- Email: [email protected]
319 Variability in Patient Care Process Measures Across 7 Massachusetts Academic Emergency Departments
Research Forum Abstracts Conclusion: Triage nurses overestimate the language skills of patients and therefore may not offer the translation services deemed to be the standard of care. Spanish speaking patients feel less well understood and less satisfied with care as compared to their English-speaking counterparts, although most patients are still relatively satisfied with their triage experience.
319
Variability in Patient Care Process Measures Across 7 Massachusetts Academic Emergency Departments
Yiadom MY, Hopkins JB, Imperato J, Sanchez L, Fisher J, Pearlmutter M, Kosowsky JM, White B, Perumalsamy P, Aljahawry N, Marill K/Cooper University Hospital, Camden, NJ; Milford Regional Hospital, Milford, MA; Mount Auburn Hospital, Cambridge, MA; Beth Israel Deaconess Hospital, Boston, MA; St Elizabeth’s Medical Center, Boston, MA; Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Robert Wood Johnson Medical School, Camden, NJ
Study Objectives: To identify areas of variability and consistency in clinical operations and practice parameters across academic emergency departments (EDs). Methods: A retrospective cross-sectional descriptive review of Massachusetts EDs where emergency medicine residents spend 1 month of required training time. Of the 13 eligible, 7 became participants by identifying a site PI, obtaining local institutional review board approval, and collecting the requested data. Seven domains of data were collected for 2011 including: patients, care space and disposition; clinical staffing; triage type; lab and radiology testing; process improvement trials; documentation and billing; acute coronary syndrome and congestive heart failure clinical practice. We have reported averages and 1 standard of deviation to describe central tendency and variability. Results: Average ED daily volume (177 ⫹/⫺ 79) and space (3.4 ⫹/⫺ 1.4 patients per sq ft per yr) are quite variable across facilities. Attending physician staffing has low variability (2.5 ⫹/⫺ 0.5 hrs per day) while nursing staffing is more variable (1.9 ⫹/⫺0.8 nursing hrs per patients seen). When PAs and NPs are included with residents as physician extenders, affiliate site attending physicians with their extenders see fewer patients per hour than those at primary residency sites (0.8 patients per hr ⫹/⫺ 0.2 versus 1.5 ⫹/⫺ 0.4). However, affiliate site EDs bill a higher percentage of level 5 APC charts (36%) compared to the primary sites (24%), which are also the higher volume receiving centers for high acuity patients. Most EDs use some degree of RN triage (87%), but 43% have a combination model using some degree of direct to room or physician triage. EDs with observation units did not have shorter ED length of stay (LOS) for admitted patients as compared to those without (6.5 ⫹/⫺0.8 hrs versus 5.0, ⫹/⫺0.5hrs). ED LOS for discharged patients demonstrates relatively low variability (3.9 ⫹/⫺ 0.5 hrs). In the past 10 years, 85.7% of EDs have worked on patient flow, triage and inpt admission processes. 71.4% have addressed care-space use, fast track areas, lab testing services, and consultations. Only 57.1% have worked on radiology testing services. The greatest variability in payer mix occurs amongst private insurance (28.9%, ⫹/⫺25.6) and self-pay patients (25.5%, ⫹/⫺22.3), with much less variability amongst Medicare (24.2% ⫹/⫺11.7) and Medicaid (21.5% ⫹/⫺12.0) patients. All EDs use either a Troponin T or an ultrasensitive Troponin I. The average interval for 2 troponin assays as part of an acute coronary syndrome evaluation was 6hrs. All discharged a maximum of 10% of patients with a primary diagnosis of congestive heart failure from the ED. Conclusion: As academic EDs cope with increasing volume and patient complexity, a variety of innovative approaches have been taken to improve throughput and care quality. However, throughput to discharge seems relatively homogeneous. Larger EDs are managing with fewer resources and a poorer income generation scenario. The area of least process improvement innovation was radiology testing. Regarding cardiovascular care, there is potential practice and throughput improvement for patients being evaluated for acute coronary syndrome with a more evidence-based use of cardiac enzymes by using intervals shorter than 6 hours, and with congestive heart failure patients where less than 10% are discharged.
