- Email: [email protected]
378 Patient Satisfaction in the Clinical Decision Unit
Research Forum Abstracts orders, 1.9 labs, 1.1 radiographs and 1.1 consults. The vast majority of tertiary ED repeated tests were on patients from three outside facilities (28.4% of patients). Within this group there were 17 patients with repeated complete blood count (CBC), 12 with repeated basic metabolic panel (BMPs) and 6 with repeated electrocardiogram (EKG). There were 10 patients with repeated radiographs. Overall there was an average of 1.0 repeated tests per patient, 0.79 labs and 0.14 radiographs. In only 20 cases (6.7%) there was mention of the outside ED directly consulting a specialist at the accepting tertiary center, who advised ED to ED transfer. Thirty patients did not receive specialist consults in the ED of which 19 were discharged (13 to follow-up with PCP and 6 to followup with a specialist). The tertiary care emergency physician significantly disagreed with the referring diagnosis in 28 cases (9.8%). The patients’ dispositions were: floor 39.5%, discharged with specialist follow-up 29.4%, discharged with primary care physician (PCP) follow-up 11.8%, intensive care unit 8.8%, Operating room 5.4%, step-down unit 4.3%, with one patient going to interventional Radiology and one leaving against medical advice. Conclusion: The majority of patients in this study required surgical specialty care due to injuries. However, several cases may not have benefitted from transfer, as they neither required specialist care nor admission, as well as select cases that were “over-called” by the referring physician. Only for a small proportion of cases did the outside ED attempt to consult a specialist before transferring. Better communication and cooperation with outside referring EDs is needed to assure the most appropriate care for all patients.
376
Current Quality Assurance Process in Emergency Physician Ultrasounds
Ndubuisi A, Kapoor M, Gupta S, Brown C, Das D/Staten Island University Hospital, Staten Island, NY; North Shore LIJ Franklin Hospital, Valley Stream, NY
Study Objectives: Since the use of emergency ultrasound (US) has exponentially increased in the emergency department (ED), the quality assurance (QA) process has become an even more integral part of emergency medical care. The ACEP policy statement on emergency ultrasound guidelines published in 2008 asserts that the QA process is necessary to evaluate US images for technical competence and clinical accuracy in US interpretation. The QA process also provides a method to give feedback to improve physician performance. However, beyond outlining very broad parameters that may be used by ED ultrasound directors to perform the QA process, there are no generally agreed upon standards by which hospitals are now instituting this QA process. This will likely need to change as the storage and image review of ultrasounds has improved as technology has advanced. This is also a particularly important issue as we move forward in an era where more EDs are now billing for emergency ultrasounds. Our objective was to determine how EDs are currently performing their QA process and whether the dynamics of hospital staffing have any effect on their QA process. Methods: A Web-based survey was sent to all ACGME-accredited EM residency programs (n¼160). The survey consisted of 23 questions regarding number of EM attendings, presence of ultrasound fellowship, billing for ultrasound and current QA process. The survey was distributed and results directly extracted from the online tool SurveyMonkey. Analysis was performed via descriptive statistics, Fisher exact test, and Chi Square analysis for categorical data. Results: There was a 50% response rate to the survey. Fifty percent of total respondents have an emergency US fellowship. Of all respondents, 68.8% (55/80) have US-trained faculty. Of the sites with US fellowship, 36/40, have US-trained attendings, while sites without an US fellowship, 19/40, have US-trained faculty, P¼<.0001. In sites with an US fellowship, 35/40 conduct formal QA of EDperformed US scans versus 22/40 in sites without an US fellowship, P¼.003. At hospital sites with an US fellowship that conduct formal QA, 35/35 of them have the QA process performed by the US director. In the non-fellowship sites, 18/22 of hospitals have the QA performed by the US director, P¼.019. At the non-fellowship sites without an US director conducting QA, 4/22 utilized the following for QA: (1) assigned faculty member, (2) program director/director of pediatric ED, (3) hospital US credentialing committee, or (4) radiology department. At hospitals with an US fellowship, 29/35 conducted QA weekly or less, 5/35 bi-weekly to monthly, 1/35 other versus non fellowship sites where 5/22 conducted QA weekly or less, 13/22 bi-weekly to monthly, 4/22 other (including rolling, yearly, quarterly), P<.001. Conclusions: Based on the results of the survey, hospital sites with an US fellowship are more likely to perform a formal QA process. Overwhelmingly, the majority of the hospitals manage their QA process within the ED. Of hospital sites with a QA process, ultrasounds are likely to be reviewed on a weekly basis. This is also the optimal method to provide feedback, performance improvement and assurance that ultrasounds are being conducted correctly.
