- Email: [email protected]
44: Transitioning from Paper to Electronic Documentation in an Urban Emergency Department: Effect on Provider Efficiency
Research Forum Abstracts and antibiotic treatment guided by the results; and 2) empiric treatment with clindamycin. The 2007 Medicare costs and National Physician Fee Schedule were used to capture ED and hospital costs, including those associated with complications and death. All analyses were conducted using Decision Maker® software. Results: In our base case analysis PCN skin testing is the dominant strategy, being both more effective and less costly. Sensitivity analysis demonstrates PCN skin testing continues to have a marginal cost-effectiveness ratio less than $50,000 per quality adjusted life year until the cost of skin testing increases to more than $657.10 per patient. Similarly an increase in the percentage of patients with true PCN allergy above 47.7%, a PCN anaphylaxis rate above 82.5%, an anaphylaxis mortality rate above 12.6%, or an increase in the cost of a course of PCN and metronidazole to greater than $723.37 would each independently increase the cost of the PCN skin testing strategy above a willingness to pay threshold of $50,000 per quality adjusted life year. Conclusion: PCN skin testing for ED patients presenting with odontogenic infections and self-reported PCN allergy is more effective and less costly than treating empirically with clindamycin. Although the marginal cost-effectiveness of skin testing increases as the prevalence of PCN allergy, the percentage of allergic patients who have true anaphylaxis, and the costs of PCN/metronidazole and the skin test rise, the cost-effectiveness ratio remains less than $50,000 per quality adjusted life year for all clinically reasonable values of these parameters.
43
Implementation of a Sepsis Quality Intitiative in a Community Hospital and its Impact on Morbidity and Mortality in Septic Shock
Gunaga S, Kella V, Walker J, Nedzlek C, Pensler M/Henry Ford Wyandotte Hospital, Wyandotte, MI
Study Objective: The 2008 Surviving Sepsis Campaign guidelines emphasize the importance of early identification and early goal-directed therapy (EGDT) in patients with severe sepsis and septic shock. While these recommendations have shown outcome benefit in larger hospitals, the generalizability and reproducibility of these findings to the community setting remains a question. We sought to determine whether a joint emergency department (ED) and intensive care unit (ICU) septic shock quality initiative would decrease in-hospital mortality, mechanical ventilation requirements, and vasopressor use in patients presenting to the ED with septic shock. Methods: Septic shock was defined as a suspected or confirmed source of infection in the presence of hypotension requiring vasopressor support or a blood lactate concentration ⬎ 4 mmol per liter. In phase I, a retrospective chart review was conducted on all adult patients identified with septic shock in the ED of a 320 bed community-based teaching hospital. The phase I patients were extracted from the medical records between January 1st, 2006 and April 30th, 2007. In phase II, patients were prospectively followed after the implementation of an ED-based EGDT protocol and a septic shock ICU admission bundle took effect on May 1st, 2007. All septic shock patients in phase I were defined as the historical control group, and all patients in phase II were defined as the treatment group. Charts were reviewed by trained medical student abstractors who were blinded to study questions, using a health system-wide sepsis database. Results: During the 2 year review period, 146 septic shock patients were identified. 98 of these patients made up the phase I group, and 48 patients made up the phase II group. Baseline characteristics between the two groups were similar, with average APACHE II scores of 20 ⫹ 4 in the phase I group and 19 ⫹ 4 in the phase II group. In-hospital mortality was 23% in the phase II group, as compared to 38 percent in the phase I group (P ⫽ 0.06). The patients in the phase II group had a reduction in mechanical ventilation during the first 6 hours of care (31% vs. 45%, P ⫽ 0.07) and from 6 to 72 hours (29% vs. 46%, P ⫽ 0.06) when compared to the patients in the phase I group. The need for vasopressor support in the phase II group was significantly decreased during the interval of 0 to 6 hours (44% vs. 69%, P ⫽ 0.004) as well as from 6 to 24 hours (44% vs. 63%, P ⫽ 0.03), and reduced at 24 to 72 hours (17% vs. 36%, P ⫽ 0.08) when compared with the patients in the phase I group. Conclusion: Implementation of a collaborative ED and ICU based EGDT protocol and ICU septic shock admission bundle is both feasible and beneficial with
Volume , . : October
respect to outcomes and health care resource consumption in a community-based hospital. This study confirms that ED care significantly impacts outcomes in severe sepsis and septic shock patients.
