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Emergency department division of nonurgent patients to an off-site walk-in facility
and transfer (Federal COBRA, California SB-12 and Title 22) as determined by the University of California legal counsel. In the first six months of this new triage system, 4,186 patients were turned away from the ED, representing 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 82% were referred to off-site nonuniversity clinics, and 18% were referred to clinics within the institution. Of this number, no patients were retriaged to an ED, and only 54 patients ( 1.3 % ) complained about their referral out of the ED. In conclusion, a selective triage system may be used to effectively decompress an ED.
139 Emergency Department Division of Nonurgent Patients to an Off-Site Walk-In Facility KT Sivertson, A DiGiovanna, GD Kelen/Division of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Studies indicate that one-third or more of hospital emergency department patient visits are for nonurgent problems. A plan to require hospital EDs to divert Medicaid patients with nonurgent problems to other facilities is being evaluated by nearly all state Medicaid agencies. A diversion plan (developed by the State Department of Health and Mental Hygiene) was modeled after a project initiated by the department of emergency medicine of an inner-city university hospital on March 1, 1985. Patients presenting to the ED had previously been triaged as needing primary care, immediate care, or critical care. Using the same triage criteria, patients identified as requiring primary care are sent to an associated, but geographically distant (seven blocks), urgent care center. The number of patients registering for primary care in the ED has declined significantly (P < .01, chi-square) from 14,002 in fiscal 1984 (19% of 74,141 total registrations) to 5,210 in fiscal 1988 (9% of 55,121 total registrations). Registrations at the urgent care center for the same period ranged from 17,500 to 18,800 patients per year. Demographics of the primary care patients at the two facilities are similar with respect to age, sex, and race. The patient group that continues to receive care in the ED is significantly (P < .01, chisquare) sicker as indicated by the proportion of critical care cases, 2.5% of fiscal 1988 registrations (1,396 cases) versus 1.5% of fiscal 1984 registrations (1,138 cases), and hospital admissions, 14% of fiscal 1988 registrations (7,672 admissions)versus 8% of fiscal 1984 registrations (6,I52 admissions). We conclude that nonurgent patients can be diverted to a walk-in facility with a resultant change in care-seeking behavior over time. There is a corresponding increase in acuity of the patient group in the ED.
140 Early Unexpected Deaths Following Admission From the Emergency Department JG Mueller, DJ Fligner~ N Wigder/Department of Emergency Medicine, Christ Hospital and Medical Center, Oak Lawn, Illinois Death within 24 hours of admission has been suggested as a quality assurance monitor for emergency departments. We conducted a retrospective review of all patients who expired within the first 24 hours after admission from our ED during one year to determine the validity and utility of this monitor. Each death was classified as either expected or unexpected. An unexpected death was defined as a patient for whom the final diagnosis was different from the ED diagnosis, or one for whom the final and ED diagnoses were the same and none of the following existed: terminal cancer, severe dementia, CPR performed in the ED, mechanical ventilation, appropriate ICU admission, or a do not resuscitate order. The quality assurance assessment and action also were reviewed for each case to determine how often the emergency physician was notified of an unexpected death. During the 12-month period there were 10,582 admissions through the ED, of which 137 (1.29%) expired within 24 hours; 23 (0.22%) patients were found to have unexpected mortality. Of these 23 patients, the emergency physician was officially notified only two (8.70 %) times. The mean age of patients with unexpected mortality was 75.6 years (range, 44 to 94), and the majority of final diagnoses involved cardiac (43%),vascular (22%), or infectious (26%) processes. We conclude that a notable number of patients admitted through our ED expire early on and unexpectedly and that the emergency physician involved usually is not notified. We suggest that ED quality assurance programs notify physicians of all early unexpected mortality.
18:4 April 1989
141 Use of Autopsy Results in the Emergency Department's Quality Assurance Plan MC Burke, RV Aghababian, BV Blackbourne/Divisionof Emergency Medicine, The University of Massachusetts Medical Center, Worcester The autopsy is traditionally viewed as the ultimate quality assurance indicator in clinical medicine, yet very few clinical departments actually incorporate autopsy results in their formal quality assurance plan. Consequently, to investigate how autopsy results could be included in our emergency department plan, the clinical and autopsy diagnoses of 244 patients were compared to identify conditions that were unapparent or misdiagnosed at the time of death. Differences between clinical and autopsy diagnoses were categorized as class I, II, III, or IV findings. Major unexpected findings (classes I and II) were found in ten (4%) cases; the most commonly missed diagnoses were aortic dissection (three, 1.2%) and pulmonary embolus (two, 0.8%). Minor unexpected findings (classes III and IV) were discovered in 14 (5.8%) cases. The results clearly identify unexpected findings and point to the need for more aggressive evaluations of certain conditions. Systematic review of autopsy data presented has led to meaningful changes and delivery of care to emergency patients. Autopsies are a vital source of outcome-based information that should be part of every ED's quality assurance and risk management plan.
