- Email: [email protected]
Implementing a Trigger Tool Adverse Event Analysis in an Emergency Out-of-Hospital Setting
Research Forum Abstracts Results: During the study period 46,533 patients were treated in the ED, and 9,493 were admitted to inpatient status. Twenty-six RRT24ED events occurred amongst these admitted patients representing 0.27% of admissions (95%CI 0.18%, 0.40%). Most of these activations were for neurological changes (11) and respiratory status changes (10). ED contributory factors were identified in 2 cases, and both of these were individual rather than system factors. These factors included (i) not measuring arterial/venous/end-tidal CO2 in a ventilatory failure patient, and (ii) not transfusing a patient with GI bleeding. In two cases there was long-term morbidity or mortality related to the RRT event; in neither of these cases were ED factors judged to have contributed. Just one of these cases was independently referred to the ED. Conclusions: The RRT24ED process supplemented ad hoc referrals for peer review of cases, highlighting cases which would never have received attention within the EM department otherwise. This novel and unique case review process revealed opportunities for education and performance improvement. Systematic approaches to case detection may be useful adjuncts to traditional case referrals for review.
Reason for Activation
Cases
Health Care Provider Concerned Respiratory Status Heart Rate Blood Pressure Neurological Changes Chest Pain Acute change in pain, fluid status, skin color Uncontrolled bleeding Early warning score
2 10 1 2 11 0 0
ED factors contributing to RRT
Cases
ED ED ED No
system factors people factors system and people factors ED system or people factors
228
229 Independently Referred 0 1 0 0
Significant M&M 0 0 0 2
Mind the (Knowledge) Gap: The Effect of a Communication Tool on Emergency Department Patients’ Comprehension of and Satisfaction With Care
Sharp BR, Singal B, Fowler J, Paz-Arabo P, Fowkes H, Carter T, Dilts-Skaggs M-K, Simmons S/University of Wisconsin, Madison, WI; St. Joseph Mercy Hospital, Ann Arbor, MI; St. Mary Mercy Hospital, Livonia, MI; Southern Ohio Medical Center, Portsmouth, OH
Study Objectives: Patient-physician communication in the emergency department (ED) has been demonstrated as inadequate in multiple prior studies with various strategies proposed to improve knowledge transfer in the ED. We developed a communication tool through focus groups and a subsequent pilot study to be utilized by patients and care providers to facilitate communication during a visit in the ED. Our hypothesis was that this structured communication guide, when used in the ED, would increase patient comprehension of and satisfaction with care. Methods: This multi-site trial was conducted at four different emergency departments in Michigan and Ohio. Utilizing a quasi-experimental, before and after study design to avoid learning bias by the providers, 317 patients were surveyed on comprehension of and satisfaction with care, followed by 326 patients who also received the communication instrument, titled “MyInformER.” This included areas for physicians, nurses, techs, patients and their families to write ED plan details such as wait time, labs, studies, PO status, patient questions or notes. Comprehension of ED care was assessed by two blinded nurse chart reviews compared to patient reported answers and scored as concordant, partially concordant, or discordant. Satisfaction with communication was measured via the Communication Assessment Tool-Team (CAT-T) instrument, which is a validated instrument to assess patient satisfaction
S84 Annals of Emergency Medicine
Implementing a Trigger Tool Adverse Event Analysis in an Emergency Out-of-Hospital Setting
Payet I, Bounes V, Wolfe R, Ducassé J-L/Hôpitaux de Toulouse, Toulouse, France, Beth Israel Deaconess Medical Center, Boston, MA
0 0
0 2 0 24
