reported as involved in any event were narcotic analgesics, antibiotics, anticoagulants, and beta-blockers. Device problems were the second most common factor cited as a cause of AE and NM (11.1% and 18.8%, respectively). Personal blame was commonly sited as a cause (38.9% in AE and 29.9% in NM). Very few participants reported system problems (5.6% in AE and 2.1% in NM). Staff rarely reported they had entered or intended to enter the events in the hospital’s event reporting system. Conclusions: AE and NM are common in the ED, but staff rarely report to the hospital’s event reporting system. Physicians reported more adverse events while nurses reported more near misses. One of the most concerning emerging themes we identified was that of a culture of blame. ED staff in our study did not tend to report a system-based perspective when considering adverse events and near misses that they witness. Future efforts to encourage systems-based thinking are essential to improving patient safety.
253
Computerized Prescriber Order Entry Decreases Patient Satisfaction and Emergency Physician Productivity
Bastani A, Walch R, Todd B, Dimsdale S, Donaldson D, Dennis B, Bonanno D, Anderson W/William Beaumont Hospital Troy, Troy, MI
Study Objective: Current literature has demonstrated a reduction in medication errors with the implementation of computerized prescriber order entry (CPOE) in academic centers, especially in the pediatric population. Due to its fast-paced environment, high patient turnover and the broad age of patients, many hospitals are moving towards CPOE beginning with their emergency departments (EDs). With ED crowding reaching epidemic proportions, the indirect effects of CPOE in ED must be evaluated alongside the purported advantages. The indirect effect of CPOE on ED throughput and patient satisfaction has not yet been described in a community hospital setting. Our objective was to evaluate the impact of CPOE on these ED metrics. Methods: We conducted a before and after study of ED patient data at our 320 bed suburban community hospital with an ED census of 70,000 visits annually. The before study cohort was comprised of 60 days of data from August 28, 2009 through October 27, 2009. On October 28th, 2009 CPOE began in the ED at our institution. We then allowed a one-month adjustment period, and collected data in the after cohort from December 1, 2009 through Jan 31, 2010. Our primary outcome measure was the effect of CPOE on ED throughput as measure by the effect on: 1) Door to Room time, 2) Room to Doc time, 3) Door to Doc time, 4) Length of Stay for both admitted and discharged patients, 5) % of patients who left without being seeing and 6) % of time spent on diversion. Our secondary outcome measure was patient satisfaction as provided by Press Ganey surveys. Data was analyzed using descriptive statistics, and means were compared using a standard t-test. Results: A total of 10,578 patients were evaluated in the before group compared with 11,483 patients in the after group. All primary outcome measures are displayed in Table #1. There was a 10-minute, 34.2% increase (p ⬍0.0001), in Room to Doc time from the before to the after cohort. This increase made up the majority of 14 minute, 23.1% increase, (p ⬍0.0001) in Door to Doc time that also occurred after CPOE initiation. Admitted patients length of stay decreased 7 minutes (p ⬍0.0001)
Annals of Emergency Medicine S83