- Email: [email protected]
286 “When We” Visual Cue Checklist Reduces Variation and Improves Adherence to Emergency Department Best Practices
Research Forum Abstracts electronic medical record. The Hallas method was used to score preventability. We used multiple established systems to score severity [Hatwig Siegel, Pearson, and National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)] given that they are equally used in DRP literature, and to allow for better comparisons. All severity scores grade DRPs with increasing levels of severity, and with varying degrees of complexity. Severity scoring systems, when necessary, were modified to fit the ED setting. Descriptive statistics were performed for categorical data and were summarized as frequencies and means SD, as applicable. Differences in DRP preventability and severity were expressed as proportions, with a two-sided P<0.05 being significant. Results: A total of 1094 ED patients were evaluated, of which 44 (4%) were excluded. Among the 1050 patients included, 310 (30%) had at least 1 DRP. The study population demographics reflected that of our ED (female: 571 (54%); age: 57 21 years). Patients were prescribed 9 7 outpatient medications at the time of ED visit. When classified according to the Pearson severity scoring system, there were significantly more DRPs that were either moderate (221/310 [71%]) or severe (49/310 [16%]) compared to mild (14/310 [5%]) (P<.001). Non-adherence cases (26/310 [8%]) were not scored by Pearson. The Hartwig Siegel severity scoring system mirrored the same results, albeit in more sub-categories. The DRPs were more likely to be deemed definitely (72/310 [23%]) and possibly/probably preventable (105/310 [34%]) than unavoidable (133/310 [43%]), (P¼.01). Using NCC MERP Severity scoring system, most DRPs were in category E (temporary harm or required intervention) (115/310 [37%]), category F (E + increase in LOS) (141/310 [46%]), and category H (intervention to sustain life) (50/310 [16%]). Conclusion: The majority (270/310 [87%]) of ED visits among patients with DRPs were categorized as moderate or severe. Most (177/310 [57 %]) ED visits related to the DRPs were preventable. Additional research is critical to evaluate financial implications of preventing DRPs, and establishing methodology to reduce the over occurrence.
285
Return Visits to the Emergency Department in Patients Discharged Following Hypoglycemic Episodes
Betten DP, Castle DJ, Hughes MJ, Henney J/Michigan State University, East Lansing, MI
Study Objectives: Presentation to the emergency department (ED) due to hypoglycemia among diabetics is not an uncommon event. Traditional teaching has been for hospital admission and extended observation for recurrence of hypoglycemia among individuals on long-acting insulin and oral diabetic medications. Home observation has been considered by some to be a reasonable alternative if the risk of recurrent hypoglycemia is felt to be low. The following study was performed to evaluate the likelihood and patterns of recurrent hypoglycemia in individuals discharged from the ED following a hypoglycemic event. Methods: A retrospective chart review of electronic medical records was performed over 2 calendar years using the Ninth Revision of the International Classification of Diseases (ICD-9) diagnosis for hypoglycemia for patients evaluated in a single ED with an annual volume of 100,000 patients. Chart reviews were performed to identify unique patient encounters with symptomatic blood sugar readings less than 55 mg/dL who were taking oral or injectable diabetic medications. Specific medications taken, blood sugar readings obtained, and general demographic information was ascertained. For those discharged, hospital records from all nearby health systems as well as all area county Emergency Medical Service (EMS) encounters and county death records were reviewed for any further patient contact that took place within 7 days of discharge. Return hospital visits or EMS encounters within 48 hours were arbitrarily defined as recurrent hypoglycemic events. Data is reported as frequency of occurrence with 95% confidence interval (CI) and with significance determined using Chi Square analysis. Results: There were 272 hypoglycemic patients identified meeting inclusion criteria with 76 patients admitted and 196 patients discharged (144 insulin only, 33 insulin and oral agents, 19 oral agents alone) over the study period. Of those discharged, 3 patients on oral agents alone, 15.8% (CI 0-32.2%), 3 patients on insulin and oral agents, 9.1% (CI 0-18.9%), and 4 of 144 patient on insulin alone, 2.7% (CI 0.1-5.4%) had return visits to the ED within 48 hours. Patients taking oral agents alone had a significantly greater likelihood of return ED visits compared to those taking insulin without any oral agents (P¼.01). Patients taking an oral agent with or without insulin additionally had a significant risk of return ED visits compared to insulin only patients (P¼.01). All 4 patients who returned after being discharged who were taking injectable insulin alone (5.9% [CI 0.3-11.5%]) were noted to be on long-acting oncedaily dosed insulin glargine (Lantus). No patients were identified by county death records or EMS records over the 7 days following discharge.
