Colorado physicians' knowledge of and attitudes toward mandatory reporting laws

RESEARCH FORUM ABSTRACTS

72 FunctionalLimitationsof EmergencyDepartment Codes

International

Classification of Diseases-Ninth Revision

Tintinalli Jt:, Waller A/Universi~ of North Carolina, Chapel Hill, NC The suitability of the International Classification of Diseases (ICD) as a claims database for emergency medicine has never been established. Study objectives: To determine the agreement between diagnoses entered on the emergency department record and the ICD code, and to determine the suitability of ICD codes for reimbursement decisions. Methods: Retrospective chart reviews were performed to assess: (1) agreement for diagnoses between the ED record (EDR), the ED practice database (EDPD); and the ED claims database (EDCD); (2) ability of ICD-9 code to determine medical necessity, for reimbursement rejections and for LMRPs. Codes were assigned by' certified nosologists, and ED diagnoses were recorded by the attending emergency physician. A single expert reviewed all records. Reimbursement rejections categorized as "not a medical emergency" by 2 managed care payers were reviewed Conditions were classified as "not meeting the prudent layperson standard (PLS)" if chart revievr indicated a minor disorder lasting 1 day or more with normal vital signs, or a minor injury, that did not require radiographs or suturing. A convenience sample of ED visits not in compliance with LMRPs was reviewed to determine the relationship between ICD code and medical necessity. Descriptive statistics and proportions of agreement were calculated as appropriate The studies were exempted from institutional review board review Results: Eighty-five randomly selected ED patient encounters from September 1996 were and the proportion of agreement between the numbers of diagnoses entered on the EDR, EDPD, and EDCD ',;'as 48% to 52%, and for any single diagnosis was 71')o to 81%. Two hundred ED visits were retrospectively reviewed for accounts still open in September 1998. Eighty-six percent of denials by payer No. 1, and 62% by' payer No. 2 were felt to meet the PLS. The ICD-9 diagnosis code was unable to identify' cases that met the PLS. Most denials were eventually paid based on chart review. To assess medical necessity' for ancilla W tests, 30 ED visits for 29 different patients were analyzed. In 7 0 % all ancillary tests were felt to be appropriate [n 63%, there ",','asno similarity between chief complaint, risks for morbidity, comorbtd diseases, and ICD code. Conclusion: There is insufficient agreement in both numbers and quality of diagnoses between the EDR, EDPD, and EDCD for the ICD code alone to sep,.e as an EDCD ICD codes alone cannot identify which ED visits meet the PLS. LMRPs that use ICD codes alone to determine medical necessity miselassified 70% of cases. For optimal reimbursement, emergency medicine should develop a system for diagnosis recording that incorporates chief complaint, risk factors, and comorbid diseases, as well as acute diagnoses.

273

EmergencyDepartmentStuffEstimatesof PatientSatisfaction: The Squeaky Wheel Gets the Grease

Boudreaux l:13,Ary R, Mandn/C/Louisiana State University, Baton Rouge, LA Stud)-" objective: Theories outlining determinants of patient satisfaction point out that the heaIth care providers' own beliefs and attitudes influence their behasaor toward the patient and, therefore, indirectly, influence patient satisfaction. Hence, emergency department staffs expectations regarding patient satisfaction may' actually" influence patient satisfaction through its effect on staff behavmr. For example, if a provider overestimates his or her patient's satisfaction, he or she may" miss important but subtle cues of dissatisfaction, causing him or her to miss an opportunity to rectify the situation before the patient leaves the ED. Our study, investigated the accuracy of ED staffs estimates of their patients' satisfaction with services. We hypothesized that ED staff would exhibit a self-serving bias (ie, they would estimate patient satisfaction as higher than it actually is). Methods: The study was conducted through a municipal ED with approximately' 89,000 visits per year. Actual patient satisfaction was assessed using a telephone interview with 22 indicators across several domains, including registration, nursing staff, physician staff, wait times, discharge instructions, and other miscellaneous areas Shortly after the assessment was complete, but before the results of the survey were disseminated, ED staff were asked to "predict" the results by' estimating the average rating they' believed patients gave for each of the 22 indicators. Staff members ','.'ere also asked to estimate the patients' average length of stay'. To further reduce bias, ED staff were not informed that the patient satisfaction sun'ey was being conducted. Independent samples t tests were used to compare averages for each item obtained through staff ratings versus averages derived from actual patient satisfaction. Results: Sup,'eys were solicited from 478 (42.1%) of 1,1,39 patients and 59 (77.6%) of 76 ED staff (nurses, residents, physicians). Statistically significant differences existed