320
Factors Contributing to Patient Satisfaction in Emergency Department
Forstater A, Brooks L, Hojat M, Lopez B/Jefferson Medical College, Philadelphia, PA
Study Objectives: To examine the relative importance of a variety of factors that contribute to patient satisfaction in the emergency department (ED). Methods: The study was conducted at a tertiary care, urban university hospital with an ACGME-accredited emergency medicine residency training program, as part
S114 Annals of Emergency Medicine
of a study examining the relationship between physician empathy and patient satisfaction in the ED. Questions selected from the Press Ganey Survey were administered to patients to assess the extent of their satisfaction. See Figure 1 Survey ((with: doctors, nurses, and staff; wait times to see a receptionist, nurse, and doctor; the doctor’s explanations of medical tests and treatment; doctor’s concern; and control of pain. Questions were answered on a 4-point Likert scale.) Results: 139 subjects completed the 12-item patient satisfaction survey. Factor analysis of the items resulted in 3 factors, each with an eigenvalue greater than one. Based on the content of the items under each factor, the first construct was entitled “nurse/staff courtesy” (eigenvalue⫽4.8, ⫽ 43% of the variance), the second construct was “time/promptness of services” (eigenvalue⫽1.5 ⫽ 13% of the variance), and the third was “physician factor” (eigenvalue⫽1.01 ⫽ 9% of the variance). Multiple regression analysis was used to examine the unique contribution of each factor in predicting overall satisfaction ratings. In this statistical model, patient’s overall satisfaction with medical services was the outcome measure, and factor scores on the 3 above-mentioned constructs were the predictors. Findings suggest that 64% (R2⫽.64, p ⬍ .01) of the overall patient satisfaction scores could be predicted by the 3 constructs in the following order: “nurse/staff courtesy” (standardized beta coefficient⫽.51, p ⬍ .01), “physician factor” (beta coefficient⫽.24, p ⬍ .01), and “time/promptness of services” (beta coefficient⫽.23, p ⬍ .01). Conclusion: Our findings suggest that all 3 aforementioned constructs significantly predict patients’ satisfaction with care in ED. However, the courtesy of staff and nurses appears to be the most important contributor, followed by physician factor and lastly, with timeliness of services. These findings have implications for improving patient satisfaction in the ED. Future studies should prospectively investigate these factors in a variety of settings.
321
The Use of Camera Phones for the Follow-up of SoftTissue Injuries After Discharge from the Emergency Department: A Feasibility Study
Sutliffe C, Fleeger T, De Vries H, Bush C, Jones JS/Grand Rapids MEP/Michigan State University, Grand Rapids, MI
Study Objective: Previous studies have concluded that that a large proportion of patients with sutured lacerations will fail to recognize early signs of wound infection, despite explicit instructions. The purpose of this study was to determine the feasibility of using camera phones for the follow-up of soft-tissue injuries in patients discharged from the emergency department. The ease of use of a familiar device like the mobile phone with a built-in digital camera has particular appeal in wound follow-up, enabling color image transfer directly to a treating physician. Methods: This was a prospective, observational survey using a convenience sample of ED patients with soft-tissue injuries (eg, bite, crush injury or laceration). Eligibility criteria: age over 18 years old and owning a mobile phone capable of sending pictures to another mobile device or an e-mail recipient. Consenting patients were given instructions on how to send clinical images via their mobile camera phone. During the initial instructions, a photo was taken of the wound. Patients were then asked to email a photo of their wound at 3 and 5 days following ED discharge. All photos were reviewed independently as computer images by 3 ED physicians. Photo sharpness, color accuracy, distortion and presence of artifacts were measured using a standardized classification system. Physicians were also asked if overall image quality was high enough to rule out wound infection. Intra-observer agreement was determined using kappa statistic. Descriptive statistics (mean, SD) and frequency tables were used to describe results. Results: A total of 50 patients were enrolled; the majority of patients (94%) used picture messaging “frequently” and 44 (88%) used their camera regularly to take