Volume 64, no. 4s : October 2014
377
What Do Patients Say About Emergency Departments in Online Reviews?
Kilaru AS, Paciotti B, Ha Y, Ranard B, Griffis H, Merchant R/Perelman School of Medicine, Philadelphia, PA
Study Objectives: The preferences and perspectives of patients have become essential to the delivery of health care, but the collection of patient-centered quality metrics in the emergency department (ED) remains preliminary. Patients have adopted Web-based tools to report on the quality of their health care experiences. We sought to analyze the content of hospital reviews posted on Yelp, a popular consumer ratings Web site, and to identify key themes regarding patient experiences in the ED. Methods: We conducted a qualitative analysis of unstructured consumer reviews for hospitals available on www.yelp.com. We selected a random sample of 100 US hospitals, stratified by the overall rating given by Yelp users. Hospitals without an ED and with fewer than 5 reviews were excluded. We identified the Yelp Web site for each hospital and collected all reviews posted before August 1, 2013. An iterative coding process was used to identify patterns and key themes in the text of the reviews. First, we identified reviews describing experiences in the ED. Using modified grounded theory, we then examined the content of the reviews to develop a set of codes. We summarized the codes and examined relationships among codes to identify key themes. The data was double-coded, and discrepancies were reviewed to ensure inter-rater reliability and establish consensus. Results: There were 1736 reviews for the 100 hospitals. Of these, 572 (33%) described patient experiences involving the ED. Inter-rater reliability exceeded 90% for all coding. Patients were primarily the authors of reviews, with others written by family members. Reviews described both positive and negative experiences. Key themes emerged, with representative quotations provided in parentheses: 1. Reviewers regularly commented on wait times in the ED, associating the overall efficiency of the visit with quality (“They took me for [ankle] x-rays within 45 minutes. Thought that was great. But they left me in the waiting room for 6.5 more hours before telling me it was just sprained”). 2. Reviews cited attentiveness and communication from providers as essential aspects of quality (“I can’t say enough about the caring professionalism of the staff. I was attended to promptly and my concerns and emotions were met with respect and courtesy”). 3. Reviews explained decisions to visit the ED, with reasons including acuity, pain control, and visits during off-hours. Reviews also discussed choices between EDs, citing proximity and wait times as factors (“I injured my ankle at the gym...since it was Sunday, I figured I would go to the ER to get an x-ray. I thought about the ____ ER but anyone who’s been there has always told me that they waited hours upon hours to get helped”). 4. Reviews contained information on post-discharge outcomes, including diagnostic errors and access to follow-up care in addition to difficulties with billing (“The doctors blew off my abdominal pain as symptoms of endometriosis even though I insisted this was nothing like that pain. They found nothing, did nothing and sent me home. The next day at my doctor’s office they determined I had a huge ovarian cyst which required surgery”). Conclusions: Consumer rating Web sites allow patients to provide rapid and public feedback on multiple aspects of ED quality, including wait times, relationships with providers, and post-discharge outcomes. Online platforms may complement traditional instruments to assess patient-centered quality outcomes.