OCTOBER 1999. PART 2 34:4 ANNALSOF EMERGENCYMEDICINE

between ED staffs estimates of patient satisfaction and actual patient satisfaction across 19 of the 22 indicators (P< 005l Across each of these 19 indicators, staff consistently" estimated average satisfaction scores to be lower than what patients actually, reported. Staff did not overestimate scores on any items The 19 items were spread across multiple domains Addinonally, staff overestimated average patient length of stay' by more than 2 hours (P<.001). Conclusion: In contrast to the hypothesized self-ser,,4ng bias, ED staff consistently estimated patients to be less satisfied than they' actually were. This trend held true across multiple domains, including satisfaction with registration, nursing and physician staff, and wait times. Moreover, ED staff estimated average length of stay to be more than 2 hours longer than it actually ,,,,'as (5 7 hours versus 3 5 hours) Such biases may" act as a self-fulfilling prophecy, negatively affecting both patient satisfaction and employee morale Future research should focus on assessing provider estimates of patient satisfaction in "real time" (versus asking for estimates of averages).

274 The Utility and Fatiiity of UB-9(2Data for Emergency Department Profiling Sacchetti A, Warden T. Moakes ME, Harris R/Our Lady of LourdesMedical Center, Camden, NJ; Sinai Hospital, Baltimore, MD: Coerdinated Hea~thServices, Horsham, PA Study" objective: The Universal Billing Code of 1992 (UB-92) is the hospital standard for itemized patient charges This study' examines use of UB-92 information for emergency" physician profiling and education. The study was conducted at a community hospital emergency" department Methods: Routine urine cultures LUCs) ',,.'ere considered unnecessary' in a low-risk (LR) ED population defined as discharged females 16 to 60 years of age undergoing unnalysis (UA) as part of ED treatment. UB-92 data from 3 consecutive months of ED visits were abstracted for patient age, primary' International Class{fication of Diseases-ninth revision (ICD-9) diagnosis, disposition, sex, emergency physician, and unna W studies. Statistical analysis was through Z 2. Results: Of a total of 7,780 ED patients. 1,850 underwent UA v.'ith 1.O92 (59%) undergoing UC. There were 328 LR patients, 163 (50%) of whom underwent both UA and LC compared with 929 (61%) of 1,522 non-LR patients (P< OO2). There was a significant difference in UC utihzation among the 6 full-time emergency" physicians with rates between 32% to 65% of LR patients (P=.O06) Recognized problems included failure of UB-92 to distinguish between registration attending and treating physician dunng limes of multiple physician presence and automatic entry' of a UC with every UA by certain unit clerks. Conclusion: The UB-92 has the potential to profile utilization of certain resources wnhin the ED and by individual emergency' physicians and to identify specific departmental pr~'ess problems

75 Colorado Physicians' Knowledge of and AttitudesToward Mandatory Reporting Laws Heury O. Utz A~,OeWitt C, FeIdhausK/Denver Health Medical Center, Denver, CO Study" objective: La,.vs that mandate police involvement in cases of domestic violence (DV)-related injuries have been cnlicized because of concerns that these laws violate patient confidemiality, increase the risk of violence for the xlctim, and deter vicums from seeking medical care In 1995. Colorado established a law mandating physician reporting of DV-related injuries The purpose of our study' was to measure physicians' understanding of this lay,, to identify" physicians" attitudes toward this law, and to determine any' differences between emergency physicians and primary care physicians (PCPs) in regard to the law. Methods: A confidential, anonymous sup,'ey sent to all members of the Colorado ACEP chapter and internal medicine, ohstetrics, and family practice physician members of the Colorado Medical Society" Results: Of 2,038 surveys mailed. 697 (34%) were returned: 72% of respondents ;','ere male (n=498/689). Emergency physicians comprised 25% (n= 169/670) of the respondents, 41% (n=276/670) were family practitioners, 14% (n=96/670) were obstetncians, and 19% (n= 1291670) were internists Eighty percent (n=541/674) practiced in an urban setting, and 38% (n=260/685) stated that they" had received some training regarding the DV reporting law. Ninety-two percent (n=630/684) correctly idenrifed the current definition of the reporting law. Fifty-seven percent (n=390/687) correctly answered a scenano invoh'mg an acute DV injury', and only 48% (n=334/696) correctly anssvered a question involving a patient wnh a history' of DV. Only 41% (n= 180/443'~ stated the)' always reported DV-related ir~junes to the police. Emergency physicians were significantly more likely to report DV to the police than PCPs (61.%

S71

RESEARCH FORUM A B S T R A C T S

versus 30%; P<.001). Emergency physicians were also more likely to feel that these laws would not increase the risk of retaliation (68% versus 55%; P=.006) and do not deter patients from seeking medical care (54% versus 49%; P=.003). Conclusion: Physicians tn Colorado do not completely understand the mandatory reporting laws, and a significant number may not comply with the law. Emergency physicians are more likely than PCPs to be aware of the mandatory reporting law, to comply with the law, and feel that the law is not detrimental to patient care.

