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Hospital emergency department surveillance system
ORDINALCONTRIBUTION
Hospital Emergency Department Surveillance System: A Data Base for Patient Care, Management, Research and Teaching Anne L. Kaszuba, BA Geoffrey Gibson, PhD Baltimore, Maryland
The J o h n s H o p k i n s H e a l t h S e r v i c e s R e s e a r c h a n d D e v e l o p m e n t C e n t e r and E m e r g e n c y D e p a r t m e n t h a v e d e v e l o p e d a p r o c e s s i n g and f e e d b a c k m e c h a n i s m to p r o v i d e a d a t a b a s e for m a n a g e m e n t p l a n n i n g , a l l o c a t i n g available r e s o u r c e s , r e s e a r c h s t r a t e g i e s to e v a l u a t e the q u a l i t y of c a r e and t e a c h i n g p r o g r a m s to t r a i n p h y s i c i a n s in e m e r g e n c y m e d i c i n e . A 10~ s a m p l e o f all e m e r g e n c y d e p a r t m e n t v i s i t s is r a n d o m l y s e l e c t e d each day, a n d d a t a c o l l e c t e d o n p a t i e n t age, sex, r a c e , m a r i t a l s t a t u s , mode o f arrival, m e t h o d of p a y m e n t , c e n s u s t r a c t o f r e s i d e n c e , c o m plaint, d i a g n o s i s , d i s p o s i t i o n , d a t e o f visit, a n d t i m e s o f e n t r y a n d departure. In a d d i t i o n , p r o c e s s d a t a o n n u r s i n g c a r e a r e c o l l e c t e d . A s u b sample is s e l e c t e d for t e l e p h o n e o r h o u s e h o l d f o l l o w - u p a i m e d at gathering o u t c o m e d a t a as p a r t o f t h e s u r v e i l l a n c e s t u d y . T u r n a r o u n d time f r o m the s u b j e c t ' s e m e r g e n c y d e p a r t m e n t v i s i t to p r o v i d e r ' s feedback is o n e m o n t h . Thus, an o n g o i n g , c u r r e n t d e s c r i p t i o n of u s a g e is available. R e t r i e v a l of d a t a for l o n g e r t i m e p e r i o d s p r o v i d e s v a l u a b l e information o n daily, m o n t h l y a n d s e a s o n a l u s a g e p a t t e r n s .
Kaszuba AL, Gibson G: Hospital emergency department surveillance system. JACEP 6:304-307, July, 1977. hosp/taf emergency department, data system, INTRODUCTION Because of the i n c r e a s e d and changing use of e m e r g e n c y departments, s u r v e i l l a n c e s y s t e m s a r e needed to monitor the d e m o g r a p h ic
Presented at the fourth annual ACEP/ EDNA Scientific Assembly in New Orleans, October 1976. Supported by a grant "Emergency Medical Services Research Program Projects" I'IS01907 (Geoffl'ey Gibson, PhD - - principal investigator) from the National Center for Health Services Research, DePartment of Health, Education, and Wel-
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6:7 (Jul)1977
characteristics of patients as well as t h e process and o u t c o m e of e m e r gency h e a l t h care. The data provided can be used to plan resource allocation, to describe
fare, to the Health Services Research and Development Center and the Division of Emergency Medicine, Johns Hopkins University and Medical Institutions. Address for repriat~: Anne L. Kaszuba, Health Services R'~'earch and Development Center, The Johns Hopkins Medical Institutions, 624 N. Broadway, Baltimore, Maryland 21205.
utilization, and to e v a l u a t e the impact of e m e r g e n c y services, The data systems can describe bow c h a n g i n g usage p a t t e r n s are associated w i t h d i f f er en t c a t c h m e n t areas, and the p a t i e n t s ' d i f f e r e n t c o n d i t i o n s and medical coverage, A s u r v e i l l a n c e s y s t e m is i n v a l u able for p r o v i d i n g e m e r g e n c y dep a r t m e n t p er so n n el i n f o r m a t i o n on p a t i e n t c o m p l i a n c e a nd o u t c o m e . Good i n p u t and process of care do not assure good outcome; input and process m e a s u r e s of performance do not assure accurate e v a l u a t i o n of services. Thus, the emergency d e p a r t m e n t faculty needs a system to survey pat i e n t outcome, to m o n i t o r the perf o r m a n c e of r e s i d e n t s , to c o n d u c t medical audits of the quality of care, and to m e e t legal responsibilities. Increasing external pressure to m o n i t o r utilization and to audit the q u a l i t y of c a r e - - P r o f e s s i o n a l Standards Review Organizations (PRSOs/ and, spemfically for emerg e n c y d e p a r t m e n t s , the g u i d e l i n e s for s t a n d a r d medical r e c o r d k e e p i n g and e v a l u a t i o n as set forth in the E m e r g e n c y M e d i c a l S e r v i c e s Syst e m s Act of 19731 - - u n d e r l i n e the value of a surveillance system. One-shot studies to e v a l u a t e emergency d e p a r t m e n t care h a v e limita-
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DATA
ITEMS
COLLECTED
Phase I a
1. Patient Characteristics* Identity Address Telephone Financial coverage Race Sex Date of birth Marital Status 2. Visit Characteristics Date and time* Mode of arrival* Patient complaintlDiagnostic and therapeutic procedures* Diagnosist DispositionlCharges* Identity of providerl-
P h a s e II b
Whether nursing process standards were met by chart documentation of each of the following: 1. Triage note 2. Vital signs a. Temperature b. Pulse c. Respiration d. Blood presure 3. Exit interview a. F o l l o w - u p care instructions b. Patient signature c. Exiting nurse signatu re