Volume , . : October
319
Variability in Patient Care Process Measures Across 7 Massachusetts Academic Emergency Departments
Yiadom MY, Hopkins JB, Imperato J, Sanchez L, Fisher J, Pearlmutter M, Kosowsky JM, White B, Perumalsamy P, Aljahawry N, Marill K/Cooper University Hospital, Camden, NJ; Milford Regional Hospital, Milford, MA; Mount Auburn Hospital, Cambridge, MA; Beth Israel Deaconess Hospital, Boston, MA; St Elizabeth’s Medical Center, Boston, MA; Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Robert Wood Johnson Medical School, Camden, NJ
Study Objectives: To identify areas of variability and consistency in clinical operations and practice parameters across academic emergency departments (EDs). Methods: A retrospective cross-sectional descriptive review of Massachusetts EDs where emergency medicine residents spend 1 month of required training time. Of the 13 eligible, 7 became participants by identifying a site PI, obtaining local institutional review board approval, and collecting the requested data. Seven domains of data were collected for 2011 including: patients, care space and disposition; clinical staffing; triage type; lab and radiology testing; process improvement trials; documentation and billing; acute coronary syndrome and congestive heart failure clinical practice. We have reported averages and 1 standard of deviation to describe central tendency and variability. Results: Average ED daily volume (177 ⫹/⫺ 79) and space (3.4 ⫹/⫺ 1.4 patients per sq ft per yr) are quite variable across facilities. Attending physician staffing has low variability (2.5 ⫹/⫺ 0.5 hrs per day) while nursing staffing is more variable (1.9 ⫹/⫺0.8 nursing hrs per patients seen). When PAs and NPs are included with residents as physician extenders, affiliate site attending physicians with their extenders see fewer patients per hour than those at primary residency sites (0.8 patients per hr ⫹/⫺ 0.2 versus 1.5 ⫹/⫺ 0.4). However, affiliate site EDs bill a higher percentage of level 5 APC charts (36%) compared to the primary sites (24%), which are also the higher volume receiving centers for high acuity patients. Most EDs use some degree of RN triage (87%), but 43% have a combination model using some degree of direct to room or physician triage. EDs with observation units did not have shorter ED length of stay (LOS) for admitted patients as compared to those without (6.5 ⫹/⫺0.8 hrs versus 5.0, ⫹/⫺0.5hrs). ED LOS for discharged patients demonstrates relatively low variability (3.9 ⫹/⫺ 0.5 hrs). In the past 10 years, 85.7% of EDs have worked on patient flow, triage and inpt admission processes. 71.4% have addressed care-space use, fast track areas, lab testing services, and consultations. Only 57.1% have worked on radiology testing services. The greatest variability in payer mix occurs amongst private insurance (28.9%, ⫹/⫺25.6) and self-pay patients (25.5%, ⫹/⫺22.3), with much less variability amongst Medicare (24.2% ⫹/⫺11.7) and Medicaid (21.5% ⫹/⫺12.0) patients. All EDs use either a Troponin T or an ultrasensitive Troponin I. The average interval for 2 troponin assays as part of an acute coronary syndrome evaluation was 6hrs. All discharged a maximum of 10% of patients with a primary diagnosis of congestive heart failure from the ED. Conclusion: As academic EDs cope with increasing volume and patient complexity, a variety of innovative approaches have been taken to improve throughput and care quality. However, throughput to discharge seems relatively homogeneous. Larger EDs are managing with fewer resources and a poorer income generation scenario. The area of least process improvement innovation was radiology testing. Regarding cardiovascular care, there is potential practice and throughput improvement for patients being evaluated for acute coronary syndrome with a more evidence-based use of cardiac enzymes by using intervals shorter than 6 hours, and with congestive heart failure patients where less than 10% are discharged.