with communication. Linear mixed models were used to limit other differences between the groups to offset the before and after design. Results: Patients were found to have frequent knowledge deficits about discharge instructions including diagnosis (48%), follow-up instructions (49%) and reasons to return (62%), but also about the nature of care received while in the emergency department including whether medication was administered (12.4%), or imaging (18.5%) and laboratory tests (7.3%) were performed. Elderly patients (age 65-84) and extremely elderly patients (age>84) in both control and intervention groups were found to have 1.1 (p<0.01) and 1.7 (p<0.01) more knowledge gaps respectively than patients aged 25-44. In the multivariable hierarchical models the intervention had no effect on the total number of discordances, or the total number of discordances plus partial concordances, p¼0.36 and 0.15, respectively. The mean number of discordances was 4.6 (95% CI: 4.1-5.1) for the control group and 4.4 (95% CI: 3.9-4.9) for the intervention group. The mean number of discordances plus partial concordances was 5.3 (95% CI: 4.8-5.8) for the control group and 5.0 (95% CI: 4.5-5.5) for the intervention group. There was no difference in total CAT-T scores between groups, p¼0.34 and no statistical difference for a score based on questions specifically addressing communication, p¼0.43. Conclusions: Patients frequently misunderstand medical care in the ED and their post-care instructions. Comprehension does seem to decrease with increasing age, as elderly patients show significantly higher knowledge gaps. A standardized communication instrument, guiding the patient and provider to discuss the medical care, does not improve patient satisfaction with communication or patient understanding of the care received. Other strategies to improve communication and close this knowledge gap must be explored.
Study Objective: To evaluate the implementation of a quality evaluation program based on the trigger tool analysis method in a medicalized out-of-hospital setting. Methods: Type of study: Quality improvement study based on retrospective analysis of triggered medical records. Setting: The dispatching center of the Midi-Pyrénées out-of-hospital emergency service (SAMU 31) processes more than 400,000 calls a year for over 225,000 medical records and covers a large area in south of France (1,200,000 inhabitants). Based on validated guidelines and physician perception, the response to a call can be a medical advice, a visit from a family physician, a non medicalized ambulance or a medicalized one. One of the investigators undergone a fellowship in a US hospital using the qualitative emergency department trigger tool analysis to learn the method and adapt it to a medicalized out-of-hospital setting. We studied the first 9 months of the implementation, from 2012, July, to 2013, April. Type of participants: We defined 6 triggers to analyze (death of any patient, delay for departure of medical team (>5min), delay for arrival on scene (>30min), first team non-medicalized with secondary medical reinforcement, long length of stay on scene (>45min), patient reoriented to another hospital during the first 48 hours after admission). Analysis: The data triggered were automatically extracted from medical records, analyzed by two investigators, and classified within 4 categories (adequate care, near-miss, non-preventable and preventable care-related adverse events). For each trigger, positive predictive value of preventable adverse event was calculated. Gravity of each adverse event was assessed using the Agency for Healthcare Research and Quality (AHRQ) severity scale. Results: Total, 174 536 patients were dispatched within the 9 months studied, of which 4404 (2.5%) were triggered. 73 (0.04%) presented a preventable adverse event (41 records were triggered by a medical reinforcement and 19 by a reorientation of patient trigger), 16 records (0.01%) corresponded to a near miss and 30 (0.02%) to a non-preventable adverse event. Positive predictive value was 11.8 % for the trigger delay for departure, 6 % for reorientation of patients, 6% for medical reinforcement, 3.4% for long length of stay on scene, 2.9% for delay for departure and 1.1% for death of patient. Concerning severity, 11 adverse events were classified as serious, eg, 6 on the AHRQ severity scale (7 were related to a trigger medical reinforcement and 4 to death of patient). Most of preventable adverse events (21) were classified 3 on the AHRQ severity scale and were related in 15 case to a trigger medical reinforcement, in 5 case to reorientation of patients and in one case to delay for arrival.
Volume 62, no. 4s : October 2013
Research Forum Abstracts Conclusions: Implementing trigger tool qualitative analysis is feasible and efficient in out-of-hospital emergency medicine. Preventable adverse events are rare, representing 0.04% records. Implementing more rigorous policies, guidelines and caregivers formation will lead to more improvement.