*collected on all emergency department visits 1-collected on the sample of visits
P h a s e III c Patient interviews
Onset of health problem Frequency of health problem Reason f o r u s i n g an erner. gency department Attempt to obtain care at other sites -When -Where -Result Intention to obtain additional care -Where -When Self-care/medications Satisfaction w i t h emergency department .visit -Personnel -Length of visit Problems status measure Limitation of regular activities
Fig. l a, b, c. Data items collected. tions. Retrospective conditionspecific studies can only evaluate the care given a p a r t i c u l a r group of patients at specific times. In contrast, a c o n t i n u i n g s u r v e i l l a n c e study can e v a l u a t e total system performance, a n d i d e n t i f y p r o b l e m s w h e n they occar. In collaboration with the Health Services Research and Development Center, The J o h n s Hopkins Emergency D e p a r t m e n t has developed a c o n t i n u i n g prospective data collection and feedback m e c h a n i s m to improve p a t i e n t m a n a g e m e n t , t e a c h i n g and service. This paper outlines the methodology of the Hospital E m e r g e n c y D e p a r t m e n t Surveillance System.
METHODS
In p l a n n i n g an emergency departm e n t surveillance system, the methodologica] issues to be addressed include data sources, items to collect, collection methods, and definition and s e l e c t i o n of the s t u d y sample. Individual hospital and emergency dep a r t m e n t resources a n d objectives will influence these choices. The choice of data sources is based upon the types of data required for study objectives, and the availability and r e l i a b i l i t y of e x i s t i n g sources. 36/305
Although the emergency d e p a r t m e n t e n c o u n t e r form is a relatively reliable and complete source of demographic and process data, it lacks information on p a t i e n t o u t c o m e . F r e q u e n t l y , p a t i e n t charts are incomplete, difficult to procure, and even when cornplete and easily accessible, only p r o v i d e i n f o r m a t i o n g e n e r a t e d by hospital encounters. Many emergency d e p a r t m e n t patients are noncompliers a n d use m u l t i p l e sources of care. In contrast, the p a t i e n t himself, while n e i t h e r the most economical nor most easily accessible data source, is u s u a l l y the only complete source of o u t c o m e data. For the purpose of t e a c h i n g and q u a l i t y assurance activities, the p a t i e n t interview should be given serious consideration to supplemerit the emergency d e p a r t m e n t enc o u n t e r form or s t a n d a r d i z e d d a t a collection systems, such as t h a t of the C o m m i s s i o n on P r o f e s s i o n a l a n d Hospital Activities (Ann Arbor, Michigan,, which contain only encounter form data. Secondly, the costs and benefits attached to each particular item to be c o l l e c t e d m u s t be w e i g h e d . Prer e c o r d e d d a t a , s u c h as m a r i t a l status, for example, is relatively easy to capture, b u t is also limited in its application. P a t i e n t c o m p l a i n t and diagnosis, on the other hand, are key
in s u r v e i l l a n c e , b u t are not easily coded in t e r m s of p e r s o n n e l level, time and reliability. The cost/benefit t r a d e - o f f is also a n issue. Since a s u r v e i l l a n c e study sample is representative of a n entire emergency dep a r t m e n t population, i t will comprise a complex mix of medical problems. Clearly, no condition-specific measure of outcome is applicable to all subjects. A n y m e a s u r e such as life a n d d e a t h c a n be e a s i l y obtained through periodic death certificate reviews, b u t has l i t t l e v a l u e in the d a i l y e v a l u a t i o n of e m e r g e n c y dep a r t m e n t care. W h i l e conditior~specific m e a s u r e s provide a precise description of p a t i e n t outcome, they are costly both methodologically ar/~l operationally. The t h i r d methodologic issue involves the selection of data collectiofl methods. With regard to prerecorded data, such as t h a t in the emergency d e p a r t m e n t e n c o u n t e r form, th~ choice is between prospective daily data collection and retrospectiv~ weekly or m o n t h l y record review; While the former is more costly in terms of manpower, it allows quicker d a t a p r o c e s s i n g a n d feedback, and facilitates the selection of subjects for follow-up interview. The collection Of i n t e r v i e w data 6:7 (Jul) 1977 J ~ P
f
Interview Questions 1) How strong is the pain or discomfort caused b y your c o n d i t i o n ? Do you have a. no discomfort or pain b. a little d i s c o m f o r t or pain c. moderate d i s c o m f o r t or pain d. a great deal of discomfort or pain 2) How much of the time do you have d i s c o m f o r t or pain caused by your condition? Do you have it a. none of the time b. some of the time c. about half of the time d. most of the time e. all of the time 3) How concerned or worried are you about your condition? Do you have a. no concern or worry b. a l i t t l e c o n c e r n or worry c. moderate concern or worry d. a great deal of concern or worry