320
Factors Contributing to Patient Satisfaction in Emergency Department
Forstater A, Brooks L, Hojat M, Lopez B/Jefferson Medical College, Philadelphia, PA
Study Objectives: To examine the relative importance of a variety of factors that contribute to patient satisfaction in the emergency department (ED). Methods: The study was conducted at a tertiary care, urban university hospital with an ACGME-accredited emergency medicine residency training program, as part
S114 Annals of Emergency Medicine
of a study examining the relationship between physician empathy and patient satisfaction in the ED. Questions selected from the Press Ganey Survey were administered to patients to assess the extent of their satisfaction. See Figure 1 Survey ((with: doctors, nurses, and staff; wait times to see a receptionist, nurse, and doctor; the doctor’s explanations of medical tests and treatment; doctor’s concern; and control of pain. Questions were answered on a 4-point Likert scale.) Results: 139 subjects completed the 12-item patient satisfaction survey. Factor analysis of the items resulted in 3 factors, each with an eigenvalue greater than one. Based on the content of the items under each factor, the first construct was entitled “nurse/staff courtesy” (eigenvalue⫽4.8, ⫽ 43% of the variance), the second construct was “time/promptness of services” (eigenvalue⫽1.5 ⫽ 13% of the variance), and the third was “physician factor” (eigenvalue⫽1.01 ⫽ 9% of the variance). Multiple regression analysis was used to examine the unique contribution of each factor in predicting overall satisfaction ratings. In this statistical model, patient’s overall satisfaction with medical services was the outcome measure, and factor scores on the 3 above-mentioned constructs were the predictors. Findings suggest that 64% (R2⫽.64, p ⬍ .01) of the overall patient satisfaction scores could be predicted by the 3 constructs in the following order: “nurse/staff courtesy” (standardized beta coefficient⫽.51, p ⬍ .01), “physician factor” (beta coefficient⫽.24, p ⬍ .01), and “time/promptness of services” (beta coefficient⫽.23, p ⬍ .01). Conclusion: Our findings suggest that all 3 aforementioned constructs significantly predict patients’ satisfaction with care in ED. However, the courtesy of staff and nurses appears to be the most important contributor, followed by physician factor and lastly, with timeliness of services. These findings have implications for improving patient satisfaction in the ED. Future studies should prospectively investigate these factors in a variety of settings.
321
The Use of Camera Phones for the Follow-up of SoftTissue Injuries After Discharge from the Emergency Department: A Feasibility Study
Sutliffe C, Fleeger T, De Vries H, Bush C, Jones JS/Grand Rapids MEP/Michigan State University, Grand Rapids, MI
Study Objective: Previous studies have concluded that that a large proportion of patients with sutured lacerations will fail to recognize early signs of wound infection, despite explicit instructions. The purpose of this study was to determine the feasibility of using camera phones for the follow-up of soft-tissue injuries in patients discharged from the emergency department. The ease of use of a familiar device like the mobile phone with a built-in digital camera has particular appeal in wound follow-up, enabling color image transfer directly to a treating physician. Methods: This was a prospective, observational survey using a convenience sample of ED patients with soft-tissue injuries (eg, bite, crush injury or laceration). Eligibility criteria: age over 18 years old and owning a mobile phone capable of sending pictures to another mobile device or an e-mail recipient. Consenting patients were given instructions on how to send clinical images via their mobile camera phone. During the initial instructions, a photo was taken of the wound. Patients were then asked to email a photo of their wound at 3 and 5 days following ED discharge. All photos were reviewed independently as computer images by 3 ED physicians. Photo sharpness, color accuracy, distortion and presence of artifacts were measured using a standardized classification system. Physicians were also asked if overall image quality was high enough to rule out wound infection. Intra-observer agreement was determined using kappa statistic. Descriptive statistics (mean, SD) and frequency tables were used to describe results. Results: A total of 50 patients were enrolled; the majority of patients (94%) used picture messaging “frequently” and 44 (88%) used their camera regularly to take
Volume , . : October