378
Patient Satisfaction in the Clinical Decision Unit
Rentala M, Berry B, Tiberio A, Warren S, Mahmooth Z, Sheppard P, Ward MF/North Shore-LIJ Health System, New Hyde Park, NY
Study Objectives: Clinical decision units (CDUs), or observation units, are areas where patients are sent from the emergency department (ED) if they require further observation and treatment. If after 24-48 hours patients cannot be sent home, they are generally admitted to the hospital. These units have been shown to decrease the cost of care, hospital admissions, and total length of stay in the ED and inpatient settings. Specialized asthma and chest pain observation units have also been shown to improve patient satisfaction, but satisfaction has never been assessed in general CDUs. Patient satisfaction is important because satisfied patients are less likely to file malpractice claims and more likely to comply with their plans of care, follow through with referrals, and consume less resource. The objective of this study was to assess patient satisfaction and possible factors associated with satisfaction at a general CDU. Methods: The study was conducted at an academic, tertiary medical center. The CDU sees approximately 4,000 patients annually. Consenting patients in the CDU were given a 10-item questionnaire upon discharge relating to various aspects of their stay. Seven of the items were assessed on a Likert scale from 1 to 10, with 10 being the highest
Annals of Emergency Medicine S135
Research Forum Abstracts score. For the purposes of this abstract, we analyzed questions relating to pain management, overall quality of medical treatment, discharge process, overall experience, and satisfaction with food in the CDU. For each of these items, we calculated descriptive statistics for each of the survey items. A linear regression of diagnosis on survey response scores was carried out to determine the effect of diagnosis on satisfaction. Results: A total of 226 patients completed the survey and were included in the analysis. The mean age of patients in the CDU was 50.6 years and 57% were female. In an analysis including all respondents, patients gave an average score of 9.3 (SD¼1.4), 9.5 (1.1), 9.2 (1.4), 9.4 (1.1), 7.4 (2.5) for pain management, overall medical treatment, discharge process, overall experience, and quality of food respectively. Most sampled patients were admitted to the CDU for chest pain (43%), followed by syncope/near syncope (8%), abdominal pain (8%), and cellulitis (4%). There was no statistically significant difference among satisfaction scores for any of the survey items based on diagnosis (P>.05). Conclusion: CDUs have the potential for high patient satisfaction scores and therefore could possibly improve overall ED satisfaction scores and reduce the need for inpatient admissions. This study was limited in its sample size, which might have been the reason for not being able to observe any difference by diagnosis group. The next steps include comparing CDU satisfaction scores to ED-only and inpatient satisfaction scores to assess for variation. CDU satisfaction scores could also be analyzed to determine if they vary by length of stay.
379
Efficacy of Glucagon for the Relief of Esophageal Obstruction in Adult Emergency Department Patients
Kleaveland AS, Baumann MR, Rolfe S, Strout TD/Maine Medical Center, Portland, ME
Study Objective: Esophageal food impaction is frequently encountered in the emergency setting and research regarding the efficacy of treatment with glucagon is limited. We sought to determine the effect of glucagon administration on esophageal bolus relief in a cohort of adult emergency department (ED) patients. Methods: Adult patients ( 16 years old) presenting to our academic tertiary care ED with esophageal food bolus were identified through query of our electronic health records system. Data regarding patient characteristics, past medical and surgical history, bolus type and location, pharmacologic and endoscopic treatment, endoscopic findings, the presence of nausea and vomiting, bolus relief, and patient disposition were abstracted by trained reviewers using a standardized data collection tool; inter-rater reliability was established. Chi-square analysis and the independent samples t-test were used to compare glucagon response groups. Results: During the two-year study period, 98 adult patients sought treatment in our ED for 103 esophageal food bolus episodes. The median subject age was 52 years (range 16 - 94) and 60% (n ¼ 62) were male. The vast majority of food boluses were comprised of meat (86%, n ¼ 89) and the distal esophagus was the most frequently documented bolus location (37%, n ¼ 38). Subjects received glucagon in all 103 cases, with bolus passage following glucagon administration reported in 22 cases (21%). Six subjects (6%) were noted to experience spontaneous resolution of their symptoms after vomiting post-glucagon administration while one subject passed a bolus after drinking water. Sixty-seven subjects (65%) underwent subsequent endoscopic treatment, confirming esophageal anatomic abnormality in all 67 (100%) endoscopic cases. Significant differences in age, sex, and history were not noted when glucagon responders and non-responders were compared. Conclusions: In this setting and sample, esophageal food boluses consisted primarily of meat located in the distal esophagus. Glucagon was administered in all cases and was associated with bolus passage approximately 20% of the time. Patients with anatomic esophageal abnormalities confirmed on endoscopy were significantly less likely to respond to glucagon when compared to those with normal anatomy.