230
Characteristics of Patients Leaving an Emergency Department Against Medical Advice: Analysis of a National Database
Peterson T, Donnelly JP, Lo A/University of Alabama at Birmingham, Birmingham, AL
Study Objective: To describe clinical and sociodemographic characteristics of patients who left an emergency department (ED) against medical advice (AMA) and compare these characteristics with those of patients who did not leave AMA (NonAMA) and of patients who left without being seen (LWBS), using a nationally representative sample. Methods: This was a retrospective cross-sectional analysis using the National Hospital Ambulatory Care Survey (NHAMCS) from 2001-2010. Multivariate and bivariate analysis was performed to separately compare the AMA patient group to the LWBS group and the Non-AMA groups. Results: From 2001 through 2010 there were approximately 1.2 million adult (18 years and older) ED visits per year in the U.S. that involved patients leaving AMA, comprising 1% of all adult ED visits. Compared with patients who did not leave AMA, AMA patients were more likely to be male (50% vs. 45.8% p <0.0001), black/African American (26.7% vs. 22.7 % p 0.0006), reported to have self-pay coverage (26.2% vs. 16% p <0.0001), and to have visited the ED for a complaint of chest pain (13.6% vs. 6.7% p <0.0001). The AMA group was less likely to have an injury-related complaint (27.4% vs. 35.3% p <0. 0001). There was not a statistical difference in the distribution of triage acuity between the 2 groups (p ¼ 0.1586). Compared with the LWBS group, AMA patients were more likely male (50% vs. 45.6% p 0.0007), to have a higher triage acuity (2 h 10.5% vs. 21.8% p 0.0001), and to have visited the ED with chest pain as a chief complaint (13.6% vs. 4.6% p <0.0001). However, the AMA patients were less likely black/African American (26.7% vs. 32.9% p 0.0003), self-pay (26.2% vs. 28.7% p <0.0001), less likely to have an injury related complaint (27.4% vs. 21.7% p<0.0001), and had shorter wait times (57.9 min vs. 74 min p ¼ 0.02) than the LWBS patients. Conclusions: Patients who left AMA were overall more likely to be male, visit the ED for a complaint of chest pain and less likely to have an injury-related reason for visit. They were also notably distinct from LWBS patients in terms of additional clinical and sociodemographic characteristics. Appreciation of these distinctions is important for analysis and potential interventions to reduce AMA rates in target patient populations. More research is needed to determine whether targeted interventions would lead to an expected reduction in ED visit recidivism and improved health care outcomes.
231
Is There a Correlation Between Emergency Department Crowding Measures and Acute Myocardial Infarction Mortality?
Khare R, Powell E, Kang R, Courtney DM, McHugh M, Samuel P, Dresden S, Adams J, Lee T/Northwestern University, Chicago, IL
Background: The National Quality Forum has endorsed crowding measures which include emergency department (ED) length of stay (LOS) and rates of left without being seen (LWBS). Little is known about the association these performance measures have with patient outcomes for time-sensitive diseases such as acute myocardial infarction (AMI). Study Objectives: To evaluate the association of both ED LOS for admitted patients and rate of LWBS with the outcome of 30-day mortality rate of AMI while controlling for other differences that may influence patient outcomes. Methods: Using merged 2008 data from Centers for Medicare & Medicaid Services and University HealthSystem Consortium (UHC) we examined Medicare patients ages 65 and older with a principal diagnosis of AMI from 23 hospitals across the US. We limited the cohort to patients admitted to UHC facilities. The facilities were categorized into quartiles for each of the two quality measures. Using a multivariate logistic regression model to account for clustering, we examined the association of the 2 quality measures as predictor variables for the outcome of 30-day mortality after adjustment for comorbidities, age, sex, and race. Results: A total of 3825 patients with an average age of 77.0 (SD 7.9) and 53.5% male were included in the analysis. The average ED LOS of admitted patients across