Volume 64, no. 4s : October 2014
Conclusion: Individuals taking blood sugar lowering agents discharged from the ED following a hypoglycemic event may be at risk of recurrent visits related to further hypoglycemic episodes. This risk is considerably greater in those taking oral agents and those on long-acting insulin. Hospital observation in this high-risk population should be considered.
286
“When We” Visual Cue Checklist Reduces Variation and Improves Adherence to Emergency Department Best Practices
Haydar SA, Bhattacharyya A, Kerr MS, Leger JD, Strout TD/Maine Medical Center, Portland, ME; Tufts University School of Medicine, Boston, MA
Study Objectives: Unnecessary variation in the delivery of health care has been shown to result in increased costs and suboptimal patient outcomes. Checklists have been shown to be beneficial in improving the standardization of patient care and interdisciplinary communication in various settings, but little is known about the use of checklists in the emergency setting. The purpose of this study was to evaluate the effect of the implementation of a standardized, visually oriented checklist on emergency clinician adherence to best practices, physician communication with patients and registered nurses (RNs), and patient and RN understanding of the care plan. Methods: We employed a simple interrupted time-series design to evaluate the effect of the implementation of a standardized visual checklist on emergency clinician adherence to best practices, communication with patients and RNs, and patient and nurse understanding of the plan of care. Data were collected in a prospective manner using direct observation of emergency physicians’ first encounters with a convenience sample of patients before-and-after implementation of the visual checklist. Checklist items were developed following review of the relevant literature and internal quality improvement data. Items included: formal introduction of self and role to patient and family; handwashing; use of the in-room white board; completion of targeted history and physical exam; pain management discussion and plan; care planning and goal setting; addressing patient/family concerns or questions; and discussing the plan of care with the patient’s primary nurse. Results: During the study, 137 first encounter interactions were observed: 67 (49%) before and 70 (51%) after implementation of the visual checklist. The proportion of clinicians washing or sanitizing their hands (91% versus 100%, c2 ¼ 6.657, df ¼ 1, P¼.010), introducing themselves and their role to the patient (82% versus 99%, c2 ¼ 10.828, df ¼ 1, P<.001), using the white board (3% versus 46%, c2 ¼ 19.910, df ¼ 1, P<.001), discussing pain management (64% versus 95%, c2 ¼ 15.960, df ¼ 1, P<.001), and ensuring patient questions were addressed (39% versus 78%, c2 ¼ 21.847, df ¼ 1, P<.001) all increased following implementation of the checklist. Registered nurse understanding of the care plan also improved postimplementation, t ¼ -2.451, df ¼ 132, P¼.016. Patient understanding of the plan of care did not vary significantly, t ¼ -1.687, df ¼ 117, P¼.094. The proportion of clinicians observed discussing the care plan and setting goals with the patient increased (85% versus 93%) but did not reach statistical significance (c2 ¼ 2.043, df ¼ 1, P¼.153) as did the proportion of clinicians discussing the plan of care with the patient’s primary RN (58% versus 71%, c2 ¼ 2.257, df ¼ 1, P¼.133). Conclusion: In this setting and sample, use of a visual checklist focused on standardizing first encounters with patients in the emergency setting improved handwashing, clinician introductions and white board utilization, pain management planning, responsiveness to patient questions, and RN understanding of the plan of care. This study provides a foundation for future research exploring additional checklist-based performance improvement strategies. This research provides evidence to support the efficacy of using visual cues to improve adherence to best practices in the emergency setting.