380
A Triage-Based Algorithm to Decrease Median Time to Pain Management for Long Bone Fractures
Figure #1. Median Time to Pain Management for Long Bone Fracture. 2% points from a hospital’s CMS reimbursement. One of the newest metrics relating to the ED is “OP-21: Median Time to Pain Management for Long Bone Fracture.” The bar for this metric is currently set at a median time of 47 minutes. During the initial reporting period for OP-21, our institution was not meeting this metric. Therefore our objective was to evaluate the effectiveness of a triage-based “Long Bone Fracture Algorithm” (LBFA) to decrease “Median Time to Pain Management for Long Bone Fracture” (TTPM). Methods: At our 80,000-visit community hospital ED, we conducted a before and after study from January 2013 to March 2014. The before cohort extended for the first eight months of the trial and provided baseline data detailing our TTPM. During a one-month washout period in September 2013, a LBFA was created by a multidisciplinary team of ED physician, administrative and nursing personnel. Three key elements of the LBFA include 1) assigning patients in this cohort as priority 2, thereby alerting staff to mobilize the patient into the ED within ten minutes of arrival, 2) dreating a “just in time” TTPM tool that stayed with the patient and would include a place to document ED arrival time as well as provide space to document the final time a patient should receive pain control in order to meet the metric, and 3) educating the triage and minor care staff to document whether the patient received pain medications at home prior to arrival or if they declined pain medications upon initial exam or triage. The after cohort consisted of the following six months to track our process with the LBFA. Our primary outcome measure was TTPM as compared between both cohorts. Data was analyzed using descriptive statistics and a Mann-Whitey U test was to assess for statistical significance. Results: A total of 116 consecutive cases were evaluated in the before cohort over an eight-month period. The median TTPM was 56.50 minutes during that time with 77 (66.4%) of cases not meeting the metric. After a one-month implementation period, a total of 85 consecutive cases comprised the after cohort over the following six months. The median TTPM was 47 minutes with 42 (49.4%) of the cases not meeting the metric. The difference between both cohorts was 9.5 minutes [95% CI of 8.22 minutes] and a P¼.0110. A graphical breakdown of the before cohort and the after cohorts broken down by month is illustrated in Figure 1 which illustrates a continued improvement in the metric throughout the after cohort. Conclusion: A triage-based long bone fracture algorithm can decrease median time to pain management for long bone fracture in a community hospital setting.
