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361 Redesigned Acute Stroke Process in the Emergency Department Improves Quality Metrics
Research Forum Abstracts
360
Emergency Department Triage Nurse Inter-Rater Reliability of Bedside Point-of-Care Clinical Ultrasound Imaging to Assess Skin and Soft Tissue Infection in Light-Skinned and Dark-Skinned Patients
Riley D, Kauari V, Mishoe J, Chou D, Estores M, Nowak N, Soderman M, Garber J, Ghany S, Gordon M, Orth R/Columbia University Medical Center, New York, NY
Background: The United States Agency for Healthcare Research and Quality endorses the importance of a clinician’s accurate diagnosis of skin and soft tissue infection as a way to improve patient safety especially with the nation wide emergence of community-acquired methicillin resistant Staphylococcus aureus. A reliable and accurate bedside ultrasound imaging classification approach to skin and soft tissue infection may assist the emergency department (ED) triage nurse in safely identifying those patients with skin and soft tissue infection in both light-skinned and darkskinned patients and help the ED triage nurse stratify those patients who need medical versus surgical therapy. Study Objectives: To assess the reliability of ED triage nurse-performed bedside ultrasound imaging (inter-rater reliability testing) for the detection and classification of skin and soft tissue infections into surgical vs non-surgical levels of skin and soft tissue infection in patients with light skin and dark skin (Fitzpatrick Skin Color Classification stratification). Methods: Prospective, blinded, convenience sample, in urban teaching hospital ED. Adult volume approximately 120,000 patients/year. All enrolled patients received bedside ultrasound by an ED triage nurse who underwent point-of-care ultrasonography training and criterion standard image review (experienced RDMS, RMSK ED attending physician) assessed for possible skin and soft tissue infection. Groups were compared via a two-rater linear weighted kappa statistic. A total sample size of 160 patients was determined to attain a desired kappa of > 0.6 in each group. Results: ED triage nurse pre-ultrasound versus post-ultrasound assessment of patients changed clinical management in 19/163 ¼11.7% cases. Conclusion: ED triage nurses can reliably use bedside utrasound imaging to evaluate for skin and soft tissue infection. Substantial inter-rater agreement for light skinned and dark-skinned patients was revealed. Substantial inter-rater agreement was found overall. ED triage nurse-performed bedside point of care ultrasonography can reliably assist the emergency physician to initiate medical vs. surgical therapy for patients with skin and soft tissue infections.
stroke-like symptoms, were excluded. Two main outcomes were studied: (1) Patient arrival to physician evaluation and (2) patient arrival to CT brain completion. Data was compared before and after Stroke Alert implementation. Kruskal-Wallis analysis was performed to test for statistical significance. Results: Pre-Stroke Alert data was collected from October 2012 through February 2013 with 62 patients fitting the inclusion criteria. Time from arrival to physician evaluation was 10 minutes and time from arrival to CT completion was 41 minutes. Post-Stroke Alert data was collected from March 2013 through June 2013 with 56 patients fitting the inclusion criteria. Time from arrival to physician evaluation decreased to 4 minutes and arrival to CT completion decreased to 21 minutes. Both main outcomes measures showed a statistically significant difference between the pre/post metrics (P < .01). We have been able to consistently maintain our throughput and process measures over the last 15 months at 6 minutes for arrival to physician and 22 minutes for arrival to CT completion (June 1, 2014 to March 31, 2015). Conclusion: A redesigned acute stroke process in the ED was associated with a significant reduction in core stroke metrics that included time from patient arrival to evaluation by a physician, as well as patient arrival to the completion of a brain CT. These improved metrics been have sustainable since the process redesign was implemented.
Table. Reliability of ED Nurse Ultrasound for Detecting Skin-ST Infection in Light & Dark Skin Patients.