Volume 62, no. 4s : October 2013
the four quartiles was 5.40, 6.95, 8.41, and 12.22 hours, while the proportion of LWBS was 1.44%, 2.94%, 5.07% and 9.81%. The crude 30-day AMI mortality rate for each quartile for ED LOS of admitted patients was 10.7% for the 1st (shortest ED LOS) quartile, 10.1% for the 2nd quartile, 9.2% for the 3rd quartile, and 12.3% for the fourth (longest ED LOS) quartile. When comparing the 3rd quartile to the 4th (longest ED LOS) for admitted patients quartile, the risk-adjusted OR of 30-day mortality was 0.74 (95% CI ¼ 0.57 to 0.95 When comparing the 1st quartile (the lowest LWBS rate) to the 2nd quartile, the risk-adjusted OR of 30-day mortality was 0.77 (95% CI ¼ 0.60 to 0.99). None of the other quartile comparisons for mean ED LOS, nor any of the LWBS quartiles were significantly different. Conclusions: There was a 26% lower odds of 30-day AMI death among patients admitted to hospitals in the 3rd quartile of ED LOS for admitted patients measure compared to hospitals who were in the 4th or longest quartile. There was a 23% lower odds or 30-day AMI death among patients admitted to hospitals in the quartile with the lowest LWBS rate when compared to the 2nd quartile. This study shows that future policies should not incentivize hospitals who have the quickest ED stays for admitted patients, but should further evaluate why hospitals in the 3rd quartile have a significantly lower AMI mortality than those in the 4th quartile. LWBS rates are important; however, further evaluations must be done to determine the correlation between LWBS and AMI 30-day mortality rates.
232
A Comparison of Confirmed Intrauterine Pregnancy by Ultrasound In Patients With Vaginal Bleeding in Early Pregnancy With HCG levels Above and Below 2000
Smith T, Stoltzfus J, Eberhardt M/St Lukes University Health Network, Bethlehem, PA; St. Luke’s University Health Network, Bethlehem, PA
Study Objective: To determine how many patients who present to an emergency department (ED) for vaginal bleeding in early pregnancy have ultrasounds (US) that are diagnostic for intrauterine pregnancy (IUP). A secondary objective was to compare the number of US positive for IUP with HCG levels of 2000 and below verses HCG levels greater than 2000. Methods: This is a retrospective chart review conducted at an academic community ED with an annual volume of 68,000. Charts of patients with a final diagnosis of hemorrhage before the completion of 22 weeks pregnancy (ICD - 9 codes: 640.03, 640.83, 640.93) were reviewed. Ultrasound results were recorded as diagnostic of IUP when fetal heart rate was present or fetal pole was seen. All indeterminate studies were included as negative IUP. HCG results taken on the same day as the US was performed were included. Results: One hundred thirteen charts were reviewed. One hundred eleven had US results available and 112 had HCG levels. Eighty-three patients had an US confirmed IUP and 28 did not. There were 44 patients with an HCG level of less than 2000 and 68 patients with HCG above 2000. Twenty-six of 44 of those with HCG under 2000 had IUP on US while 16/44 did not. This is compared to 58/68 with HCG greater than 2000 with an IUP on US and only 10/68 in this group did not. There is a statistically significant association between threatened abortion status and IUP (p < .0001), with more threatened abortion patients experiencing IUP (79.4%). When comparing HCG levels, there is a statistically significant association between HCG status (< 2000)and IUP status(p¼.002) with HCG greater than 2000 resulting in more cases of IUP (85.3%) compared to HCG less than 2000(59.1%). Conclusions: Patients presenting to the ED for vaginal bleeding in early pregnancy are more likely to have an US diagnostic for IUP than not. In this study, HCG levels of less than 2000 still resulted in IUP on US 59% of the time but this is less than in patients with higher HCG levels.