Fig, 2. Interview questions to measure changes in patients' conditions. carries w i t h it a n o t h e r set of method0logic questions. One m u s t first determine t h e m o s t a p p r o p r i a t e t y p e of follow-up: t e l e p h o n e or h o u s e hold interview, or m a i l questionnaire. Interviews by t e l e p h o n e a r e m o r e e c o n o m i c a l t h a n those c o n d u c t e d in the h o u s e h o l d , a n d can be constructed to i n c l u d e r e l i a b i l i t y a n d validity t e s t s . H o w e v e r , t e l e p h o n e interviews are not a p p r o p r i a t e as a sole d a t a collection method w h e n a significant n u m b e r of p a t i e n t s lack telephone service. In this case, o u r experience h a s shown t h a t the telephone i n t e r v i e w serves w e l i as t h e first m e t h o d of f o l l o w - u p , w i t h hack-up by e i t h e r h o u s e h o l d i n t e r view or m a i l questionnaire. Yet, although the m a i l q u e s t i o n n a i r e is inexpensive a n d t i m e s a v i n g , it is of questionable value, p a r t i c u l a r l y w i t h highly t r a n s i e n t p o p u l a t i o n s , a n d those w i t h g e n e r a l l y low r e a d i n g levels. The final issue to be addressed is the d e f i n i t i o n and s e l e c t i o n of t h e J:~P
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Administrative Statistical Report 1. Frequency distributions of patient and visit characteristics 2. Characteristics of specific patient groups a. By method of payment b. Walk-outs c. Frequent users d. Ambulance patients e. Specialty service (ie, alcoholism, counseling, social work counseling, psychiatric counseling)
Teaching Statistical Report 1. 2. 3. 4.
Relation of final diagnosis to initial complaint Relation of procedures performed to provider Relation of disposition to provider Relation of diagnostic and therapeutic procedures and disposition to patient outcome 5. Condition-specific performance in meeting physician process standards of c a r e 6. Condition-specific performance in meeting nursing process standards of care
Research Statistical Report 1. 2. 3. 4. 5. 6.
General: Frequency d i s t r i b u t i o n s - - patient and visit characteristics Distribution of population by census tract Distribution of complaints by census tract Relation of final diagnosis to complaint Relation of procedures performed to complaint Relation of diagnosis to outcome
Fig. 3. Administrative, teaching and research statistical reports generated from Surveillance System.
s t u d y sample. Since t h e e m e r g e n c y d e p a r t m e n t p o p u l a t i o n can be defined e i t h e r in t e r m s of visits of patients, one m u s t d e t e r m i n e which is m o r e in k e e p i n g w i t h s t u d y objecrives. If the p r i m a r y study i n t e r e s t is g e n e r a l u t i l i z a t i o n trends, c a t c h m e n t , a r e a a n d f r e q u e n c y d i s t r i b u t i o n of c o n d i t i o n s , a s a m p l i n g of v i s i t s is preferred. If, however, the objective is to develop p a t i e n t profiles to describe t h e b e h a v i o r of emergency dep a r t m e n t u s e r s , a s a m p l i n g of pat i e n t s is the a p p r o p r i a t e choice. Simple random and systematic random sampling are preferred methods of s a m p l e selection. The size of t h e s a m p l e d e p e n d s on t h e resources a v a i l a b l e for d a t a collection and processing, and upon the precision and confidence with which one w i s h e s to e s t i m a t e population parameters.
Study Design Since July, 1975, the Johns Hopk i n s H e a l t h S e r v e s Research and D e v e l o p m e n t C e n t e r and E m e r g e n c y D e p a r t m e n t h a v e worked t o g e t h e r to develop and i m p l e m e n t s t r a t e g i e s to
d e s c r i b e a n d e v a l u a t e the care offered to e m e r g e n c y d e p a r t m e n t patients. In response to the need to develop an ongoing system to describe p a t i e n t p o p u l a t i o n p a r a m e t e r s , to compare p a t t e r n s of utilization over time, a n d to provide information reg a r d i n g compliance with medical and n u r s i n g s t a n d a r d s for t h e p r o c e s s and outcome of care, they developed the Hospital E m e r g e n c y D e p a r t m e n t S u r v e i l l a n c e Study. The s u r v e i l l a n c e study population consists of a s y s t e m a t i c 10~ s a m p l e of all e m e r g e n c y d e p a r t m e n t visits. T h i s s a m p l i n g f r a m e is u n c o m p l i cated, can be r o u t i n e l y applied and assures a sample distribution by shift s i m i l a r to t h a t of the e m e r g e n c y d e p a r t m e n t population. The s a m p l e size of 10~ assures that, for periods of two weeks or more, reliable popul a t i o n e s t i m a t e s can be made for all v a r i a b l e s of interest, including those appearing in proportions less than 1~. D a t a collection is accomplished in t h r e e p h a s e s . F i r s t , c o d e d dem o g r a p h i c and process d a t a e n t e r the hospital's outpatient billing depart-
