207 A “Top Five” List for Emergency Medicine: A Pilot to Improve the Value of Emergency Care

Research Forum Abstracts ED discharge. Candidate predictors included hospital structural characteristics, patient demographic information, and ED primary discharge diagnosis. We fit multivariable, hierarchical logistic regression to account for clustering of ED visits by hospitals. Results: The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Readmission within 7 days of ED discharge occurred in 130,526 (2.6%). In multivariate analysis, 7-day readmission was associated with having Medi-Cal, California’s Medicaid program, (OR 1.4, 95% CI 1.4-1.5) or Medicare insurance (OR 1.5, 95% CI 1.5-1.6), and eloping or leaving against medical advice (OR 1.9, 95% CI 1.9-2.0). The 6 most common ED discharge diagnoses associated with the outcome were renal disease (OR 4.1, 95% CI 3.6-4.6), congestive heart failure (OR 3.2, 95% CI 3.0-3.4), diseases of the blood which include a diagnosis of anemia and sickle cell disease (OR 3.2, 95% CI 3.0-3.4), neoplasms (OR 2.9, 95% CI 2.7-3.1), mental illness (OR 2.6, 95% CI 2.6-2.7), and non-infectious lung disease including pleurisy, pneumothorax, and pneumonitis (OR 2.6, 95% CI 2.4-2.9). Hospital characteristics associated with readmission were for-profit status (OR 1.2, 95% CI 1.1-1.3) and teaching affiliation (OR 1.2, 95% CI 1.0-1.3). Conclusion: We found that 2.6% of patients discharged from California emergency departments were readmitted to a hospital bed within 7 days. We identified several hospital structural features, patient characteristics, and ED discharge diagnoses that are associated with increased risk of early readmissions. Further studies of causal pathways are needed to identify interventions to reduce potentially avoidable readmissions.

205 EMF

A Qualitative Analysis of the Factors Associated With Unanticipated Short-Term Death Following Emergency Department Discharge

Gabayan GZ, Sun BC, Asch SM, Timmermans S, Hoffman JR, Derose SF/West Los Angeles VA and UCLA, LA, CA; Oregon Health and ScienceUniversity, Portland, OR; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; UCLA, LA, CA; University of Southern California, LA, CA; Kaiser Permanente Southern California, Pasadena, CA

Study Objectives: The emergency department (ED) is an inherently high-risk setting in which unanticipated events often occur during or after discharge. Early death after ED discharge may signify a sentinel event which could indicate opportunities to improve care. Previous work assessing qualitative themes associated with post-ED discharge mortality is limited by incomplete capture of cases and use of non-representative samples. In this study we describe the patient-level and processlevel themes associated with short-term death following ED discharge in a large portion of California patients. Methods: We conducted a retrospective qualitative analysis using grounded theory of ED patients who were discharged to home or a non-acute care facility from any of six hospitals in an integrated health care system in Southern California. This system provides comprehensive care to over 3.5 million members and emergency services in 14 facilities. The study cohort was similar in age, race, and ethnic characteristics as the general California population. Subjects were age 18 or older, health plan members with an electronic ED record, and a discharge from a health plan ED with subsequent death within 7 days from 1/1/07 to 12/31/08. In and out of state death was identified using the California vital statistics files and the Social Security Death Index. Patients with referral to or receiving hospice care and with Do Not Resuscitate/Do Not Intubate orders were excluded. Complete electronic health records (n⫽61) were randomly chosen for review in a 2-step process involving theme identification (n⫽30) and validation (n⫽31). Results: There were a total of 290,092 patients with 446,120 visits to 6 Southern California EDs in 2007 and 2008. Death within 7 days of discharge occurred in 203 cases, resulting in a visit-level rate of 0.05%. A total of 61 electronic health records were randomly chosen and reviewed. Patient-level themes that emerged included mental status change, recent fall, abnormal vital signs, ill appearance, and presenting symptom present at discharge. Process-level themes were a discrepancy in history of present illness between providers, missing or incomplete vital signs, incomplete physical exam, misdiagnosis due to a narrow differential diagnosis, underestimation of sickness level despite concerning presentation, and discharge plan changed by third party. Overarching themes present in a majority of patients included older age and renal disease. Conclusion: Our study determined a combination of patient-level and processlevel themes in patients who die within 7 days after ED discharge. Our preliminary

S74 Annals of Emergency Medicine

findings serve as the foundation for a future quantitative review of cases in this cohort and may help identify important factors that can help guide future quality improvement and patient safety endeavors.

