- Email: [email protected]
Rapid Response Team Activations Within 24 Hours of Admission from the Emergency Department: An Innovative Approach for Performance Improvement
Research Forum Abstracts hospital prior to labs resulting. For each blood culture that results as a true negative, the hospital incurs a $290 charge. For each positive blood culture, the hospital incurs an additional $160-$340 charge with an average total cost of $540 per positive culture. Therefore, the cost for each ordered blood culture for the hospital ranges between $290 and $630 depending on the result. Based on the results from this study, there was a $218,080 charge to the hospital for the 752 true negative blood cultures, and an additional $31,860 for the 59 true and false positive blood cultures. Conclusions: Emergency physicians routinely order blood cultures on patients in the emergency department with the knowledge that the results will not typically be available for several days. These patients are also generally empirically treated with antibiotics despite the blood culture results which won’t result for a few days after discharge from the emergency department. This study showed that only 7/811 (0.8%) required immediate action by the emergency physician. There is also a significant cost to the health care system estimated at $218,080 charge to the hospital for the 752 true negative blood cultures, and an additional $31,860 for the 59 true and false positive blood cultures.
225
Mechanical and Thrombotic Complication Rates for Central Line Insertion in Emergency Medicine: A MultiCenter Cohort Study
Wright SW, Conine B, Lindsell CJ, Yamin C, Smith C, Hart K, Trott A/University of Cincinnati, Cincinnati, OH
Study Objectives: In the United States, physicians insert more than 5 million central venous catheters (CVCs) every year. CVC insertion is a core procedure for emergency physicians. Unfortunately, the use of CVCs is associated with adverse events that increase cost, and patient morbidity. Reported mechanical and thrombotic complication rates vary from 1.5 to 19% and 2 to 26%, respectively. The complication rates of CVC inserted in the ED by emergency physicians have not been reported and could be an under-recognized area of patient safety and morbidity. Our study objective is to estimate the mechanical and thrombotic complication rates for CVCs inserted by emergency physicians. Methods: This cohort study includes all patients with a CVC inserted in the EDs of three hospitals in Cincinnati, Ohio between January 2007 and June 2012. The hospitals include an urban, academic medical center, and 2 smaller, community hospitals. Combined volume is w160,000 visits per year. Patients with CVC placement were identified through billing and ICD-9 data, and evaluated by chart review using a priori definitions and standardized case report forms by a trained research nurse. Results: During the study period, 1932 lines were placed. Complication rates are reported in the Table. Conclusions: Both mechanical and thrombotic complications are low in this large cohort of emergency medicine patients relative to reported rates in other settings. The majority of CVCs in this study were placed by PGY-2 emergency medicine residents and of the 121 events, only 20 (1.0%) required intervention. More study is required to further characterize this important area of EM patient safety in order to establish best practice parameters and to minimize future morbidity.
improvement, infection control initiatives and has been driven as low as 1.17 infections per 1000 patient days in the 350 hospital On the CUSP: Stop BSI AHRQ funded project. Central venous catheters (CVCs) are commonly placed in the emergency department (ED) setting and represent a core procedure for the emergency physician. Reporting is not specifically required for CLABSI rates of lines placed in the ED’s outpatient setting, however, examination of these lines represents an important and rarely reported area of possible patient morbidity and safety. Our study objective was to examine the CLABSI rates for lines inserted in the ED setting at three large urban EDs. Methods: This IRB approved, cohort study includes all patients with a CVC inserted in the EDs of three hospitals in Cincinnati, Ohio between January, 2007 and June, 2012. The hospitals include a large, urban, academic medical center, and two smaller, community hospitals representing 160,000 patient visits per year. Patients were identified through billing and ICD-9 data followed by chart review utilizing a priori definitions and standardized case report forms by a trained research RN. A representative sample was examined by the investigators to determine average number of line days. Blood stream infections were identified through standard, daily, hospital-based quality/infection control RN rounds. Results: During the study period, 1932 lines were placed. Average total complication rate was 6.45%. Average line duration was 3 days and 3 BSIs were identified, for a CLABSI rate of 0.52/1000 patient days. Conclusions: Reporting of CLABSI rates in the outpatient setting of the ED is not yet required by government agencies or payers in general. However, this study shows that it is possible, with implementation of recommended infection control practices, to improve upon published rates of inpatient unit CLABSI, in the unique environment of the ED.