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m e n t information system via the acc o u n t i n g copy of the encounter form, In addition to the data routinely capt u r e d on all p a t i e n t s ( F i g u r e la), data on p a t i e n t complaint and diagnosis and on provider identification are e n t e r e d for the s t u d y sample. C o m p l a i n t is coded by a modified version of the N a t i o n a l Ambulatory Medical Care Survey Symptom C l a s s i f i c a t i o n Code. '~ This c o d i n g scheme is easy to use, and an accurate reflection of the patient's comp l a i n t as stated in his own words. Hospital a d a p t a t i o n of H-1CDA ~ is used to code diagnosis. The second phase of data collection consists of a b s t r a c t i n g and coding n u r s i n g process data. These d a t a items (Figure ]b/ are entered on a separate abstract form, and are subsequently i n t e g r a t e d with the phase one data by the subject's identification n u m b e r . Phase three data items (Figure lcl are those collected through subject interview. Ten percent of the study s a m p l e is s e l e c t e d for t e l e p h o n e follow-up two weeks after the emergency d e p a r t m e n t visit. This time period was s e l e c t e d b e c a u s e most acute health problems will have resolved by then, yet still be fresh in the patient's mind. Subjects not accessible by telephone are followed-up through household interview. DISCUSSION The Health Services Research and D e v e l o p m e n t C e n t e r developed the Problem S t a t u s Measure (PSMI s to m e a s u r e health outcome. The PSM has been validated on studies based on the C o l u m b i a Medical P l a n , a prepaid group practice. The PSM is a p p r o p r i a t e for a v a r i e t y of conditions, and measures health status in four dhnensions: frequency o{' syrup-
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toms, i n t e n s i t y of symptoms, degree of activity limitation, and a m o u n t of anxiety caused by the condition. The simplicity of this measure makes it e s p e c i a l l y a t t r a c t i v e for t e l e p h o n e i n t e r v i e w i n g of e m e r g e n c y d e p a r t m e n t patients (Figure 2). By applying these four indicators to the time of" the subjects' visit to the emergency department, the time of the i n t e r v i e w , and the time bet w e e n these two points, change in health status can be measured. The a c t i v i t i e s t h u s far described require a four-week turnaround time, and c u l m i n a t e in the generation of m o n t h l y s t a t i s t i c a l reports a i m e d at p r o v i d i n g e m e r g e n c y dep a r t m e n t personnel with a current, reliable source of data appropriate for m e e t i n g the objectives outlined. Specifically, three types of statistical reports are to be generated: administrative, teaching, and research (Fig-
nre 3 ~.
ulty can identify, scrutinize and re, spend to problems in the appropriat~ way: t r e a t m e n t protocol, in-servit~ workshoPS, or change in staffing. The third type or statistical report provides research staff with a data base for p l a n n i n g clinical and servi~ i n t e r v e n t i o n s relevant to emergene~ d e p a r t m e n t problems. By describing the e m e r g e n c y d e p a r t m e n t popula, tion, the Sur~veillance Study serv~ as an i n v a l u a b l e source of denornina. tor data, e s s e n t i a l to methedologi~ d e v e l o p m e n t . C o n t i n u i n g surveiL lance of the population helps evalua. tion of the impact of research strafe. gies not only o n , s t u d y patients, but also on the emergency department as a whole. In s u m m a r y , this Hospital Erner. g e n c y D e p a r t m e n t Surveillance S t u d y will s e r v e as the basis for m a n y a d m i n i s t r a t i v e , faculty and re. search decisions at the Johns Hop. kins E m e r g e n c y Department. In this capacity, it will e n a b l e the erner. gency d e p a r t m e n t personnel not only to p r e d i c t p a t i e n t d e m a n d , but to prepare to meet t h a t demand, and to measure performance.
By p r o v i d i n g frequency d i s t r i b u tions of each of the variables, the a d m i n i s t r a t i v e r e p o r t g i v e s the e m e r g e n c y d e p a r t m e n t personnel a reliable data base to make management decisions regarding staffing patterns, cost justification, and resource allocation. These reports will n o t o n l y aid in p l a n n i n g , b u t in e v a l u a t i n g the impact of a d m i n i s t r a tive interventions.
l. Emergency Medical Services 5'ystems: Program .Guidelines, Health Services Administration, Public Health Administration, US Department of Health, Education, and Welfare, 1973.
The teaching report helps medical and n u r s i n g faculty to monitor the performance of staff with regard to process a n d o u t c o m e m e a s u r e s of care. The S u r v e i l l a n c e System has been designed with flexibility: if facu l t y n o t e s s e r i o u s d e f i c i e n c i e s in care with regard to a specific condition, or set of conditions, oversamp l i n g of t h e s e c a n be e a s i l y i n t e grated with the regular sampling. Fac-
2. 'National Ambulatory Medical Care Survey: Symptom Classification. Series 2, No 63. Department of Health, Education, and Welfare. Publication No. (HRA) 751337. December, 1974. 3. Hospital Adaptation of ICDA, ed 2. Commission on Professional and Hospital Activities, Ann Arbor, Michigan, September, 1973. 4. Mushlin, A: An Experimental Mechanism for Quality Assurance in a Prepaid Group Practice. Proceedings of the Group Health Institute, June, 1974.