287
Streamlining Patients With Isolated Hip Fractures from the Emergency Department to the Operating Room Utilizing a Novel Hip Fracture Pathway
Bastani A, Donaldson D, Cloutier D, Forbes A, Ali A, Anderson W/Troy Beaumont Hospital, Troy, MI
Study Objectives: There are approximately 341,000 emergency department (ED) visits annually for patients who present with acute hip fractures. These patients are not typically diagnostically challenging; however, once the diagnosis of a hip fracture is made, surgery within 48 hours of hospital admission has resulted in a clinically significant decrease in mortality and length of stay. In July 2013 our institution developed a new ED-based algorithm for these patients managed by the trauma service.
Annals of Emergency Medicine S101
285
Return Visits to the Emergency Department in Patients Discharged Following Hypoglycemic Episodes
Betten DP, Castle DJ, Hughes MJ, Henney J/Michigan State University, East Lansing, MI
Study Objectives: Presentation to the emergency department (ED) due to hypoglycemia among diabetics is not an uncommon event. Traditional teaching has been for hospital admission and extended observation for recurrence of hypoglycemia among individuals on long-acting insulin and oral diabetic medications. Home observation has been considered by some to be a reasonable alternative if the risk of recurrent hypoglycemia is felt to be low. The following study was performed to evaluate the likelihood and patterns of recurrent hypoglycemia in individuals discharged from the ED following a hypoglycemic event. Methods: A retrospective chart review of electronic medical records was performed over 2 calendar years using the Ninth Revision of the International Classification of Diseases (ICD-9) diagnosis for hypoglycemia for patients evaluated in a single ED with an annual volume of 100,000 patients. Chart reviews were performed to identify unique patient encounters with symptomatic blood sugar readings less than 55 mg/dL who were taking oral or injectable diabetic medications. Specific medications taken, blood sugar readings obtained, and general demographic information was ascertained. For those discharged, hospital records from all nearby health systems as well as all area county Emergency Medical Service (EMS) encounters and county death records were reviewed for any further patient contact that took place within 7 days of discharge. Return hospital visits or EMS encounters within 48 hours were arbitrarily defined as recurrent hypoglycemic events. Data is reported as frequency of occurrence with 95% confidence interval (CI) and with significance determined using Chi Square analysis. Results: There were 272 hypoglycemic patients identified meeting inclusion criteria with 76 patients admitted and 196 patients discharged (144 insulin only, 33 insulin and oral agents, 19 oral agents alone) over the study period. Of those discharged, 3 patients on oral agents alone, 15.8% (CI 0-32.2%), 3 patients on insulin and oral agents, 9.1% (CI 0-18.9%), and 4 of 144 patient on insulin alone, 2.7% (CI 0.1-5.4%) had return visits to the ED within 48 hours. Patients taking oral agents alone had a significantly greater likelihood of return ED visits compared to those taking insulin without any oral agents (P¼.01). Patients taking an oral agent with or without insulin additionally had a significant risk of return ED visits compared to insulin only patients (P¼.01). All 4 patients who returned after being discharged who were taking injectable insulin alone (5.9% [CI 0.3-11.5%]) were noted to be on long-acting oncedaily dosed insulin glargine (Lantus). No patients were identified by county death records or EMS records over the 7 days following discharge.
Volume 64, no. 4s : October 2014
Conclusion: Individuals taking blood sugar lowering agents discharged from the ED following a hypoglycemic event may be at risk of recurrent visits related to further hypoglycemic episodes. This risk is considerably greater in those taking oral agents and those on long-acting insulin. Hospital observation in this high-risk population should be considered.