44
Transitioning from Paper to Electronic Documentation in an Urban Emergency Department: Effect on Provider Efficiency
Malhotra MK, Roberts D, Goyal N, Vallee PA, Nagarwala J, Rolland L, Martin GB/Henry Ford Hospital, Detroit, MI
Background: Electronic systems for documentation in the emergency department (ED) have been aggressively promoted and are being used widely. However, there has been no objective study of their impact on the delivery of patient care. Study Objectives: To quantify the impact on patient care efficiency as a result of changing from a paper template system to an electronic physician documentation system in the ED. Methods: This was a prospective, observational study conducted at an urban Level 1 trauma center which forms the main teaching hospital for an emergency medicine (EM) 1-3 residency program. A checklist of tasks routinely performed by EM residents in the ED was created by the authors. Data was collected by a thirdparty observer who recorded the current task being performed by each resident physician at 20-second intervals for the length of the shift. The first set of data was collected while the paper template system (T-System, Inc. ©) was still in use. The second set of data was collected immediately following implementation of the electronic documentation system (EmSTAT Physician Documentation ©). The final set of data was collected one month later. Each set represented five days of data collection with observations carried out for one shift on each of those days. Results: EM senior residents were observed throughout a 10-hour shift on fifteen different days and approximately 20,000 data samples were generated. The total time related to documentation was compared for the three collection periods. The percentage of time spent on documentation while using the paper template system was 22.5%. In the period immediately following the transition to the electronic documentation system, the time spent on documentation increased to 29%. One month later, the percentage of time spent on documentation was found to be 28.1%. Conclusion: Based on these observations, we conclude that the transition to electronic medical documentation in the ED has an adverse effect on patient care efficiency. After one month of use, the percentage of time spent on documentation remained markedly increased over times noted during use of paper templates. Further long-term studies should be completed to see if practitioners become more proficient in using an electronic documentation system over time.
45
Computerized Recruiting for Clinical Research in the Emergency Department
Kashyap R, Herasevich V, Afessa B, Gajic O, Stead L, Decker W, Smith V/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: Patient recruitment in timely manner is critical for the success of prospective studies, particularly in the emergency department (ED), where it often depends on immediate identification of eligible patients. We report use of a real-time Automated Notification System (ANS) to identify potential patients for a clinical research protocol at the time of ED registration on the basis of information routinely collected; we hypothesize that the ANS improves the patient recruitments. Methods: We performed a comparison of patient recruitments before and after the ANS implementation over a period of 2 years. The first 12 months (Sept.2005Aug. 2006) of study recruitments were done on the basis of e-mail and phone calls from nurses and physicians or direct manual screening. The second 12 months (Sept.2006-Aug. 2007) of the study a computer system generated a pager alert, every time systolic blood pressure (SBP) of an ED patient recorded less than 90 mm Hg. After this pager alert, patients were approached for inclusion criteria assessment and recruitment, if study criteria were met. Results: In the 12 months before use of the automated notification system, the investigator enrolled 23 patients out of 64647 patients seen in ED. During 12 months of using the automated notification system, the investigator was paged by the automated notification system 180 times Monday - Friday (8 AM-4 PM) resulting in 48 enrolled patients out of 66202 patients seen in The ED, which is significantly higher than during the previous period (48/66202 versus 23/64647, p⫽ 0.006). Conclusion:The automated notification system is a more efficient and effective tool in the recruitment of patients for research studies in the ED. Use requires online linked registration, a database, and paging systems.
Annals of Emergency Medicine S55
43
Implementation of a Sepsis Quality Intitiative in a Community Hospital and its Impact on Morbidity and Mortality in Septic Shock
Gunaga S, Kella V, Walker J, Nedzlek C, Pensler M/Henry Ford Wyandotte Hospital, Wyandotte, MI
Study Objective: The 2008 Surviving Sepsis Campaign guidelines emphasize the importance of early identification and early goal-directed therapy (EGDT) in patients with severe sepsis and septic shock. While these recommendations have shown outcome benefit in larger hospitals, the generalizability and reproducibility of these findings to the community setting remains a question. We sought to determine whether a joint emergency department (ED) and intensive care unit (ICU) septic shock quality initiative would decrease in-hospital mortality, mechanical ventilation requirements, and vasopressor use in patients presenting to the ED with septic shock. Methods: Septic shock was defined as a suspected or confirmed source of infection in the presence of hypotension requiring vasopressor support or a blood lactate concentration ⬎ 4 mmol per liter. In phase I, a retrospective chart review was conducted on all adult patients identified with septic shock in the ED of a 320 bed community-based teaching hospital. The phase I patients were extracted from the medical records between January 1st, 2006 and April 30th, 2007. In phase II, patients were prospectively followed after the implementation of an ED-based EGDT protocol and a septic shock ICU admission bundle took effect on May 1st, 2007. All septic shock patients in phase I were defined as the historical control group, and all patients in phase II were defined as the treatment group. Charts were reviewed by trained medical student abstractors who were blinded to study questions, using a health system-wide sepsis database. Results: During the 2 year review period, 146 septic shock patients were identified. 98 of these patients made up the phase I group, and 48 patients made up the phase II group. Baseline characteristics between the two groups were similar, with average APACHE II scores of 20 ⫹ 4 in the phase I group and 19 ⫹ 4 in the phase II group. In-hospital mortality was 23% in the phase II group, as compared to 38 percent in the phase I group (P ⫽ 0.06). The patients in the phase II group had a reduction in mechanical ventilation during the first 6 hours of care (31% vs. 45%, P ⫽ 0.07) and from 6 to 72 hours (29% vs. 46%, P ⫽ 0.06) when compared to the patients in the phase I group. The need for vasopressor support in the phase II group was significantly decreased during the interval of 0 to 6 hours (44% vs. 69%, P ⫽ 0.004) as well as from 6 to 24 hours (44% vs. 63%, P ⫽ 0.03), and reduced at 24 to 72 hours (17% vs. 36%, P ⫽ 0.08) when compared with the patients in the phase I group. Conclusion: Implementation of a collaborative ED and ICU based EGDT protocol and ICU septic shock admission bundle is both feasible and beneficial with
Volume , . : October
respect to outcomes and health care resource consumption in a community-based hospital. This study confirms that ED care significantly impacts outcomes in severe sepsis and septic shock patients.