206

HIV Screening in the Emergency Department: To Test or Not to Test? It Depends on the Question

Montoy JC, Kaplan BC, Dow WH/University of California, San Francisco, San Francisco, CA; University of California, Berkeley, Berkeley, CA

Study Objective: Choice architecture has the potential to influence patients’ health and health care decisions. In its 2006 HIV-screening guidelines, the Centers for Disease Control and Prevention (CDC) endorsed opt-out screening, though the opt-out scheme has not been rigorously studied against opt-in or other test offers. We measure how HIV test acceptance rates are affected by the way in which the test offer is made in a randomized field experiment on HIV screening at an urban emergency department (ED). This study also examines monetary incentives (reported elsewhere) and uses a survey to collect HIV-related risk factors. Methods: We test 3 defaults: traditional opt-in (test only those patients who request testing), opt-out (routine testing unless patients decline), and active-choice testing (patients are required to state whether they want to be tested). Patients are approached by research assistants during the course of their routine care. They are offered HIV tests according to opt-in, active choice, and opt-out treatment assignments randomized at the patient level; they are also offered questionnaires, the timing of which (before or after test offer) is assigned randomly at the patient level. Monetary incentives are cross-randomized with both offer scripts and questionnaire timing. Patient education and test protocols are held constant across all treatments. Results: 2,159 of 2,544 approached patients consented to study inclusion. Among participants, 1308 accepted an HIV test; 5 tests were positive, 4 of which were confirmed positive. Routine opt-in testing yielded a 51.2% acceptance rate. In comparison, active choice yielded a 60.7% acceptance rate (OR: 1.47, 95% CI: 1.190 – 1.827, p ⬍ 0.001). Opt-out testing yielded a 69.4% acceptance rate (OR: 2.16, 95% CI: 1.728 – 2.710, p ⬍ 0.001). Patients reporting risk behaviors were 14 percentage points more likely to accept testing than those denying any risk factors (95% CI: 0.037 – 0.220, p ⫽ 0.006); there were no significant differences in responses to treatments. Those who were offered a questionnaire prior to the HIV test offer were 11 percentage points less likely to accept testing than those offered the HIV test first (95% CI: -0.149 – -0.068, p ⬍ 0.001); this was true for both high- and low-risk patients. Conclusion: Active-choice and opt-out test schemes increased the proportion of patients who accepted HIV testing by clinically significant levels. Small nudges have the power to shape patient decisionmaking – in this case, variation in one sentence shifts the behavior of more than one third of test refusers, and offering patients a questionnaire discourages test acceptance. Given the large changes in behavior in response to small changes in wording, care should be taken when making inferences of patient preferences based on observed patient behavior, particularly in a climate of increased focus on patient-centered decisionmaking.

207

A “Top Five” List for Emergency Medicine: A Pilot to Improve the Value of Emergency Care

Schuur JD, Carney DP, Berner AR, Benzer TI, Larson RE, Lyn ET, Michael JA, Raja AS, Ross NG, Venkatesh AK/Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA; Newton-Wellesley Hospital, Newton, MA; Massachusetts General Hospital, Boston, MA; Faulkner Hospital, Jamaica Plain, MA; North Shore Medical Center, Salem, MA; Harvard Affiliated Emergency Medicine Residency, Boston, MA