233
Overuse of Laboratory Testing in Symptomatic First Trimester Pregnant Patients in the Emergency Department
Geyer BC, Stone MB, Adduci AJ, Sodickson AD, Raja AS/Brigham and Women’s Hospital, Boston, MA
Study Objectives: Emergency physicians often evaluate first trimester pregnant patients with abdominal pain and/or vaginal bleeding, with the primary goal of confirming intrauterine pregnancy (IUP). Fortunately, in patients who are not at increased risk for heterotopic pregnancy, the visualization of an IUP essentially excludes the diagnosis of ectopic pregnancy. While the initial evaluation of these patients has historically included a quantitative serum human chorionic gonadotropin (quant-
Annals of Emergency Medicine S85
Reason for Activation
Cases
Health Care Provider Concerned Respiratory Status Heart Rate Blood Pressure Neurological Changes Chest Pain Acute change in pain, fluid status, skin color Uncontrolled bleeding Early warning score
2 10 1 2 11 0 0
ED factors contributing to RRT
Cases
ED ED ED No
system factors people factors system and people factors ED system or people factors
228
229 Independently Referred 0 1 0 0
Significant M&M 0 0 0 2
Mind the (Knowledge) Gap: The Effect of a Communication Tool on Emergency Department Patients’ Comprehension of and Satisfaction With Care
Sharp BR, Singal B, Fowler J, Paz-Arabo P, Fowkes H, Carter T, Dilts-Skaggs M-K, Simmons S/University of Wisconsin, Madison, WI; St. Joseph Mercy Hospital, Ann Arbor, MI; St. Mary Mercy Hospital, Livonia, MI; Southern Ohio Medical Center, Portsmouth, OH
Study Objectives: Patient-physician communication in the emergency department (ED) has been demonstrated as inadequate in multiple prior studies with various strategies proposed to improve knowledge transfer in the ED. We developed a communication tool through focus groups and a subsequent pilot study to be utilized by patients and care providers to facilitate communication during a visit in the ED. Our hypothesis was that this structured communication guide, when used in the ED, would increase patient comprehension of and satisfaction with care. Methods: This multi-site trial was conducted at four different emergency departments in Michigan and Ohio. Utilizing a quasi-experimental, before and after study design to avoid learning bias by the providers, 317 patients were surveyed on comprehension of and satisfaction with care, followed by 326 patients who also received the communication instrument, titled “MyInformER.” This included areas for physicians, nurses, techs, patients and their families to write ED plan details such as wait time, labs, studies, PO status, patient questions or notes. Comprehension of ED care was assessed by two blinded nurse chart reviews compared to patient reported answers and scored as concordant, partially concordant, or discordant. Satisfaction with communication was measured via the Communication Assessment Tool-Team (CAT-T) instrument, which is a validated instrument to assess patient satisfaction
S84 Annals of Emergency Medicine
Implementing a Trigger Tool Adverse Event Analysis in an Emergency Out-of-Hospital Setting
Payet I, Bounes V, Wolfe R, Ducassé J-L/Hôpitaux de Toulouse, Toulouse, France, Beth Israel Deaconess Medical Center, Boston, MA
0 0
0 2 0 24
with communication. Linear mixed models were used to limit other differences between the groups to offset the before and after design. Results: Patients were found to have frequent knowledge deficits about discharge instructions including diagnosis (48%), follow-up instructions (49%) and reasons to return (62%), but also about the nature of care received while in the emergency department including whether medication was administered (12.4%), or imaging (18.5%) and laboratory tests (7.3%) were performed. Elderly patients (age 65-84) and extremely elderly patients (age>84) in both control and intervention groups were found to have 1.1 (p<0.01) and 1.7 (p<0.01) more knowledge gaps respectively than patients aged 25-44. In the multivariable hierarchical models the intervention had no effect on the total number of discordances, or the total number of discordances plus partial concordances, p¼0.36 and 0.15, respectively. The mean number of discordances was 4.6 (95% CI: 4.1-5.1) for the control group and 4.4 (95% CI: 3.9-4.9) for the intervention group. The mean number of discordances plus partial concordances was 5.3 (95% CI: 4.8-5.8) for the control group and 5.0 (95% CI: 4.5-5.5) for the intervention group. There was no difference in total CAT-T scores between groups, p¼0.34 and no statistical difference for a score based on questions specifically addressing communication, p¼0.43. Conclusions: Patients frequently misunderstand medical care in the ED and their post-care instructions. Comprehension does seem to decrease with increasing age, as elderly patients show significantly higher knowledge gaps. A standardized communication instrument, guiding the patient and provider to discuss the medical care, does not improve patient satisfaction with communication or patient understanding of the care received. Other strategies to improve communication and close this knowledge gap must be explored.