44
Transitioning from Paper to Electronic Documentation in an Urban Emergency Department: Effect on Provider Efficiency
Malhotra MK, Roberts D, Goyal N, Vallee PA, Nagarwala J, Rolland L, Martin GB/Henry Ford Hospital, Detroit, MI
Background: Electronic systems for documentation in the emergency department (ED) have been aggressively promoted and are being used widely. However, there has been no objective study of their impact on the delivery of patient care. Study Objectives: To quantify the impact on patient care efficiency as a result of changing from a paper template system to an electronic physician documentation system in the ED. Methods: This was a prospective, observational study conducted at an urban Level 1 trauma center which forms the main teaching hospital for an emergency medicine (EM) 1-3 residency program. A checklist of tasks routinely performed by EM residents in the ED was created by the authors. Data was collected by a thirdparty observer who recorded the current task being performed by each resident physician at 20-second intervals for the length of the shift. The first set of data was collected while the paper template system (T-System, Inc. ©) was still in use. The second set of data was collected immediately following implementation of the electronic documentation system (EmSTAT Physician Documentation ©). The final set of data was collected one month later. Each set represented five days of data collection with observations carried out for one shift on each of those days. Results: EM senior residents were observed throughout a 10-hour shift on fifteen different days and approximately 20,000 data samples were generated. The total time related to documentation was compared for the three collection periods. The percentage of time spent on documentation while using the paper template system was 22.5%. In the period immediately following the transition to the electronic documentation system, the time spent on documentation increased to 29%. One month later, the percentage of time spent on documentation was found to be 28.1%. Conclusion: Based on these observations, we conclude that the transition to electronic medical documentation in the ED has an adverse effect on patient care efficiency. After one month of use, the percentage of time spent on documentation remained markedly increased over times noted during use of paper templates. Further long-term studies should be completed to see if practitioners become more proficient in using an electronic documentation system over time.
45
Computerized Recruiting for Clinical Research in the Emergency Department
Kashyap R, Herasevich V, Afessa B, Gajic O, Stead L, Decker W, Smith V/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: Patient recruitment in timely manner is critical for the success of prospective studies, particularly in the emergency department (ED), where it often depends on immediate identification of eligible patients. We report use of a real-time Automated Notification System (ANS) to identify potential patients for a clinical research protocol at the time of ED registration on the basis of information routinely collected; we hypothesize that the ANS improves the patient recruitments. Methods: We performed a comparison of patient recruitments before and after the ANS implementation over a period of 2 years. The first 12 months (Sept.2005Aug. 2006) of study recruitments were done on the basis of e-mail and phone calls from nurses and physicians or direct manual screening. The second 12 months (Sept.2006-Aug. 2007) of the study a computer system generated a pager alert, every time systolic blood pressure (SBP) of an ED patient recorded less than 90 mm Hg. After this pager alert, patients were approached for inclusion criteria assessment and recruitment, if study criteria were met. Results: In the 12 months before use of the automated notification system, the investigator enrolled 23 patients out of 64647 patients seen in ED. During 12 months of using the automated notification system, the investigator was paged by the automated notification system 180 times Monday - Friday (8 AM-4 PM) resulting in 48 enrolled patients out of 66202 patients seen in The ED, which is significantly higher than during the previous period (48/66202 versus 23/64647, p⫽ 0.006). Conclusion:The automated notification system is a more efficient and effective tool in the recruitment of patients for research studies in the ED. Use requires online linked registration, a database, and paging systems.
Annals of Emergency Medicine S55