Kappa Inter-rater
361
Light Skinned N[104
Dark Skinned N[59
Overall N[163
0.83 (95% CI 0.70 to 0.96)
0.76 (95% CI 0.58 to 0.94)
0.81 (95% CI 0.70 to 0.91)
Redesigned Acute Stroke Process in the Emergency Department Improves Quality Metrics
Podolsky SR, Ferguson SL, Travis GC, Legenza DC, Foster V, Guzi KL, Thallner EA, Roth SM, Meldon SW, Hussain MS, Acute Stroke Process Improvement Team/ Cleveland Clinic, Cleveland, OH
Study Objectives: Improve stroke metrics for patients presenting to the emergency department (ED) with acute stroke-like symptoms. Specifically, this performance improvement project sought to reduce to core quality metrics: (1) patient arrival to evaluation by a physician and (2) patient arrival to the completion of a computed tomography (CT) brain without contrast. Methods: We conducted a prospective study in a large, urban, academic ED in conjunction with the Neurology Stroke Team. A multidisciplinary committee (physicians, nurses, pharmacists, RTs, medics) used continuous improvement methodologies to create a stroke alert process for ED patients with stroke-like symptoms (using the Cincinnati scale) and last known well (LKW) less than eight hours. Our goal was to complete a hierarchy of 8 primary actions in less than 10 minutes before CT brain. Targeted education sessions were delivered to all provider levels. Participants included all patients fitting the inclusion criteria of stroke-like symptoms and LKW < 8 hours. Patients with an LKW > 8 hours, or without
S130 Annals of Emergency Medicine
362
Emergency Physician Intrapenile Injection for Priapism Significantly Reduces the Need for Bedside Urological Consultation
Zimmerman P, Fiesseler F, Riggs R, Salo D/Morristown Medical Center, Morristown, NJ; Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ
Background: Priapism is a sporadic disease seen in the emergency department (ED). It requires prompt evaluation and treatment to avoid potentially significant sequelae. Treatment of this disease is highly variable and often performed by specialist rather than the treating emergency physician. Study Objectives: To determine the treatment modalities used for patients presenting to the ED with priapism and whether any specific techniques reduce the need for bedside urological consult. Methods: Retrospective cohort study utilizing an electronic ED database. Individual patient charts were extracted using the final ICD9 diagnosis for priapism over a 2-year period (June 2012 to June 2014). Enrolling hospitals (N¼15) represent both urban/suburban and academic/community settings. All charts were de-identified and subsequently reviewed for predetermined data points by blinded study personnel. Patients were excluded if the diagnosis was determined not to be priapism or for chart unavailability. Pediatrics was defined as being < 21 years of age. Statistics: Fisher’s Exact Test, with a predetermined significant P < .05, two tailed. Study was approved by the IRB.
Volume 66, no. 4s : October 2015
360
Emergency Department Triage Nurse Inter-Rater Reliability of Bedside Point-of-Care Clinical Ultrasound Imaging to Assess Skin and Soft Tissue Infection in Light-Skinned and Dark-Skinned Patients
Riley D, Kauari V, Mishoe J, Chou D, Estores M, Nowak N, Soderman M, Garber J, Ghany S, Gordon M, Orth R/Columbia University Medical Center, New York, NY
Background: The United States Agency for Healthcare Research and Quality endorses the importance of a clinician’s accurate diagnosis of skin and soft tissue infection as a way to improve patient safety especially with the nation wide emergence of community-acquired methicillin resistant Staphylococcus aureus. A reliable and accurate bedside ultrasound imaging classification approach to skin and soft tissue infection may assist the emergency department (ED) triage nurse in safely identifying those patients with skin and soft tissue infection in both light-skinned and darkskinned patients and help the ED triage nurse stratify those patients who need medical versus surgical therapy. Study Objectives: To assess the reliability of ED triage nurse-performed bedside ultrasound imaging (inter-rater reliability testing) for the detection and classification of skin and soft tissue infections into surgical vs non-surgical levels of skin and soft tissue infection in patients with light skin and dark skin (Fitzpatrick Skin Color Classification stratification). Methods: Prospective, blinded, convenience sample, in urban teaching hospital ED. Adult volume approximately 120,000 patients/year. All enrolled patients received bedside ultrasound by an ED triage nurse who underwent point-of-care ultrasonography training and criterion standard image review (experienced RDMS, RMSK ED attending physician) assessed for possible skin and soft tissue infection. Groups were compared via a two-rater linear weighted kappa statistic. A total sample size of 160 patients was determined to attain a desired kappa of > 0.6 in each group. Results: ED triage nurse pre-ultrasound versus post-ultrasound assessment of patients changed clinical management in 19/163 ¼11.7% cases. Conclusion: ED triage nurses can reliably use bedside utrasound imaging to evaluate for skin and soft tissue infection. Substantial inter-rater agreement for light skinned and dark-skinned patients was revealed. Substantial inter-rater agreement was found overall. ED triage nurse-performed bedside point of care ultrasonography can reliably assist the emergency physician to initiate medical vs. surgical therapy for patients with skin and soft tissue infections.