Study Objective: To evaluate the implementation of a quality evaluation program based on the trigger tool analysis method in a medicalized out-of-hospital setting. Methods: Type of study: Quality improvement study based on retrospective analysis of triggered medical records. Setting: The dispatching center of the Midi-Pyrénées out-of-hospital emergency service (SAMU 31) processes more than 400,000 calls a year for over 225,000 medical records and covers a large area in south of France (1,200,000 inhabitants). Based on validated guidelines and physician perception, the response to a call can be a medical advice, a visit from a family physician, a non medicalized ambulance or a medicalized one. One of the investigators undergone a fellowship in a US hospital using the qualitative emergency department trigger tool analysis to learn the method and adapt it to a medicalized out-of-hospital setting. We studied the first 9 months of the implementation, from 2012, July, to 2013, April. Type of participants: We defined 6 triggers to analyze (death of any patient, delay for departure of medical team (>5min), delay for arrival on scene (>30min), first team non-medicalized with secondary medical reinforcement, long length of stay on scene (>45min), patient reoriented to another hospital during the first 48 hours after admission). Analysis: The data triggered were automatically extracted from medical records, analyzed by two investigators, and classified within 4 categories (adequate care, near-miss, non-preventable and preventable care-related adverse events). For each trigger, positive predictive value of preventable adverse event was calculated. Gravity of each adverse event was assessed using the Agency for Healthcare Research and Quality (AHRQ) severity scale. Results: Total, 174 536 patients were dispatched within the 9 months studied, of which 4404 (2.5%) were triggered. 73 (0.04%) presented a preventable adverse event (41 records were triggered by a medical reinforcement and 19 by a reorientation of patient trigger), 16 records (0.01%) corresponded to a near miss and 30 (0.02%) to a non-preventable adverse event. Positive predictive value was 11.8 % for the trigger delay for departure, 6 % for reorientation of patients, 6% for medical reinforcement, 3.4% for long length of stay on scene, 2.9% for delay for departure and 1.1% for death of patient. Concerning severity, 11 adverse events were classified as serious, eg, 6 on the AHRQ severity scale (7 were related to a trigger medical reinforcement and 4 to death of patient). Most of preventable adverse events (21) were classified 3 on the AHRQ severity scale and were related in 15 case to a trigger medical reinforcement, in 5 case to reorientation of patients and in one case to delay for arrival.
Volume 62, no. 4s : October 2013
Research Forum Abstracts Conclusions: Implementing trigger tool qualitative analysis is feasible and efficient in out-of-hospital emergency medicine. Preventable adverse events are rare, representing 0.04% records. Implementing more rigorous policies, guidelines and caregivers formation will lead to more improvement.