REFERENCES
6:7 (Jul)1977 J ~ P
Hospital Emergency Department Surveillance System: A Data Base for Patient Care, Management, Research and Teaching Anne L. Kaszuba, BA Geoffrey Gibson, PhD Baltimore, Maryland
The J o h n s H o p k i n s H e a l t h S e r v i c e s R e s e a r c h a n d D e v e l o p m e n t C e n t e r and E m e r g e n c y D e p a r t m e n t h a v e d e v e l o p e d a p r o c e s s i n g and f e e d b a c k m e c h a n i s m to p r o v i d e a d a t a b a s e for m a n a g e m e n t p l a n n i n g , a l l o c a t i n g available r e s o u r c e s , r e s e a r c h s t r a t e g i e s to e v a l u a t e the q u a l i t y of c a r e and t e a c h i n g p r o g r a m s to t r a i n p h y s i c i a n s in e m e r g e n c y m e d i c i n e . A 10~ s a m p l e o f all e m e r g e n c y d e p a r t m e n t v i s i t s is r a n d o m l y s e l e c t e d each day, a n d d a t a c o l l e c t e d o n p a t i e n t age, sex, r a c e , m a r i t a l s t a t u s , mode o f arrival, m e t h o d of p a y m e n t , c e n s u s t r a c t o f r e s i d e n c e , c o m plaint, d i a g n o s i s , d i s p o s i t i o n , d a t e o f visit, a n d t i m e s o f e n t r y a n d departure. In a d d i t i o n , p r o c e s s d a t a o n n u r s i n g c a r e a r e c o l l e c t e d . A s u b sample is s e l e c t e d for t e l e p h o n e o r h o u s e h o l d f o l l o w - u p a i m e d at gathering o u t c o m e d a t a as p a r t o f t h e s u r v e i l l a n c e s t u d y . T u r n a r o u n d time f r o m the s u b j e c t ' s e m e r g e n c y d e p a r t m e n t v i s i t to p r o v i d e r ' s feedback is o n e m o n t h . Thus, an o n g o i n g , c u r r e n t d e s c r i p t i o n of u s a g e is available. R e t r i e v a l of d a t a for l o n g e r t i m e p e r i o d s p r o v i d e s v a l u a b l e information o n daily, m o n t h l y a n d s e a s o n a l u s a g e p a t t e r n s .
Kaszuba AL, Gibson G: Hospital emergency department surveillance system. JACEP 6:304-307, July, 1977. hosp/taf emergency department, data system, INTRODUCTION Because of the i n c r e a s e d and changing use of e m e r g e n c y departments, s u r v e i l l a n c e s y s t e m s a r e needed to monitor the d e m o g r a p h ic
Presented at the fourth annual ACEP/ EDNA Scientific Assembly in New Orleans, October 1976. Supported by a grant "Emergency Medical Services Research Program Projects" I'IS01907 (Geoffl'ey Gibson, PhD - - principal investigator) from the National Center for Health Services Research, DePartment of Health, Education, and Wel-
J~P
6:7 (Jul)1977
characteristics of patients as well as t h e process and o u t c o m e of e m e r gency h e a l t h care. The data provided can be used to plan resource allocation, to describe
fare, to the Health Services Research and Development Center and the Division of Emergency Medicine, Johns Hopkins University and Medical Institutions. Address for repriat~: Anne L. Kaszuba, Health Services R'~'earch and Development Center, The Johns Hopkins Medical Institutions, 624 N. Broadway, Baltimore, Maryland 21205.
utilization, and to e v a l u a t e the impact of e m e r g e n c y services, The data systems can describe bow c h a n g i n g usage p a t t e r n s are associated w i t h d i f f er en t c a t c h m e n t areas, and the p a t i e n t s ' d i f f e r e n t c o n d i t i o n s and medical coverage, A s u r v e i l l a n c e s y s t e m is i n v a l u able for p r o v i d i n g e m e r g e n c y dep a r t m e n t p er so n n el i n f o r m a t i o n on p a t i e n t c o m p l i a n c e a nd o u t c o m e . Good i n p u t and process of care do not assure good outcome; input and process m e a s u r e s of performance do not assure accurate e v a l u a t i o n of services. Thus, the emergency d e p a r t m e n t faculty needs a system to survey pat i e n t outcome, to m o n i t o r the perf o r m a n c e of r e s i d e n t s , to c o n d u c t medical audits of the quality of care, and to m e e t legal responsibilities. Increasing external pressure to m o n i t o r utilization and to audit the q u a l i t y of c a r e - - P r o f e s s i o n a l Standards Review Organizations (PRSOs/ and, spemfically for emerg e n c y d e p a r t m e n t s , the g u i d e l i n e s for s t a n d a r d medical r e c o r d k e e p i n g and e v a l u a t i o n as set forth in the E m e r g e n c y M e d i c a l S e r v i c e s Syst e m s Act of 19731 - - u n d e r l i n e the value of a surveillance system. One-shot studies to e v a l u a t e emergency d e p a r t m e n t care h a v e limita-
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DATA
ITEMS
COLLECTED
Phase I a
1. Patient Characteristics* Identity Address Telephone Financial coverage Race Sex Date of birth Marital Status 2. Visit Characteristics Date and time* Mode of arrival* Patient complaintlDiagnostic and therapeutic procedures* Diagnosist DispositionlCharges* Identity of providerl-
P h a s e II b
Whether nursing process standards were met by chart documentation of each of the following: 1. Triage note 2. Vital signs a. Temperature b. Pulse c. Respiration d. Blood presure 3. Exit interview a. F o l l o w - u p care instructions b. Patient signature c. Exiting nurse signatu re
*collected on all emergency department visits 1-collected on the sample of visits