142 DRGs and the "Negative" Trauma Workup CM Dougherty, L Flancbaum, DN Brotman, J Avedian, SZ Trooskin/ Department of Surgery, UMDNJ - Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey Earlier diagnosis and treatment of life-threatening injuries due to regionalized trauma care systems have reduced "preventable deaths" due to injury. Concurrently, escalating health care expenditures have led to the implementation of programs designed to curtail costs. Since 1979, all hospital care in New Jersey has been reimbursed through a prospective payment system IDRGs), in which the case mix of patients is supposed to average out {ie, "profits" gained from the care of less-ill patients offset "losses" incurred from caring for sicker patients). The purpose of our study was to evaluate the financial impact of DRG reimbursement in 140 consecutive trauma patients with ISS less than 9 (not severely injured) admitted between July 1 and December 31, 1987. The average age was 30 years, and motor vehicle accident was the most common mechanism of injury (66%). Diagnostic studies included 519 radiographs (36 positive, 7%), 64 head computed tomography scans (11 positive, 17%), 60 abdominal computed tomography scans or diagnostic peritoneal lavage (all negative), eight liverspleen scans (all negative), and three bone scans {all negative). All patients had screening laboratory tests, and 48 (34%) had ECGs. Minor operative procedures were performed in 15 patients (i 1%); intensive care was needed for 22 patients (16%) including 15 with head injuries and six for rule-out cardiac contusions. Average total length of stay was 3.8 days. Patients were coded into 46 separate DRGs. One hundred twenty-three patients (88 %) were inliers; only three patients (2%) were high-trim outliers. Thirty-four of the 46 DRGs (74%) were net losers, as were 94 (67%) of the patients. Total DRG reimbursement was $177,042 for operating costs of $259,157, yielding a net negative contribution margin (loss) of $82,115 (average, $587 a patient). Thirty-eight percent of operating costs were due to room and board, 16% to radiology fees, 8.8% to intensive care, 8.6% to laboratory tests, and 6.4% to pharmacy costs. We conclude that the cost of appropriate diagnostic evaluation and care of trauma patients who are found to have only minor injuries (ISS < 9) exceeds the DRG reimbursement. The current DRG reimbursement system discourages, from a financial perspective, the performance of a thorough "negative" diagnostic workup in trauma patients..
143 Hypoxic Hazards of Paper Bag Rebreathing in Hyperventilating Patients M Ca//aham/Division of Emergency Medicine, Center for Prehospital Research and Training, University of California, San Francisco It is traditional practice to treat acute hyperventilation by having patients rebreathe into a paper bag. This treatment, when erroneously applied to patients who were hypoxemic or had myocardial ischemia, has resulted in death. These fatal cases prompted a study of the effects on oxygenation of paper bag rebreathing in
Annals of EmergencyMedicine
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139 Emergency Department Division of Nonurgent Patients to an Off-Site Walk-In Facility KT Sivertson, A DiGiovanna, GD Kelen/Division of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Studies indicate that one-third or more of hospital emergency department patient visits are for nonurgent problems. A plan to require hospital EDs to divert Medicaid patients with nonurgent problems to other facilities is being evaluated by nearly all state Medicaid agencies. A diversion plan (developed by the State Department of Health and Mental Hygiene) was modeled after a project initiated by the department of emergency medicine of an inner-city university hospital on March 1, 1985. Patients presenting to the ED had previously been triaged as needing primary care, immediate care, or critical care. Using the same triage criteria, patients identified as requiring primary care are sent to an associated, but geographically distant (seven blocks), urgent care center. The number of patients registering for primary care in the ED has declined significantly (P < .01, chi-square) from 14,002 in fiscal 1984 (19% of 74,141 total registrations) to 5,210 in fiscal 1988 (9% of 55,121 total registrations). Registrations at the urgent care center for the same period ranged from 17,500 to 18,800 patients per year. Demographics of the primary care patients at the two facilities are similar with respect to age, sex, and race. The patient group that continues to receive care in the ED is significantly (P < .01, chisquare) sicker as indicated by the proportion of critical care cases, 2.5% of fiscal 1988 registrations (1,396 cases) versus 1.5% of fiscal 1984 registrations (1,138 cases), and hospital admissions, 14% of fiscal 1988 registrations (7,672 admissions)versus 8% of fiscal 1984 registrations (6,I52 admissions). We conclude that nonurgent patients can be diverted to a walk-in facility with a resultant change in care-seeking behavior over time. There is a corresponding increase in acuity of the patient group in the ED.