Study Objectives: Overuse of health care services is a major contributor to rising health care costs. As part of an institutional affordability initiative, we created an emergency medicine (EM) “top 5” list consisting of tests, treatments, and disposition decisions that are of little value to patients. Each item had to be evidence-based, amenable to standardization, and actionable. Methods: Design: Three-phase consensus and survey process. Setting and Participants: An integrated delivery system with 2 academic and 4 community EDs. The technical expert panel included ED leadership and content experts in imaging, admissions and transfers. The provider survey was administered to all physicians, physician assistants and nurse practitioners who practice in the 6 EDs (N⫽286). Measurement: In phase I, the technical expert panel used a modified Delphi process with 2 rounds of surveys to rank a list of low-value clinical actions. The initial list was generated by TEP brainstorming and email solicitation of providers. Technical expert

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Research Forum Abstracts panel members ranked each item on 3 domains: contribution to cost, benefit to patients, and actionability by emergency medicine providers. In phase II, all providers were surveyed to assess distinct dimensions of each item using 2 5-point Likert scales: (a) potential benefit or harm to the patient and (b) actionable by the provider. In phase III, the technical expert panel voted for a final “Top Five” list based on survey results and discussion. Pearson correlation was used to assess inter-domain correlation. Results: The initial solicitation yielded 64 low-value clinical actions. The phase I ranking process narrowed this to 7 lab tests, 3 medications, 4 imaging studies and 3 disposition decisions, which were included in an provider survey that had a 78% response rate. All 17 items had a median score of “very” or “somewhat” beneficial and actionable. For all items, there was significant positive correlation between scores on benefit and actionability (␳ ⫽ 0.19-0.37, P-value ⫽ 0.09-0.001). Composite scores were similar when stratified by provider type (attending/resident versus nurse practitioners/physician assistants), setting (academic versus community), and experience (1-2 years, 3-9y versus ⬎10y). In phase III, 1 action received unanimous technical expert panel support, 5 received majority support, and 12 received at least 1 vote. The final “Top Five” list included: 1) Don’t order CT of the cervical spine for patients after trauma who do not meet the NEXUS or Canadian C-Spine Rule, 2) Don’t order CT to diagnose pulmonary embolism without first risk stratifying, 3) Don’t order MRI of the lumbar spine for patients with low back pain without “red flags,” 4) Don’t order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule, 5) Don’t order coagulation studies for patients without hemorrhage or suspected coagulopathy. Conclusion: We identified, through a consensus process, clinical actions that were of low value and within provider control. While organized emergency medicine is absent from the 17 medical specialties involved in the “Choosing Wisely” campaign, our project has piloted a methodology that emergency medicine providers can use to identify actionable targets of overuse.

Serum lactate was measured throughout the experiment. At completion of the infusion, the animals were monitored for 4 hours. At the end of the experiment, thoracotomy was performed and lung samples were evaluated for signs of fat emboli (FE). Samples were also evaluated for FE from 3 animals without IO infusions which served as negative controls for comparison. The pathologist was blinded to the experiment groups. Lung FE were recognizable as intravascular oil red O positive globules in small capillary-sized and medium-sized vessels. Normally occurring adipocytes interspersed in connective tissue surrounding the large airways served as an internal positive control. Statistical analysis was performed using analysis of variance (ANOVA). A sample size of 14 per group provided 80% power to detect a moderate effect size difference of 0.5 (or approximately 1.0 stdev) among means when testing with an analysis for variance at the alpha level of 0.05. Results: The mean maximum infusion pressure was 538 mmHg (SD 80 mmHg) for the humerus, 630 mmHg (SD 80 mmHg) for the femur, and 650 mmHg (SD 76 mmHg) for the tibia. The mean infusion rate for the tibia was 78 mL/min (SD 38.5 mL/min), 49 mL/min (SD 45.1 mL/min) for the femur and 103 mL/min (SD 34.1 mL/min) for the humerus. Infusion rate comparison of all the sites using ANOVA revealed a p⬍0.005. Comparing the infusion rates of the humerus (103 mL/min) to the femur (49 mL/min) revealed a p⬍0.01. Comparisons between the tibia with the humerus and femur did not reveal statistical significance. All the animals in the tibia arm survived to the end of the experiment; in the femur and humerus arms the survival rate was 12/14 (86%) and 11/14 (79%) respectively. In the tibia and humerus arms the serum lactate increased during the hypovolemic period and decreased after infusion of blood. In the femur arm the serum lactate increased until the experiment ended. Histopathologic examination revealed that fat emboli were present in 14/14 (100%) of the tibia arm, 10/11 (91%) of the humerus arm (samples from 3 swine were inadequate), and 8/14 (57%) of the femur group. Conclusion: The rate of intraosseus infusion of blood through the swine humerus was greater than the femur and tibia. Fat emboli were detected in lungs of most animals.