381
Characteristics of Patients Requiring Automatic Implantable Cardioverter Defibrillator or Permanent Pacemaker Implantation During the Hospital Stay in Patients Without Evidence of Ventricular Tachycardia on Presentation to the Emergency Department
Bastani A, Weintraub CH, Milewski AM, Rocchini A, Thurston K, Kumar V, Anderson W/ Troy Beaumont Hospital, Troy, MI
Garg N, Hoang N, Wong C, Ali Z, Patel R, Suarez AE/New York Hospital Queens, Flushing, NY
Study Objectives: The Centers for Medicare and Medicaid Services (CMS) is the dominant force in the determination of how emergency departments (EDs) and emergency physicians are reimbursed. One avenue in which CMS exerts its influence is through the Outpatient Prospective Payment System (OPPS). The OPPS is a set of outpatient and ED metrics that hospitals must report regarding the quality of care provided. The hospitals score across these metrics may result in a reduction of up to
Background: Ventricular tachycardia (VT)/V fib is the most feared complication of many cardiac and pulmonary diseases. Automatic implantable cardioverter defibrillator or permanent pacemaker (AICD/PPM) placement is recommended for patients with LVEF <45% in several clinical trials. Given the changing health care and narrowing guidelines for telemetry use, our study aims to identify the characteristics of patients presenting to emergency department (ED) without
S136 Annals of Emergency Medicine
Volume 64, no. 4s : October 2014
376
Current Quality Assurance Process in Emergency Physician Ultrasounds
Ndubuisi A, Kapoor M, Gupta S, Brown C, Das D/Staten Island University Hospital, Staten Island, NY; North Shore LIJ Franklin Hospital, Valley Stream, NY
Study Objectives: Since the use of emergency ultrasound (US) has exponentially increased in the emergency department (ED), the quality assurance (QA) process has become an even more integral part of emergency medical care. The ACEP policy statement on emergency ultrasound guidelines published in 2008 asserts that the QA process is necessary to evaluate US images for technical competence and clinical accuracy in US interpretation. The QA process also provides a method to give feedback to improve physician performance. However, beyond outlining very broad parameters that may be used by ED ultrasound directors to perform the QA process, there are no generally agreed upon standards by which hospitals are now instituting this QA process. This will likely need to change as the storage and image review of ultrasounds has improved as technology has advanced. This is also a particularly important issue as we move forward in an era where more EDs are now billing for emergency ultrasounds. Our objective was to determine how EDs are currently performing their QA process and whether the dynamics of hospital staffing have any effect on their QA process. Methods: A Web-based survey was sent to all ACGME-accredited EM residency programs (n¼160). The survey consisted of 23 questions regarding number of EM attendings, presence of ultrasound fellowship, billing for ultrasound and current QA process. The survey was distributed and results directly extracted from the online tool SurveyMonkey. Analysis was performed via descriptive statistics, Fisher exact test, and Chi Square analysis for categorical data. Results: There was a 50% response rate to the survey. Fifty percent of total respondents have an emergency US fellowship. Of all respondents, 68.8% (55/80) have US-trained faculty. Of the sites with US fellowship, 36/40, have US-trained attendings, while sites without an US fellowship, 19/40, have US-trained faculty, P¼<.0001. In sites with an US fellowship, 35/40 conduct formal QA of EDperformed US scans versus 22/40 in sites without an US fellowship, P¼.003. At hospital sites with an US fellowship that conduct formal QA, 35/35 of them have the QA process performed by the US director. In the non-fellowship sites, 18/22 of hospitals have the QA performed by the US director, P¼.019. At the non-fellowship sites without an US director conducting QA, 4/22 utilized the following for QA: (1) assigned faculty member, (2) program director/director of pediatric ED, (3) hospital US credentialing committee, or (4) radiology department. At hospitals with an US fellowship, 29/35 conducted QA weekly or less, 5/35 bi-weekly to monthly, 1/35 other versus non fellowship sites where 5/22 conducted QA weekly or less, 13/22 bi-weekly to monthly, 4/22 other (including rolling, yearly, quarterly), P<.001. Conclusions: Based on the results of the survey, hospital sites with an US fellowship are more likely to perform a formal QA process. Overwhelmingly, the majority of the hospitals manage their QA process within the ED. Of hospital sites with a QA process, ultrasounds are likely to be reviewed on a weekly basis. This is also the optimal method to provide feedback, performance improvement and assurance that ultrasounds are being conducted correctly.