P h a s e III c Patient interviews
Onset of health problem Frequency of health problem Reason f o r u s i n g an erner. gency department Attempt to obtain care at other sites -When -Where -Result Intention to obtain additional care -Where -When Self-care/medications Satisfaction w i t h emergency department .visit -Personnel -Length of visit Problems status measure Limitation of regular activities
Fig. l a, b, c. Data items collected. tions. Retrospective conditionspecific studies can only evaluate the care given a p a r t i c u l a r group of patients at specific times. In contrast, a c o n t i n u i n g s u r v e i l l a n c e study can e v a l u a t e total system performance, a n d i d e n t i f y p r o b l e m s w h e n they occar. In collaboration with the Health Services Research and Development Center, The J o h n s Hopkins Emergency D e p a r t m e n t has developed a c o n t i n u i n g prospective data collection and feedback m e c h a n i s m to improve p a t i e n t m a n a g e m e n t , t e a c h i n g and service. This paper outlines the methodology of the Hospital E m e r g e n c y D e p a r t m e n t Surveillance System.
METHODS
In p l a n n i n g an emergency departm e n t surveillance system, the methodologica] issues to be addressed include data sources, items to collect, collection methods, and definition and s e l e c t i o n of the s t u d y sample. Individual hospital and emergency dep a r t m e n t resources a n d objectives will influence these choices. The choice of data sources is based upon the types of data required for study objectives, and the availability and r e l i a b i l i t y of e x i s t i n g sources. 36/305
Although the emergency d e p a r t m e n t e n c o u n t e r form is a relatively reliable and complete source of demographic and process data, it lacks information on p a t i e n t o u t c o m e . F r e q u e n t l y , p a t i e n t charts are incomplete, difficult to procure, and even when cornplete and easily accessible, only p r o v i d e i n f o r m a t i o n g e n e r a t e d by hospital encounters. Many emergency d e p a r t m e n t patients are noncompliers a n d use m u l t i p l e sources of care. In contrast, the p a t i e n t himself, while n e i t h e r the most economical nor most easily accessible data source, is u s u a l l y the only complete source of o u t c o m e data. For the purpose of t e a c h i n g and q u a l i t y assurance activities, the p a t i e n t interview should be given serious consideration to supplemerit the emergency d e p a r t m e n t enc o u n t e r form or s t a n d a r d i z e d d a t a collection systems, such as t h a t of the C o m m i s s i o n on P r o f e s s i o n a l a n d Hospital Activities (Ann Arbor, Michigan,, which contain only encounter form data. Secondly, the costs and benefits attached to each particular item to be c o l l e c t e d m u s t be w e i g h e d . Prer e c o r d e d d a t a , s u c h as m a r i t a l status, for example, is relatively easy to capture, b u t is also limited in its application. P a t i e n t c o m p l a i n t and diagnosis, on the other hand, are key
in s u r v e i l l a n c e , b u t are not easily coded in t e r m s of p e r s o n n e l level, time and reliability. The cost/benefit t r a d e - o f f is also a n issue. Since a s u r v e i l l a n c e study sample is representative of a n entire emergency dep a r t m e n t population, i t will comprise a complex mix of medical problems. Clearly, no condition-specific measure of outcome is applicable to all subjects. A n y m e a s u r e such as life a n d d e a t h c a n be e a s i l y obtained through periodic death certificate reviews, b u t has l i t t l e v a l u e in the d a i l y e v a l u a t i o n of e m e r g e n c y dep a r t m e n t care. W h i l e conditior~specific m e a s u r e s provide a precise description of p a t i e n t outcome, they are costly both methodologically ar/~l operationally. The t h i r d methodologic issue involves the selection of data collectiofl methods. With regard to prerecorded data, such as t h a t in the emergency d e p a r t m e n t e n c o u n t e r form, th~ choice is between prospective daily data collection and retrospectiv~ weekly or m o n t h l y record review; While the former is more costly in terms of manpower, it allows quicker d a t a p r o c e s s i n g a n d feedback, and facilitates the selection of subjects for follow-up interview. The collection Of i n t e r v i e w data 6:7 (Jul) 1977 J ~ P
f
Interview Questions 1) How strong is the pain or discomfort caused b y your c o n d i t i o n ? Do you have a. no discomfort or pain b. a little d i s c o m f o r t or pain c. moderate d i s c o m f o r t or pain d. a great deal of discomfort or pain 2) How much of the time do you have d i s c o m f o r t or pain caused by your condition? Do you have it a. none of the time b. some of the time c. about half of the time d. most of the time e. all of the time 3) How concerned or worried are you about your condition? Do you have a. no concern or worry b. a l i t t l e c o n c e r n or worry c. moderate concern or worry d. a great deal of concern or worry