227
Rapid Response Team Activations Within 24 Hours of Admission from the Emergency Department: An Innovative Approach for Performance Improvement
Lovett PB, Massone RJ, Holmes MN, Hall RV, Lill C, Lopez BL/Thomas Jefferson University, Philadelphia, PA; Thomas Jefferson University Hospital, Philadelphia, PA
Study Objectives: Performance improvement (PI) programs in emergency medicine have evolved beyond peer reviews of referred cases, and now encompass a large set of quality metrics which are measured proactively. However, peer review of cases continues to be an important element of PI, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED) (as well as certain “automatic” triggers such as death in the ED). In an effort to cast a wider net, to take a more systematic approach, and to avoid “blind spots” from individual variability in criteria for referring cases, we instituted a new process for selecting cases for peer review based on rapid response team (RRT) activations within 24 hours of admission from the ED (“RRT24ED”). In the last decade, following reports by IHI and AHRQ, there has been widespread hospital adoption of RRTs, with success in reducing the incidence of in-hospital cardiac arrest, post-operative adverse events, and emergent transfers to higher levels of care (ICUs). RRTs generally do not operate within EDs, yet we hypothesized that EDs could benefit from reviewing events occurring after admission from the ED, in particular RRT24ED events.
Table. CVC Insertion Complication Rates Class
Mechanical
Type
Arterial Puncture
Pneumothorax
Hemothorax
Dysrythmia
Air Embolism
DVT
Hematoma
Total
81 4.2
13 0.67
1 0.05
6 0.31
2 0.10
4 0.21
14 0.72
121 6.3
N %
226
Thrombotic
Central Line-Associated Blood Stream Infection Rates in Emergency Medicine: A Multi-Center Cohort Study
Wright SW, Conine B, Yamin C, Lindsell CJ, Hart K, Smith C, Trott A/University of Cincinnati, Cincinnati, OH
Study Objectives: Approximately 41,000 central line-associated blood stream infections (CLABSI) occur in U.S. hospitals each year. These infections typically cause prolongation of hospital stay, increased cost, risk of mortality and are a National Patient Safety Imperative. CLABSI can be minimized by implementation of published quality
Volume 62, no. 4s : October 2013
Methods: This was a prospective, observational study conducted from July 1, 2012 until March 31st, 2013, at a large, urban, academic medical center with EM residency. We created a new automated monthly report capturing all RRT24ED events. All patients listed in this report were reviewed by the ED PI committee, to examine for systems and/or individual issues which might yield opportunities for improvement. Cases were classified according to the indication for RRT activation, using the system outlined by AHRQ. A team of three ED PI reviewers examined both ED and inpatient charts and could bring cases to a full ED PI review committee if there was not consensus in their assessments.
Annals of Emergency Medicine S83
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
225
Mechanical and Thrombotic Complication Rates for Central Line Insertion in Emergency Medicine: A MultiCenter Cohort Study
Wright SW, Conine B, Lindsell CJ, Yamin C, Smith C, Hart K, Trott A/University of Cincinnati, Cincinnati, OH
Study Objectives: In the United States, physicians insert more than 5 million central venous catheters (CVCs) every year. CVC insertion is a core procedure for emergency physicians. Unfortunately, the use of CVCs is associated with adverse events that increase cost, and patient morbidity. Reported mechanical and thrombotic complication rates vary from 1.5 to 19% and 2 to 26%, respectively. The complication rates of CVC inserted in the ED by emergency physicians have not been reported and could be an under-recognized area of patient safety and morbidity. Our study objective is to estimate the mechanical and thrombotic complication rates for CVCs inserted by emergency physicians. Methods: This cohort study includes all patients with a CVC inserted in the EDs of three hospitals in Cincinnati, Ohio between January 2007 and June 2012. The hospitals include an urban, academic medical center, and 2 smaller, community hospitals. Combined volume is w160,000 visits per year. Patients with CVC placement were identified through billing and ICD-9 data, and evaluated by chart review using a priori definitions and standardized case report forms by a trained research nurse. Results: During the study period, 1932 lines were placed. Complication rates are reported in the Table. Conclusions: Both mechanical and thrombotic complications are low in this large cohort of emergency medicine patients relative to reported rates in other settings. The majority of CVCs in this study were placed by PGY-2 emergency medicine residents and of the 121 events, only 20 (1.0%) required intervention. More study is required to further characterize this important area of EM patient safety in order to establish best practice parameters and to minimize future morbidity.