Volume 64, no. 4s : October 2014
377
What Do Patients Say About Emergency Departments in Online Reviews?
Kilaru AS, Paciotti B, Ha Y, Ranard B, Griffis H, Merchant R/Perelman School of Medicine, Philadelphia, PA
Study Objectives: The preferences and perspectives of patients have become essential to the delivery of health care, but the collection of patient-centered quality metrics in the emergency department (ED) remains preliminary. Patients have adopted Web-based tools to report on the quality of their health care experiences. We sought to analyze the content of hospital reviews posted on Yelp, a popular consumer ratings Web site, and to identify key themes regarding patient experiences in the ED. Methods: We conducted a qualitative analysis of unstructured consumer reviews for hospitals available on www.yelp.com. We selected a random sample of 100 US hospitals, stratified by the overall rating given by Yelp users. Hospitals without an ED and with fewer than 5 reviews were excluded. We identified the Yelp Web site for each hospital and collected all reviews posted before August 1, 2013. An iterative coding process was used to identify patterns and key themes in the text of the reviews. First, we identified reviews describing experiences in the ED. Using modified grounded theory, we then examined the content of the reviews to develop a set of codes. We summarized the codes and examined relationships among codes to identify key themes. The data was double-coded, and discrepancies were reviewed to ensure inter-rater reliability and establish consensus. Results: There were 1736 reviews for the 100 hospitals. Of these, 572 (33%) described patient experiences involving the ED. Inter-rater reliability exceeded 90% for all coding. Patients were primarily the authors of reviews, with others written by family members. Reviews described both positive and negative experiences. Key themes emerged, with representative quotations provided in parentheses: 1. Reviewers regularly commented on wait times in the ED, associating the overall efficiency of the visit with quality (“They took me for [ankle] x-rays within 45 minutes. Thought that was great. But they left me in the waiting room for 6.5 more hours before telling me it was just sprained”). 2. Reviews cited attentiveness and communication from providers as essential aspects of quality (“I can’t say enough about the caring professionalism of the staff. I was attended to promptly and my concerns and emotions were met with respect and courtesy”). 3. Reviews explained decisions to visit the ED, with reasons including acuity, pain control, and visits during off-hours. Reviews also discussed choices between EDs, citing proximity and wait times as factors (“I injured my ankle at the gym...since it was Sunday, I figured I would go to the ER to get an x-ray. I thought about the ____ ER but anyone who’s been there has always told me that they waited hours upon hours to get helped”). 4. Reviews contained information on post-discharge outcomes, including diagnostic errors and access to follow-up care in addition to difficulties with billing (“The doctors blew off my abdominal pain as symptoms of endometriosis even though I insisted this was nothing like that pain. They found nothing, did nothing and sent me home. The next day at my doctor’s office they determined I had a huge ovarian cyst which required surgery”). Conclusions: Consumer rating Web sites allow patients to provide rapid and public feedback on multiple aspects of ED quality, including wait times, relationships with providers, and post-discharge outcomes. Online platforms may complement traditional instruments to assess patient-centered quality outcomes.