286
“When We” Visual Cue Checklist Reduces Variation and Improves Adherence to Emergency Department Best Practices
Haydar SA, Bhattacharyya A, Kerr MS, Leger JD, Strout TD/Maine Medical Center, Portland, ME; Tufts University School of Medicine, Boston, MA
Study Objectives: Unnecessary variation in the delivery of health care has been shown to result in increased costs and suboptimal patient outcomes. Checklists have been shown to be beneficial in improving the standardization of patient care and interdisciplinary communication in various settings, but little is known about the use of checklists in the emergency setting. The purpose of this study was to evaluate the effect of the implementation of a standardized, visually oriented checklist on emergency clinician adherence to best practices, physician communication with patients and registered nurses (RNs), and patient and RN understanding of the care plan. Methods: We employed a simple interrupted time-series design to evaluate the effect of the implementation of a standardized visual checklist on emergency clinician adherence to best practices, communication with patients and RNs, and patient and nurse understanding of the plan of care. Data were collected in a prospective manner using direct observation of emergency physicians’ first encounters with a convenience sample of patients before-and-after implementation of the visual checklist. Checklist items were developed following review of the relevant literature and internal quality improvement data. Items included: formal introduction of self and role to patient and family; handwashing; use of the in-room white board; completion of targeted history and physical exam; pain management discussion and plan; care planning and goal setting; addressing patient/family concerns or questions; and discussing the plan of care with the patient’s primary nurse. Results: During the study, 137 first encounter interactions were observed: 67 (49%) before and 70 (51%) after implementation of the visual checklist. The proportion of clinicians washing or sanitizing their hands (91% versus 100%, c2 ¼ 6.657, df ¼ 1, P¼.010), introducing themselves and their role to the patient (82% versus 99%, c2 ¼ 10.828, df ¼ 1, P<.001), using the white board (3% versus 46%, c2 ¼ 19.910, df ¼ 1, P<.001), discussing pain management (64% versus 95%, c2 ¼ 15.960, df ¼ 1, P<.001), and ensuring patient questions were addressed (39% versus 78%, c2 ¼ 21.847, df ¼ 1, P<.001) all increased following implementation of the checklist. Registered nurse understanding of the care plan also improved postimplementation, t ¼ -2.451, df ¼ 132, P¼.016. Patient understanding of the plan of care did not vary significantly, t ¼ -1.687, df ¼ 117, P¼.094. The proportion of clinicians observed discussing the care plan and setting goals with the patient increased (85% versus 93%) but did not reach statistical significance (c2 ¼ 2.043, df ¼ 1, P¼.153) as did the proportion of clinicians discussing the plan of care with the patient’s primary RN (58% versus 71%, c2 ¼ 2.257, df ¼ 1, P¼.133). Conclusion: In this setting and sample, use of a visual checklist focused on standardizing first encounters with patients in the emergency setting improved handwashing, clinician introductions and white board utilization, pain management planning, responsiveness to patient questions, and RN understanding of the plan of care. This study provides a foundation for future research exploring additional checklist-based performance improvement strategies. This research provides evidence to support the efficacy of using visual cues to improve adherence to best practices in the emergency setting.
287
Streamlining Patients With Isolated Hip Fractures from the Emergency Department to the Operating Room Utilizing a Novel Hip Fracture Pathway
Bastani A, Donaldson D, Cloutier D, Forbes A, Ali A, Anderson W/Troy Beaumont Hospital, Troy, MI
Study Objectives: There are approximately 341,000 emergency department (ED) visits annually for patients who present with acute hip fractures. These patients are not typically diagnostically challenging; however, once the diagnosis of a hip fracture is made, surgery within 48 hours of hospital admission has resulted in a clinically significant decrease in mortality and length of stay. In July 2013 our institution developed a new ED-based algorithm for these patients managed by the trauma service.
Annals of Emergency Medicine S101