improvement, infection control initiatives and has been driven as low as 1.17 infections per 1000 patient days in the 350 hospital On the CUSP: Stop BSI AHRQ funded project. Central venous catheters (CVCs) are commonly placed in the emergency department (ED) setting and represent a core procedure for the emergency physician. Reporting is not specifically required for CLABSI rates of lines placed in the ED’s outpatient setting, however, examination of these lines represents an important and rarely reported area of possible patient morbidity and safety. Our study objective was to examine the CLABSI rates for lines inserted in the ED setting at three large urban EDs. Methods: This IRB approved, cohort study includes all patients with a CVC inserted in the EDs of three hospitals in Cincinnati, Ohio between January, 2007 and June, 2012. The hospitals include a large, urban, academic medical center, and two smaller, community hospitals representing 160,000 patient visits per year. Patients were identified through billing and ICD-9 data followed by chart review utilizing a priori definitions and standardized case report forms by a trained research RN. A representative sample was examined by the investigators to determine average number of line days. Blood stream infections were identified through standard, daily, hospital-based quality/infection control RN rounds. Results: During the study period, 1932 lines were placed. Average total complication rate was 6.45%. Average line duration was 3 days and 3 BSIs were identified, for a CLABSI rate of 0.52/1000 patient days. Conclusions: Reporting of CLABSI rates in the outpatient setting of the ED is not yet required by government agencies or payers in general. However, this study shows that it is possible, with implementation of recommended infection control practices, to improve upon published rates of inpatient unit CLABSI, in the unique environment of the ED.
227
Rapid Response Team Activations Within 24 Hours of Admission from the Emergency Department: An Innovative Approach for Performance Improvement
Lovett PB, Massone RJ, Holmes MN, Hall RV, Lill C, Lopez BL/Thomas Jefferson University, Philadelphia, PA; Thomas Jefferson University Hospital, Philadelphia, PA
Study Objectives: Performance improvement (PI) programs in emergency medicine have evolved beyond peer reviews of referred cases, and now encompass a large set of quality metrics which are measured proactively. However, peer review of cases continues to be an important element of PI, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED) (as well as certain “automatic” triggers such as death in the ED). In an effort to cast a wider net, to take a more systematic approach, and to avoid “blind spots” from individual variability in criteria for referring cases, we instituted a new process for selecting cases for peer review based on rapid response team (RRT) activations within 24 hours of admission from the ED (“RRT24ED”). In the last decade, following reports by IHI and AHRQ, there has been widespread hospital adoption of RRTs, with success in reducing the incidence of in-hospital cardiac arrest, post-operative adverse events, and emergent transfers to higher levels of care (ICUs). RRTs generally do not operate within EDs, yet we hypothesized that EDs could benefit from reviewing events occurring after admission from the ED, in particular RRT24ED events.
Table. CVC Insertion Complication Rates Class
Mechanical
Type
Arterial Puncture
Pneumothorax
Hemothorax
Dysrythmia
Air Embolism
DVT
Hematoma
Total
81 4.2
13 0.67
1 0.05
6 0.31
2 0.10
4 0.21
14 0.72
121 6.3
N %
226
Thrombotic
Central Line-Associated Blood Stream Infection Rates in Emergency Medicine: A Multi-Center Cohort Study
Wright SW, Conine B, Yamin C, Lindsell CJ, Hart K, Smith C, Trott A/University of Cincinnati, Cincinnati, OH
Study Objectives: Approximately 41,000 central line-associated blood stream infections (CLABSI) occur in U.S. hospitals each year. These infections typically cause prolongation of hospital stay, increased cost, risk of mortality and are a National Patient Safety Imperative. CLABSI can be minimized by implementation of published quality
Volume 62, no. 4s : October 2013
Methods: This was a prospective, observational study conducted from July 1, 2012 until March 31st, 2013, at a large, urban, academic medical center with EM residency. We created a new automated monthly report capturing all RRT24ED events. All patients listed in this report were reviewed by the ED PI committee, to examine for systems and/or individual issues which might yield opportunities for improvement. Cases were classified according to the indication for RRT activation, using the system outlined by AHRQ. A team of three ED PI reviewers examined both ED and inpatient charts and could bring cases to a full ED PI review committee if there was not consensus in their assessments.
Annals of Emergency Medicine S83
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