Fig, 2. Interview questions to measure changes in patients' conditions. carries w i t h it a n o t h e r set of method0logic questions. One m u s t first determine t h e m o s t a p p r o p r i a t e t y p e of follow-up: t e l e p h o n e or h o u s e hold interview, or m a i l questionnaire. Interviews by t e l e p h o n e a r e m o r e e c o n o m i c a l t h a n those c o n d u c t e d in the h o u s e h o l d , a n d can be constructed to i n c l u d e r e l i a b i l i t y a n d validity t e s t s . H o w e v e r , t e l e p h o n e interviews are not a p p r o p r i a t e as a sole d a t a collection method w h e n a significant n u m b e r of p a t i e n t s lack telephone service. In this case, o u r experience h a s shown t h a t the telephone i n t e r v i e w serves w e l i as t h e first m e t h o d of f o l l o w - u p , w i t h hack-up by e i t h e r h o u s e h o l d i n t e r view or m a i l questionnaire. Yet, although the m a i l q u e s t i o n n a i r e is inexpensive a n d t i m e s a v i n g , it is of questionable value, p a r t i c u l a r l y w i t h highly t r a n s i e n t p o p u l a t i o n s , a n d those w i t h g e n e r a l l y low r e a d i n g levels. The final issue to be addressed is the d e f i n i t i o n and s e l e c t i o n of t h e J:~P
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Administrative Statistical Report 1. Frequency distributions of patient and visit characteristics 2. Characteristics of specific patient groups a. By method of payment b. Walk-outs c. Frequent users d. Ambulance patients e. Specialty service (ie, alcoholism, counseling, social work counseling, psychiatric counseling)
Teaching Statistical Report 1. 2. 3. 4.
Relation of final diagnosis to initial complaint Relation of procedures performed to provider Relation of disposition to provider Relation of diagnostic and therapeutic procedures and disposition to patient outcome 5. Condition-specific performance in meeting physician process standards of c a r e 6. Condition-specific performance in meeting nursing process standards of care
Research Statistical Report 1. 2. 3. 4. 5. 6.
General: Frequency d i s t r i b u t i o n s - - patient and visit characteristics Distribution of population by census tract Distribution of complaints by census tract Relation of final diagnosis to complaint Relation of procedures performed to complaint Relation of diagnosis to outcome
Fig. 3. Administrative, teaching and research statistical reports generated from Surveillance System.
s t u d y sample. Since t h e e m e r g e n c y d e p a r t m e n t p o p u l a t i o n can be defined e i t h e r in t e r m s of visits of patients, one m u s t d e t e r m i n e which is m o r e in k e e p i n g w i t h s t u d y objecrives. If the p r i m a r y study i n t e r e s t is g e n e r a l u t i l i z a t i o n trends, c a t c h m e n t , a r e a a n d f r e q u e n c y d i s t r i b u t i o n of c o n d i t i o n s , a s a m p l i n g of v i s i t s is preferred. If, however, the objective is to develop p a t i e n t profiles to describe t h e b e h a v i o r of emergency dep a r t m e n t u s e r s , a s a m p l i n g of pat i e n t s is the a p p r o p r i a t e choice. Simple random and systematic random sampling are preferred methods of s a m p l e selection. The size of t h e s a m p l e d e p e n d s on t h e resources a v a i l a b l e for d a t a collection and processing, and upon the precision and confidence with which one w i s h e s to e s t i m a t e population parameters.
Study Design Since July, 1975, the Johns Hopk i n s H e a l t h S e r v e s Research and D e v e l o p m e n t C e n t e r and E m e r g e n c y D e p a r t m e n t h a v e worked t o g e t h e r to develop and i m p l e m e n t s t r a t e g i e s to
d e s c r i b e a n d e v a l u a t e the care offered to e m e r g e n c y d e p a r t m e n t patients. In response to the need to develop an ongoing system to describe p a t i e n t p o p u l a t i o n p a r a m e t e r s , to compare p a t t e r n s of utilization over time, a n d to provide information reg a r d i n g compliance with medical and n u r s i n g s t a n d a r d s for t h e p r o c e s s and outcome of care, they developed the Hospital E m e r g e n c y D e p a r t m e n t S u r v e i l l a n c e Study. The s u r v e i l l a n c e study population consists of a s y s t e m a t i c 10~ s a m p l e of all e m e r g e n c y d e p a r t m e n t visits. T h i s s a m p l i n g f r a m e is u n c o m p l i cated, can be r o u t i n e l y applied and assures a sample distribution by shift s i m i l a r to t h a t of the e m e r g e n c y d e p a r t m e n t population. The s a m p l e size of 10~ assures that, for periods of two weeks or more, reliable popul a t i o n e s t i m a t e s can be made for all v a r i a b l e s of interest, including those appearing in proportions less than 1~. D a t a collection is accomplished in t h r e e p h a s e s . F i r s t , c o d e d dem o g r a p h i c and process d a t a e n t e r the hospital's outpatient billing depart-