230
Characteristics of Patients Leaving an Emergency Department Against Medical Advice: Analysis of a National Database
Peterson T, Donnelly JP, Lo A/University of Alabama at Birmingham, Birmingham, AL
Study Objective: To describe clinical and sociodemographic characteristics of patients who left an emergency department (ED) against medical advice (AMA) and compare these characteristics with those of patients who did not leave AMA (NonAMA) and of patients who left without being seen (LWBS), using a nationally representative sample. Methods: This was a retrospective cross-sectional analysis using the National Hospital Ambulatory Care Survey (NHAMCS) from 2001-2010. Multivariate and bivariate analysis was performed to separately compare the AMA patient group to the LWBS group and the Non-AMA groups. Results: From 2001 through 2010 there were approximately 1.2 million adult (18 years and older) ED visits per year in the U.S. that involved patients leaving AMA, comprising 1% of all adult ED visits. Compared with patients who did not leave AMA, AMA patients were more likely to be male (50% vs. 45.8% p <0.0001), black/African American (26.7% vs. 22.7 % p 0.0006), reported to have self-pay coverage (26.2% vs. 16% p <0.0001), and to have visited the ED for a complaint of chest pain (13.6% vs. 6.7% p <0.0001). The AMA group was less likely to have an injury-related complaint (27.4% vs. 35.3% p <0. 0001). There was not a statistical difference in the distribution of triage acuity between the 2 groups (p ¼ 0.1586). Compared with the LWBS group, AMA patients were more likely male (50% vs. 45.6% p 0.0007), to have a higher triage acuity (2 h 10.5% vs. 21.8% p 0.0001), and to have visited the ED with chest pain as a chief complaint (13.6% vs. 4.6% p <0.0001). However, the AMA patients were less likely black/African American (26.7% vs. 32.9% p 0.0003), self-pay (26.2% vs. 28.7% p <0.0001), less likely to have an injury related complaint (27.4% vs. 21.7% p<0.0001), and had shorter wait times (57.9 min vs. 74 min p ¼ 0.02) than the LWBS patients. Conclusions: Patients who left AMA were overall more likely to be male, visit the ED for a complaint of chest pain and less likely to have an injury-related reason for visit. They were also notably distinct from LWBS patients in terms of additional clinical and sociodemographic characteristics. Appreciation of these distinctions is important for analysis and potential interventions to reduce AMA rates in target patient populations. More research is needed to determine whether targeted interventions would lead to an expected reduction in ED visit recidivism and improved health care outcomes.
231
Is There a Correlation Between Emergency Department Crowding Measures and Acute Myocardial Infarction Mortality?
Khare R, Powell E, Kang R, Courtney DM, McHugh M, Samuel P, Dresden S, Adams J, Lee T/Northwestern University, Chicago, IL
Background: The National Quality Forum has endorsed crowding measures which include emergency department (ED) length of stay (LOS) and rates of left without being seen (LWBS). Little is known about the association these performance measures have with patient outcomes for time-sensitive diseases such as acute myocardial infarction (AMI). Study Objectives: To evaluate the association of both ED LOS for admitted patients and rate of LWBS with the outcome of 30-day mortality rate of AMI while controlling for other differences that may influence patient outcomes. Methods: Using merged 2008 data from Centers for Medicare & Medicaid Services and University HealthSystem Consortium (UHC) we examined Medicare patients ages 65 and older with a principal diagnosis of AMI from 23 hospitals across the US. We limited the cohort to patients admitted to UHC facilities. The facilities were categorized into quartiles for each of the two quality measures. Using a multivariate logistic regression model to account for clustering, we examined the association of the 2 quality measures as predictor variables for the outcome of 30-day mortality after adjustment for comorbidities, age, sex, and race. Results: A total of 3825 patients with an average age of 77.0 (SD 7.9) and 53.5% male were included in the analysis. The average ED LOS of admitted patients across
Volume 62, no. 4s : October 2013
the four quartiles was 5.40, 6.95, 8.41, and 12.22 hours, while the proportion of LWBS was 1.44%, 2.94%, 5.07% and 9.81%. The crude 30-day AMI mortality rate for each quartile for ED LOS of admitted patients was 10.7% for the 1st (shortest ED LOS) quartile, 10.1% for the 2nd quartile, 9.2% for the 3rd quartile, and 12.3% for the fourth (longest ED LOS) quartile. When comparing the 3rd quartile to the 4th (longest ED LOS) for admitted patients quartile, the risk-adjusted OR of 30-day mortality was 0.74 (95% CI ¼ 0.57 to 0.95 When comparing the 1st quartile (the lowest LWBS rate) to the 2nd quartile, the risk-adjusted OR of 30-day mortality was 0.77 (95% CI ¼ 0.60 to 0.99). None of the other quartile comparisons for mean ED LOS, nor any of the LWBS quartiles were significantly different. Conclusions: There was a 26% lower odds of 30-day AMI death among patients admitted to hospitals in the 3rd quartile of ED LOS for admitted patients measure compared to hospitals who were in the 4th or longest quartile. There was a 23% lower odds or 30-day AMI death among patients admitted to hospitals in the quartile with the lowest LWBS rate when compared to the 2nd quartile. This study shows that future policies should not incentivize hospitals who have the quickest ED stays for admitted patients, but should further evaluate why hospitals in the 3rd quartile have a significantly lower AMI mortality than those in the 4th quartile. LWBS rates are important; however, further evaluations must be done to determine the correlation between LWBS and AMI 30-day mortality rates.