276

Wide ,nterresident Procedure Variability Suggests Need for National Standards in Emergency Medicine Lotfipour S. Lewandowski C, Nguyen HB/Henry Ford Hospital, Detroit, MI

Study objective: To describe emergency medicine residents' experience with procedures and resuscitations in a large inner-city teaching hospital. Methods: Procedures and resuscitations were defined according to the Residency Review Committee (RRC-Emergency Medicine) guidelines. Residents were required to record their procedures directly onto a computerized data base while assigned to the emergency department. From November l, 1998, to April 30, 1999, all procedures and resuscitations performed in the ED were tabulated. Residents were unaware of this study. Fifteen common procedures are reported as follows: adult medical resuscitations (AMP,), adult trauma resuscitations (ATR), arterial line (At), central line (CL), cricothyrotomy (CT), intraosseons infusion (II), lumbar puncture (LP), nasotracheal intubation (NI), orotracheal intubation (el), pediatric resuscitations (PR), pericardiocemesis (PC), resuscitative thoracotomy (RT), saphenous cntdown (SC), thoracentesis (TC), and tube thoracostomy (TT). Results: Twenty-seven residents (PGY II, llI) were in the department during the included 6-month time period. The mean (• and range (listed in parentheses) for each procedure by the average resident is as follows: AMR 15.6• (1 to 40); ATR 8.2• (1 to 23); AL 10.4• (1 to 19); CL 10.8• (1 to 20); CT 0.0; II 1.4• (0 to 2); LP 3.6• (1 to 9), NI 0.2• (0 to 2); OI 12.6• (1 to 22); PR 1.7• (E to 4); PC 0.5• (0 to 1); RT 0.5• (0 to 1); SC 0.0; TC 0.5• (0 to 1); and TT 2.2• (0 to 6). Conclusion: There is great variability between residents as to their experience with procedures and resuscitations. The cause of this variability is undetermined, although underreporting, aggressiveness of the resident, shift distribution, pathology of patient population, or seasonal variations may play a part in this variability. Understanding the influences of these factors on resident education would aid in scheduling, evaluation, and feedback. The wide interresident variability found in our residents is consistent with previous reported series in the literature. This highlights the need For national standards for minimum competency with necessary lifesaving procedures in the ED.

277

A National Survey of the Aeromedical Transport of High-Risk Obstetrics Patients Jones AE, Galli RL. DeschampC. Summers RL, Carlton F/CarolinasMedical Center, Charlotte, NC; University of Mississippi Medical Center. Jackson, MS

Study objective: Aeromedical transport of high-risk obstetric (HROB) patients can be accomplished with minimal risk of in-flight delivery and can be advantageous for neonatal survival. A survey of helicopter aeromedical programs belonging to the Association of Air Medical Services was conducted to determine the frequency and current US practices in the transport of HROB patients. Methods: Each program was contacted by telephone, and aeromedical personnel were asked to provide answers to a survey consisting of 12 questions based on personal experience and statistics compiled by their programs. The results are reported as percent of total respondents. Results: Of the 203 programs surveyed, 133 (66%) of which operated a total of 145 helicopters, provided responses. The mean annual number of HROB transports was 50.7 accounting for 4.8% of the mean 1,049 total annual transports. Although 72% of the responding programs used the standard flight crew during the HROB transport, only 47% required crew members to maintain neonatal resuscitation certification. Only 52% of the aircraft allow pelvic access in the normal patient configuration. Although only 21% have specific HROB launch protocols, 52% reported having obstetricians involved in dispatching flights and 86% carry tocofytic agents in their standard drug kit. The greatest concerns over HROB transport included in-flight delivery (60%), inadequate fetal monitoring (6%), and lack of experience (5~163 Conclusion: Although HROB transports account for nearly 5% of aeromedical flights, many programs appear to be poorly prepared to handle these patients.