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m e n t information system via the acc o u n t i n g copy of the encounter form, In addition to the data routinely capt u r e d on all p a t i e n t s ( F i g u r e la), data on p a t i e n t complaint and diagnosis and on provider identification are e n t e r e d for the s t u d y sample. C o m p l a i n t is coded by a modified version of the N a t i o n a l Ambulatory Medical Care Survey Symptom C l a s s i f i c a t i o n Code. '~ This c o d i n g scheme is easy to use, and an accurate reflection of the patient's comp l a i n t as stated in his own words. Hospital a d a p t a t i o n of H-1CDA ~ is used to code diagnosis. The second phase of data collection consists of a b s t r a c t i n g and coding n u r s i n g process data. These d a t a items (Figure ]b/ are entered on a separate abstract form, and are subsequently i n t e g r a t e d with the phase one data by the subject's identification n u m b e r . Phase three data items (Figure lcl are those collected through subject interview. Ten percent of the study s a m p l e is s e l e c t e d for t e l e p h o n e follow-up two weeks after the emergency d e p a r t m e n t visit. This time period was s e l e c t e d b e c a u s e most acute health problems will have resolved by then, yet still be fresh in the patient's mind. Subjects not accessible by telephone are followed-up through household interview. DISCUSSION The Health Services Research and D e v e l o p m e n t C e n t e r developed the Problem S t a t u s Measure (PSMI s to m e a s u r e health outcome. The PSM has been validated on studies based on the C o l u m b i a Medical P l a n , a prepaid group practice. The PSM is a p p r o p r i a t e for a v a r i e t y of conditions, and measures health status in four dhnensions: frequency o{' syrup-
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toms, i n t e n s i t y of symptoms, degree of activity limitation, and a m o u n t of anxiety caused by the condition. The simplicity of this measure makes it e s p e c i a l l y a t t r a c t i v e for t e l e p h o n e i n t e r v i e w i n g of e m e r g e n c y d e p a r t m e n t patients (Figure 2). By applying these four indicators to the time of" the subjects' visit to the emergency department, the time of the i n t e r v i e w , and the time bet w e e n these two points, change in health status can be measured. The a c t i v i t i e s t h u s far described require a four-week turnaround time, and c u l m i n a t e in the generation of m o n t h l y s t a t i s t i c a l reports a i m e d at p r o v i d i n g e m e r g e n c y dep a r t m e n t personnel with a current, reliable source of data appropriate for m e e t i n g the objectives outlined. Specifically, three types of statistical reports are to be generated: administrative, teaching, and research (Fig-
nre 3 ~.
ulty can identify, scrutinize and re, spend to problems in the appropriat~ way: t r e a t m e n t protocol, in-servit~ workshoPS, or change in staffing. The third type or statistical report provides research staff with a data base for p l a n n i n g clinical and servi~ i n t e r v e n t i o n s relevant to emergene~ d e p a r t m e n t problems. By describing the e m e r g e n c y d e p a r t m e n t popula, tion, the Sur~veillance Study serv~ as an i n v a l u a b l e source of denornina. tor data, e s s e n t i a l to methedologi~ d e v e l o p m e n t . C o n t i n u i n g surveiL lance of the population helps evalua. tion of the impact of research strafe. gies not only o n , s t u d y patients, but also on the emergency department as a whole. In s u m m a r y , this Hospital Erner. g e n c y D e p a r t m e n t Surveillance S t u d y will s e r v e as the basis for m a n y a d m i n i s t r a t i v e , faculty and re. search decisions at the Johns Hop. kins E m e r g e n c y Department. In this capacity, it will e n a b l e the erner. gency d e p a r t m e n t personnel not only to p r e d i c t p a t i e n t d e m a n d , but to prepare to meet t h a t demand, and to measure performance.
By p r o v i d i n g frequency d i s t r i b u tions of each of the variables, the a d m i n i s t r a t i v e r e p o r t g i v e s the e m e r g e n c y d e p a r t m e n t personnel a reliable data base to make management decisions regarding staffing patterns, cost justification, and resource allocation. These reports will n o t o n l y aid in p l a n n i n g , b u t in e v a l u a t i n g the impact of a d m i n i s t r a tive interventions.
l. Emergency Medical Services 5'ystems: Program .Guidelines, Health Services Administration, Public Health Administration, US Department of Health, Education, and Welfare, 1973.
The teaching report helps medical and n u r s i n g faculty to monitor the performance of staff with regard to process a n d o u t c o m e m e a s u r e s of care. The S u r v e i l l a n c e System has been designed with flexibility: if facu l t y n o t e s s e r i o u s d e f i c i e n c i e s in care with regard to a specific condition, or set of conditions, oversamp l i n g of t h e s e c a n be e a s i l y i n t e grated with the regular sampling. Fac-
2. 'National Ambulatory Medical Care Survey: Symptom Classification. Series 2, No 63. Department of Health, Education, and Welfare. Publication No. (HRA) 751337. December, 1974. 3. Hospital Adaptation of ICDA, ed 2. Commission on Professional and Hospital Activities, Ann Arbor, Michigan, September, 1973. 4. Mushlin, A: An Experimental Mechanism for Quality Assurance in a Prepaid Group Practice. Proceedings of the Group Health Institute, June, 1974.
REFERENCES
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