232
A Comparison of Confirmed Intrauterine Pregnancy by Ultrasound In Patients With Vaginal Bleeding in Early Pregnancy With HCG levels Above and Below 2000
Smith T, Stoltzfus J, Eberhardt M/St Lukes University Health Network, Bethlehem, PA; St. Luke’s University Health Network, Bethlehem, PA
Study Objective: To determine how many patients who present to an emergency department (ED) for vaginal bleeding in early pregnancy have ultrasounds (US) that are diagnostic for intrauterine pregnancy (IUP). A secondary objective was to compare the number of US positive for IUP with HCG levels of 2000 and below verses HCG levels greater than 2000. Methods: This is a retrospective chart review conducted at an academic community ED with an annual volume of 68,000. Charts of patients with a final diagnosis of hemorrhage before the completion of 22 weeks pregnancy (ICD - 9 codes: 640.03, 640.83, 640.93) were reviewed. Ultrasound results were recorded as diagnostic of IUP when fetal heart rate was present or fetal pole was seen. All indeterminate studies were included as negative IUP. HCG results taken on the same day as the US was performed were included. Results: One hundred thirteen charts were reviewed. One hundred eleven had US results available and 112 had HCG levels. Eighty-three patients had an US confirmed IUP and 28 did not. There were 44 patients with an HCG level of less than 2000 and 68 patients with HCG above 2000. Twenty-six of 44 of those with HCG under 2000 had IUP on US while 16/44 did not. This is compared to 58/68 with HCG greater than 2000 with an IUP on US and only 10/68 in this group did not. There is a statistically significant association between threatened abortion status and IUP (p < .0001), with more threatened abortion patients experiencing IUP (79.4%). When comparing HCG levels, there is a statistically significant association between HCG status (< 2000)and IUP status(p¼.002) with HCG greater than 2000 resulting in more cases of IUP (85.3%) compared to HCG less than 2000(59.1%). Conclusions: Patients presenting to the ED for vaginal bleeding in early pregnancy are more likely to have an US diagnostic for IUP than not. In this study, HCG levels of less than 2000 still resulted in IUP on US 59% of the time but this is less than in patients with higher HCG levels.
233
Overuse of Laboratory Testing in Symptomatic First Trimester Pregnant Patients in the Emergency Department
Geyer BC, Stone MB, Adduci AJ, Sodickson AD, Raja AS/Brigham and Women’s Hospital, Boston, MA
Study Objectives: Emergency physicians often evaluate first trimester pregnant patients with abdominal pain and/or vaginal bleeding, with the primary goal of confirming intrauterine pregnancy (IUP). Fortunately, in patients who are not at increased risk for heterotopic pregnancy, the visualization of an IUP essentially excludes the diagnosis of ectopic pregnancy. While the initial evaluation of these patients has historically included a quantitative serum human chorionic gonadotropin (quant-
Annals of Emergency Medicine S85