S72

78

An Evaluation of a Multisite First Responder Automated External Defibrillation Program Lerner EB, Biliittier AJ IV, Newman MM. GrehWJ/State University of New York, Buffalo, NY; Indiana University School of Medicine. Indianapolis. IN Study objective: To describe demographic and treatment factor differences for cardiac arrest survivors and nonsurvivors treated by a muhisite philanthropic-sponsored first-responder (FR) automated external defibrillation (AED) program. Methods: FR fire and police agencies from 10 participating sites provided information For out-of-hospital cardiac arrest patients including age, gender, unwitnessed/witnessed arrest, time to defibriflation, number of shocks, time to emergency department arrival, and survival to hospital discharge. This information was compared for survivors and nonsurvivors. Results: Data were reported for 887 patients; average age was 63 years, 5 8 0 were male, 36% were witnessed arrests, 6.2 minutes was the average time to defibrillation, 29.6 minutes was the average time to ED arrival, and 4% survived to hospital discharge. Average age was 59 years for survivors and 64 years for nonsurvivors. Sixtyeight percent of survivors and 57% of nonsurvivors were male. Arrests were witnessed for 87% of survivors and 32% of nonsurvivors. The average time to defibrillation was 4.9 minutes for survivors and 5.1 minutes for nonsurvivors. Sixty-eight percent of survivors and 36% of nonsurvivors had defibrillation by FRs. The average time to ED arrival was 30.2 minutes For survivors and 2 9 7 minutes For nonsurvivors. One hundred nine patients had a known discharge status and had received shocks by FRs. Of this subgroup, 12% survived to hospital discharge. Average age was 59.7 years for survivors and 64.1 years for nonsurvivors. Sixty-nine percent of survivors and 69% of nonsurvivors were male. Arrests were witnessed for 83% of survivors and 57% of nonsurvivors. The average time to defibrillation was 4.8 minutes for survivors and 5.0 minutes for nonsnrvivors. The average time to ED arrival was 32.9 minutes for survivors and 30.5 minutes for nonsurvivors. Conclusion: As expected, younger age, witnessed arrest status, and defibrillation by FRs appeared to be associated with a greater chance of survival to hospital discharge. Interestingly, the average time to defibrillation was similar for survivors and nonsurvivors.

279 " Evaluation of Paramedics' Ability to Recognize Chest Pain of Cardiac Origin Sandy CC. Lucas RH/BeorgeWashington University School of Medicine. Washington. DC Study objective: To determine whether paramedics can identify chest pain of cardiac origin and correctly apply a protocol for prehospital administration of nitroglycerin. Methods: All patients arriving to George Washington University Medical Center Emergency Department by ambulance with a chief complaint of chest pain during an 11 -month period were eligible for the study. The ED record and the emergency medical services (EMS) run sheet were reviewed. For each patient, it was determined whether nitroglycerin was given by the paramedic, and whether they had an ED diagnosis consistent with coronary ischemia (acute myocardial infarction [AMI], unstable angina, role out MI, admitted for chest pain, and so on). Patients were excluded if they did not meet the criteria to receive nitroglycerin according to protocol (hypotension, no current chest pain, traumatic causes) or had incomplete medical records. Based on the ED diagnosis of coronary ischemia as a tree positive, the sensitivity and specificity of the paramedic's decision to administer nitroglycerin will be calculated Results: A total of 240 patients complaining of chest pain were transported to the site ED during the study period. One hundred fifteen patients met the criteria for inclusion and comprised the study group. Forty-eight (42%) of the patients were given an ED diagnosis consistent with acute coronary ischemia. Of these, only 27 (56%) received prehospital nitroglycerin. Sixty-seven (58%) patients were given diagnoses of something other than an acute coronary ischemic event. Of these, only 6 (9%) received nitroglycerin. Using Z2 analysis, the administration of nitroglycerin indicating acute coronary ischemia is statistically significant (Za 27.294, df 1, P<.000). Sensitivity is 56.3% (95% confidence interval [CI] 45.9 to 63 2), specificity is 90.8% (95% CI 83.1 to 95.9), posttive predictive value is 81.8% (95% Ci 66.8 to 91.9), and negative predictive value is 73.8% (95% CI 67.7 to 77.9) Conclusion: Paramedics in the EMS system tend to reliably determine chest pain is of noncardiac etiology and do not indiscriminately administer nitroglycerin However, they tend to underreeogntze chest pain of cardiac origin, thus not treating patients who may benefit from the acute administration of nitroglycerin. Further study is needed to determine whether this is because of atypical presentations of cardiac ischemia or other causes.

ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2