378
Patient Satisfaction in the Clinical Decision Unit
Rentala M, Berry B, Tiberio A, Warren S, Mahmooth Z, Sheppard P, Ward MF/North Shore-LIJ Health System, New Hyde Park, NY
Study Objectives: Clinical decision units (CDUs), or observation units, are areas where patients are sent from the emergency department (ED) if they require further observation and treatment. If after 24-48 hours patients cannot be sent home, they are generally admitted to the hospital. These units have been shown to decrease the cost of care, hospital admissions, and total length of stay in the ED and inpatient settings. Specialized asthma and chest pain observation units have also been shown to improve patient satisfaction, but satisfaction has never been assessed in general CDUs. Patient satisfaction is important because satisfied patients are less likely to file malpractice claims and more likely to comply with their plans of care, follow through with referrals, and consume less resource. The objective of this study was to assess patient satisfaction and possible factors associated with satisfaction at a general CDU. Methods: The study was conducted at an academic, tertiary medical center. The CDU sees approximately 4,000 patients annually. Consenting patients in the CDU were given a 10-item questionnaire upon discharge relating to various aspects of their stay. Seven of the items were assessed on a Likert scale from 1 to 10, with 10 being the highest
Annals of Emergency Medicine S135
Research Forum Abstracts score. For the purposes of this abstract, we analyzed questions relating to pain management, overall quality of medical treatment, discharge process, overall experience, and satisfaction with food in the CDU. For each of these items, we calculated descriptive statistics for each of the survey items. A linear regression of diagnosis on survey response scores was carried out to determine the effect of diagnosis on satisfaction. Results: A total of 226 patients completed the survey and were included in the analysis. The mean age of patients in the CDU was 50.6 years and 57% were female. In an analysis including all respondents, patients gave an average score of 9.3 (SD¼1.4), 9.5 (1.1), 9.2 (1.4), 9.4 (1.1), 7.4 (2.5) for pain management, overall medical treatment, discharge process, overall experience, and quality of food respectively. Most sampled patients were admitted to the CDU for chest pain (43%), followed by syncope/near syncope (8%), abdominal pain (8%), and cellulitis (4%). There was no statistically significant difference among satisfaction scores for any of the survey items based on diagnosis (P>.05). Conclusion: CDUs have the potential for high patient satisfaction scores and therefore could possibly improve overall ED satisfaction scores and reduce the need for inpatient admissions. This study was limited in its sample size, which might have been the reason for not being able to observe any difference by diagnosis group. The next steps include comparing CDU satisfaction scores to ED-only and inpatient satisfaction scores to assess for variation. CDU satisfaction scores could also be analyzed to determine if they vary by length of stay.
379
Efficacy of Glucagon for the Relief of Esophageal Obstruction in Adult Emergency Department Patients
Kleaveland AS, Baumann MR, Rolfe S, Strout TD/Maine Medical Center, Portland, ME
Study Objective: Esophageal food impaction is frequently encountered in the emergency setting and research regarding the efficacy of treatment with glucagon is limited. We sought to determine the effect of glucagon administration on esophageal bolus relief in a cohort of adult emergency department (ED) patients. Methods: Adult patients ( 16 years old) presenting to our academic tertiary care ED with esophageal food bolus were identified through query of our electronic health records system. Data regarding patient characteristics, past medical and surgical history, bolus type and location, pharmacologic and endoscopic treatment, endoscopic findings, the presence of nausea and vomiting, bolus relief, and patient disposition were abstracted by trained reviewers using a standardized data collection tool; inter-rater reliability was established. Chi-square analysis and the independent samples t-test were used to compare glucagon response groups. Results: During the two-year study period, 98 adult patients sought treatment in our ED for 103 esophageal food bolus episodes. The median subject age was 52 years (range 16 - 94) and 60% (n ¼ 62) were male. The vast majority of food boluses were comprised of meat (86%, n ¼ 89) and the distal esophagus was the most frequently documented bolus location (37%, n ¼ 38). Subjects received glucagon in all 103 cases, with bolus passage following glucagon administration reported in 22 cases (21%). Six subjects (6%) were noted to experience spontaneous resolution of their symptoms after vomiting post-glucagon administration while one subject passed a bolus after drinking water. Sixty-seven subjects (65%) underwent subsequent endoscopic treatment, confirming esophageal anatomic abnormality in all 67 (100%) endoscopic cases. Significant differences in age, sex, and history were not noted when glucagon responders and non-responders were compared. Conclusions: In this setting and sample, esophageal food boluses consisted primarily of meat located in the distal esophagus. Glucagon was administered in all cases and was associated with bolus passage approximately 20% of the time. Patients with anatomic esophageal abnormalities confirmed on endoscopy were significantly less likely to respond to glucagon when compared to those with normal anatomy.