stroke-like symptoms, were excluded. Two main outcomes were studied: (1) Patient arrival to physician evaluation and (2) patient arrival to CT brain completion. Data was compared before and after Stroke Alert implementation. Kruskal-Wallis analysis was performed to test for statistical significance. Results: Pre-Stroke Alert data was collected from October 2012 through February 2013 with 62 patients fitting the inclusion criteria. Time from arrival to physician evaluation was 10 minutes and time from arrival to CT completion was 41 minutes. Post-Stroke Alert data was collected from March 2013 through June 2013 with 56 patients fitting the inclusion criteria. Time from arrival to physician evaluation decreased to 4 minutes and arrival to CT completion decreased to 21 minutes. Both main outcomes measures showed a statistically significant difference between the pre/post metrics (P < .01). We have been able to consistently maintain our throughput and process measures over the last 15 months at 6 minutes for arrival to physician and 22 minutes for arrival to CT completion (June 1, 2014 to March 31, 2015). Conclusion: A redesigned acute stroke process in the ED was associated with a significant reduction in core stroke metrics that included time from patient arrival to evaluation by a physician, as well as patient arrival to the completion of a brain CT. These improved metrics been have sustainable since the process redesign was implemented.
Table. Reliability of ED Nurse Ultrasound for Detecting Skin-ST Infection in Light & Dark Skin Patients.
Kappa Inter-rater
361
Light Skinned N[104
Dark Skinned N[59
Overall N[163
0.83 (95% CI 0.70 to 0.96)
0.76 (95% CI 0.58 to 0.94)
0.81 (95% CI 0.70 to 0.91)
Redesigned Acute Stroke Process in the Emergency Department Improves Quality Metrics
Podolsky SR, Ferguson SL, Travis GC, Legenza DC, Foster V, Guzi KL, Thallner EA, Roth SM, Meldon SW, Hussain MS, Acute Stroke Process Improvement Team/ Cleveland Clinic, Cleveland, OH
Study Objectives: Improve stroke metrics for patients presenting to the emergency department (ED) with acute stroke-like symptoms. Specifically, this performance improvement project sought to reduce to core quality metrics: (1) patient arrival to evaluation by a physician and (2) patient arrival to the completion of a computed tomography (CT) brain without contrast. Methods: We conducted a prospective study in a large, urban, academic ED in conjunction with the Neurology Stroke Team. A multidisciplinary committee (physicians, nurses, pharmacists, RTs, medics) used continuous improvement methodologies to create a stroke alert process for ED patients with stroke-like symptoms (using the Cincinnati scale) and last known well (LKW) less than eight hours. Our goal was to complete a hierarchy of 8 primary actions in less than 10 minutes before CT brain. Targeted education sessions were delivered to all provider levels. Participants included all patients fitting the inclusion criteria of stroke-like symptoms and LKW < 8 hours. Patients with an LKW > 8 hours, or without
S130 Annals of Emergency Medicine
362
Emergency Physician Intrapenile Injection for Priapism Significantly Reduces the Need for Bedside Urological Consultation
Zimmerman P, Fiesseler F, Riggs R, Salo D/Morristown Medical Center, Morristown, NJ; Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ
Background: Priapism is a sporadic disease seen in the emergency department (ED). It requires prompt evaluation and treatment to avoid potentially significant sequelae. Treatment of this disease is highly variable and often performed by specialist rather than the treating emergency physician. Study Objectives: To determine the treatment modalities used for patients presenting to the ED with priapism and whether any specific techniques reduce the need for bedside urological consult. Methods: Retrospective cohort study utilizing an electronic ED database. Individual patient charts were extracted using the final ICD9 diagnosis for priapism over a 2-year period (June 2012 to June 2014). Enrolling hospitals (N¼15) represent both urban/suburban and academic/community settings. All charts were de-identified and subsequently reviewed for predetermined data points by blinded study personnel. Patients were excluded if the diagnosis was determined not to be priapism or for chart unavailability. Pediatrics was defined as being < 21 years of age. Statistics: Fisher’s Exact Test, with a predetermined significant P < .05, two tailed. Study was approved by the IRB.
Volume 66, no. 4s : October 2015