140 Early Unexpected Deaths Following Admission From the Emergency Department JG Mueller, DJ Fligner~ N Wigder/Department of Emergency Medicine, Christ Hospital and Medical Center, Oak Lawn, Illinois Death within 24 hours of admission has been suggested as a quality assurance monitor for emergency departments. We conducted a retrospective review of all patients who expired within the first 24 hours after admission from our ED during one year to determine the validity and utility of this monitor. Each death was classified as either expected or unexpected. An unexpected death was defined as a patient for whom the final diagnosis was different from the ED diagnosis, or one for whom the final and ED diagnoses were the same and none of the following existed: terminal cancer, severe dementia, CPR performed in the ED, mechanical ventilation, appropriate ICU admission, or a do not resuscitate order. The quality assurance assessment and action also were reviewed for each case to determine how often the emergency physician was notified of an unexpected death. During the 12-month period there were 10,582 admissions through the ED, of which 137 (1.29%) expired within 24 hours; 23 (0.22%) patients were found to have unexpected mortality. Of these 23 patients, the emergency physician was officially notified only two (8.70 %) times. The mean age of patients with unexpected mortality was 75.6 years (range, 44 to 94), and the majority of final diagnoses involved cardiac (43%),vascular (22%), or infectious (26%) processes. We conclude that a notable number of patients admitted through our ED expire early on and unexpectedly and that the emergency physician involved usually is not notified. We suggest that ED quality assurance programs notify physicians of all early unexpected mortality.
18:4 April 1989
141 Use of Autopsy Results in the Emergency Department's Quality Assurance Plan MC Burke, RV Aghababian, BV Blackbourne/Divisionof Emergency Medicine, The University of Massachusetts Medical Center, Worcester The autopsy is traditionally viewed as the ultimate quality assurance indicator in clinical medicine, yet very few clinical departments actually incorporate autopsy results in their formal quality assurance plan. Consequently, to investigate how autopsy results could be included in our emergency department plan, the clinical and autopsy diagnoses of 244 patients were compared to identify conditions that were unapparent or misdiagnosed at the time of death. Differences between clinical and autopsy diagnoses were categorized as class I, II, III, or IV findings. Major unexpected findings (classes I and II) were found in ten (4%) cases; the most commonly missed diagnoses were aortic dissection (three, 1.2%) and pulmonary embolus (two, 0.8%). Minor unexpected findings (classes III and IV) were discovered in 14 (5.8%) cases. The results clearly identify unexpected findings and point to the need for more aggressive evaluations of certain conditions. Systematic review of autopsy data presented has led to meaningful changes and delivery of care to emergency patients. Autopsies are a vital source of outcome-based information that should be part of every ED's quality assurance and risk management plan.
142 DRGs and the "Negative" Trauma Workup CM Dougherty, L Flancbaum, DN Brotman, J Avedian, SZ Trooskin/ Department of Surgery, UMDNJ - Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey Earlier diagnosis and treatment of life-threatening injuries due to regionalized trauma care systems have reduced "preventable deaths" due to injury. Concurrently, escalating health care expenditures have led to the implementation of programs designed to curtail costs. Since 1979, all hospital care in New Jersey has been reimbursed through a prospective payment system IDRGs), in which the case mix of patients is supposed to average out {ie, "profits" gained from the care of less-ill patients offset "losses" incurred from caring for sicker patients). The purpose of our study was to evaluate the financial impact of DRG reimbursement in 140 consecutive trauma patients with ISS less than 9 (not severely injured) admitted between July 1 and December 31, 1987. The average age was 30 years, and motor vehicle accident was the most common mechanism of injury (66%). Diagnostic studies included 519 radiographs (36 positive, 7%), 64 head computed tomography scans (11 positive, 17%), 60 abdominal computed tomography scans or diagnostic peritoneal lavage (all negative), eight liverspleen scans (all negative), and three bone scans {all negative). All patients had screening laboratory tests, and 48 (34%) had ECGs. Minor operative procedures were performed in 15 patients (i 1%); intensive care was needed for 22 patients (16%) including 15 with head injuries and six for rule-out cardiac contusions. Average total length of stay was 3.8 days. Patients were coded into 46 separate DRGs. One hundred twenty-three patients (88 %) were inliers; only three patients (2%) were high-trim outliers. Thirty-four of the 46 DRGs (74%) were net losers, as were 94 (67%) of the patients. Total DRG reimbursement was $177,042 for operating costs of $259,157, yielding a net negative contribution margin (loss) of $82,115 (average, $587 a patient). Thirty-eight percent of operating costs were due to room and board, 16% to radiology fees, 8.8% to intensive care, 8.6% to laboratory tests, and 6.4% to pharmacy costs. We conclude that the cost of appropriate diagnostic evaluation and care of trauma patients who are found to have only minor injuries (ISS < 9) exceeds the DRG reimbursement. The current DRG reimbursement system discourages, from a financial perspective, the performance of a thorough "negative" diagnostic workup in trauma patients..
143 Hypoxic Hazards of Paper Bag Rebreathing in Hyperventilating Patients M Ca//aham/Division of Emergency Medicine, Center for Prehospital Research and Training, University of California, San Francisco It is traditional practice to treat acute hyperventilation by having patients rebreathe into a paper bag. This treatment, when erroneously applied to patients who were hypoxemic or had myocardial ischemia, has resulted in death. These fatal cases prompted a study of the effects on oxygenation of paper bag rebreathing in
Annals of EmergencyMedicine
465/185