380
A Triage-Based Algorithm to Decrease Median Time to Pain Management for Long Bone Fractures
Figure #1. Median Time to Pain Management for Long Bone Fracture. 2% points from a hospital’s CMS reimbursement. One of the newest metrics relating to the ED is “OP-21: Median Time to Pain Management for Long Bone Fracture.” The bar for this metric is currently set at a median time of 47 minutes. During the initial reporting period for OP-21, our institution was not meeting this metric. Therefore our objective was to evaluate the effectiveness of a triage-based “Long Bone Fracture Algorithm” (LBFA) to decrease “Median Time to Pain Management for Long Bone Fracture” (TTPM). Methods: At our 80,000-visit community hospital ED, we conducted a before and after study from January 2013 to March 2014. The before cohort extended for the first eight months of the trial and provided baseline data detailing our TTPM. During a one-month washout period in September 2013, a LBFA was created by a multidisciplinary team of ED physician, administrative and nursing personnel. Three key elements of the LBFA include 1) assigning patients in this cohort as priority 2, thereby alerting staff to mobilize the patient into the ED within ten minutes of arrival, 2) dreating a “just in time” TTPM tool that stayed with the patient and would include a place to document ED arrival time as well as provide space to document the final time a patient should receive pain control in order to meet the metric, and 3) educating the triage and minor care staff to document whether the patient received pain medications at home prior to arrival or if they declined pain medications upon initial exam or triage. The after cohort consisted of the following six months to track our process with the LBFA. Our primary outcome measure was TTPM as compared between both cohorts. Data was analyzed using descriptive statistics and a Mann-Whitey U test was to assess for statistical significance. Results: A total of 116 consecutive cases were evaluated in the before cohort over an eight-month period. The median TTPM was 56.50 minutes during that time with 77 (66.4%) of cases not meeting the metric. After a one-month implementation period, a total of 85 consecutive cases comprised the after cohort over the following six months. The median TTPM was 47 minutes with 42 (49.4%) of the cases not meeting the metric. The difference between both cohorts was 9.5 minutes [95% CI of 8.22 minutes] and a P¼.0110. A graphical breakdown of the before cohort and the after cohorts broken down by month is illustrated in Figure 1 which illustrates a continued improvement in the metric throughout the after cohort. Conclusion: A triage-based long bone fracture algorithm can decrease median time to pain management for long bone fracture in a community hospital setting.
381
Characteristics of Patients Requiring Automatic Implantable Cardioverter Defibrillator or Permanent Pacemaker Implantation During the Hospital Stay in Patients Without Evidence of Ventricular Tachycardia on Presentation to the Emergency Department
Bastani A, Weintraub CH, Milewski AM, Rocchini A, Thurston K, Kumar V, Anderson W/ Troy Beaumont Hospital, Troy, MI
Garg N, Hoang N, Wong C, Ali Z, Patel R, Suarez AE/New York Hospital Queens, Flushing, NY
Study Objectives: The Centers for Medicare and Medicaid Services (CMS) is the dominant force in the determination of how emergency departments (EDs) and emergency physicians are reimbursed. One avenue in which CMS exerts its influence is through the Outpatient Prospective Payment System (OPPS). The OPPS is a set of outpatient and ED metrics that hospitals must report regarding the quality of care provided. The hospitals score across these metrics may result in a reduction of up to
Background: Ventricular tachycardia (VT)/V fib is the most feared complication of many cardiac and pulmonary diseases. Automatic implantable cardioverter defibrillator or permanent pacemaker (AICD/PPM) placement is recommended for patients with LVEF <45% in several clinical trials. Given the changing health care and narrowing guidelines for telemetry use, our study aims to identify the characteristics of patients presenting to emergency department (ED) without
S136 Annals of Emergency Medicine
Volume 64, no. 4s : October 2014