EMF 1

A GIS Evaluation of a Statewide EMS Stroke Routing Protocol on Community Hospital Bypass for Acute Stroke Patients

Asimos AW, Bogenschneider CS, Humphrey AD, Brice JH, Enright D, Rosamond WD, Goldstein LB, Studnek JR,

208

Comparison of Intraosseous Infusion Rates of Blood Under High Pressure in an Adult Hypovolemic Swine Model in Three Different Limb Sites

Lairet JR, Bebarta V, Mathis D, Warren W, Lawler C, Lairet K, Muncy T, Boudreau S, Pitotti R, Brock J, King J/San Antonio Military Medical Center, Fort Sam Houston, TX; US Army Institute of Surgical Research, Fort Sam Houston, TX

Study Objectives: To compare the flow rates of blood administered through an intraosseous (IO) needle in the proximal tibia, distal femur and the proximal humerus under high pressure (⬎300 mmHg) in an adult hypovolemic (sus scrofa) swine model. Methods: Three groups of animals with 14 per group were intubated and placed on the ventilator. Central vein access and arterial line placement for monitoring were accomplished, blood was removed through the central venous catheter until the mean arterial pressure decreased by 50% from baseline. The animals were then observed without treatment for 60 minutes. A 15 gauge 25mm needle was inserted into the proximal tibia of 14 swine and a 15 gauge 45mm needle was inserted into the distal femur and proximal humerus of 14 swine respectively. IO placement was confirmed by bone marrow aspiration, ease to saline flush and visualization under fluoroscopy. The blood removed was reinfused over 10 minutes through the IO needle using a pressure bag system to maintain an infusion pressure ⬎ 300 mmHg as measured at the infusion site.

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Background: On January 1st, 2010, the North Carolina (NC) Office of Emergency Medical Services (EMS) implemented an out-of-Stroke Triage and Destination Plan (STDP) for patients with suspected acute stroke. The STDP requires that EMS providers categorize destination hospitals as being a community hospital (CH), a Stroke Capable Hospital (SCH) or a Joint Commission Certified Primary Stroke Centers (JCCPSC). The STDP specifies that, within certain constraints, hospitals unable to routinely provide IV tissue plasminogen activator (CH) should be bypassed for patient transport to hospitals with that capability (SCH or JCCPSC). Study Objective: To determine if the STDP increased the frequency of CH bypass by EMS when transporting patients with an out-of-hosptial impression of acute stroke with the following time constraints: ability to be transported to a SCH or a JCCPSC within 2 hours from symptom onset, and with a transport time not exceeding 50 minutes. Methods: Utilizing a before-after design, geographical information system (GIS) analytical methods, and a statewide Prehospital Medical Information System database, we identified patients with a suspected acute stroke who accessed EMS within 120 minutes of symptom onset. We compared two time periods: the 12 months immediately before implementation of the STDP and the 12-month period beginning 3 months after STDP implementation. We geocoded incident and hospital addresses using Esri ArcGIS software and other available source data, including address points and/or NC Department of Transportation (DOT) Integrated Statewide Road Network (ISRN). We used Esri Network Analyst software and NC DOT ISRN data to determine the closest acute care hospital to stroke incident locations. We then identified cases in which EMS bypass of a community hospital within the specified time constraints was an option and determined if bypass occurred. Chi square analysis was used to compare the pre- and post-STDP periods. Results: We identified 2,624 patients with a symptom onset 120 minutes from EMS arrival, an out-of-hospital impression of acute stroke, and a geocodable scene

Annals of Emergency Medicine S75