- Email: [email protected]
Use of aspirin and heparin for treatment of stroke in a tertiary hospital emergency department in the 21st century
RESEARCH FORUM ABSTRACTS
cautery, the use of antibiotics, and the presence of subsequent complications. A complication was defined as a return to the ED for any reason. Results: The study cohort included 234 patients with anterior epistaxis. Eighty patients (34%) received anterior nasal packing; 154 patients (66%) did not. Seventynine (34%) patients received chemical cautery. Forty-nine (61%) of the patients who underwent nasal packing were placed on antibiotics. Of the 80 nasal packing patients who underwent nasal packing, 22 (28%) developed complications. In all instances, the complication was a recurrence of bleeding. Twenty-seven of the 154 (18%) patients who did not receive packing also returned with recurrence of bleeding. There was no significant difference in complication rates between patients who were packed, cauterized, or received no intervention. No patient returned to the ED with an infectious complication. Conclusion: Approximately one third of anterior epistaxis patients presenting to this ED received nasal packing. A high percentage of return ED visits was noted in patients discharged with and without packing, all for recurrence of anterior epistaxis. Regardless of antibiotic use, no infectious complications were cited in this cohort.
139
Automating Revenue Reconciliation Through Development of an Open-Source Tool
Nielson JA, Barton ED, Leiker T/University of Utah, Salt Lake City, UT Study objectives: The complexity of medical billing leads to errors and potential lost revenues. The errors constitute a breakdown in the billing cycle. When a breakdown in the billing cycle has occurred, the potential governmental and commercial payers do not receive accurate invoices, and, predictably, reimbursement is not actualized. The billing process for emergency department (ED) visits often relies on multiple complicated computer systems from individual vendors, as well as cooperation between many organizations, departments, and other third parties. At each step in the process, there exists a potential for omission of charges, and this is represented by discrepancies in the data between systems. Reconciling of data to other sources reveals process errors within the billing system, which range from omission of patients to incomplete or incorrect billing. Although there exist manual methods for completing this process, they are time-consuming and repetitive and require close attention to detail. We present EDReconciler, an open-source, freely distributed application designed to reconcile data from the individual data sources that represent the billing cycle pathway. Methods: The application was designed to import and process billing data from the author’s institution, and it can be extended to function in other institutions and other reconciliation settings. Each step in the billing cycle is subject to reconciliation. We found 6 useful data formats from 5 computer systems, and each was imported for reconciliation: (1) ED admission data from hospital admission system; (2) patient tracking data from clinical system; (3) HL7 data received from medical record coding service; (4) demographic information from patient research information system; (5) physician billing records; and (6) hospital facility billing records. The tool imports patient records and calculates daily census according to data from each data source. When discrepancies arise, the user may use the tool to discover names and information about patient encounters that may not have completed the billing cycle. Dollar estimates of the unbilled encounters can be computed (according to average charges per patient), which can be useful to demonstrate the need for administrative financial support of further inquiries. Global queries can be made to search for problem items such as specific billing codes or unbilled accounts. Results: The errors discovered in this analysis resulted from omitted patient records, incomplete clinical documentation, and lost charges from automatic data transfers. Early estimates show a value of $195,000 during the 4-month period studied at our institution, which is based on 650 noninvoiced patients, 60% specificity, and $500 per patient. We expect the final number to be higher with improvement of imported data reports, as well as indications that lost charges tend to come from complicated, higherbilled patients. Current work includes finalizing an estimate of losses to justify continued auditing and submission of invoices for services that remain billable. Also, implementation of long-term control procedures that include the developed application are under way. Conclusion: Reconciliation of the billing cycle using reliable data from other sources is essential to ensure appropriate revenue capture. Automated reconciliation can estimate errors, discover lost revenue, and most important, recognize process errors that cause the issues.
S 4 4
140
Use of Aspirin and Heparin for Treatment of Stroke in a Tertiary Hospital Emergency Department in the 21st Century
Hendrickson M, O’Malley M, Brooks KL/Cedars-Sinai Medical Center, Los Angeles, CA Study objectives: Stroke is the third leading cause of death in the United States and the leading cause of adult disability. The International Stroke Trial and Chinese Acute Stroke Trial demonstrated decreases in mortality, disability, and recurrent stroke for patients who received early administration of aspirin. A systematic review by the Cochrane Collaboration and the Heparin Acute Embolic Stroke Trial found no benefit in mortality for acute stroke patients who received heparin. Anderson et al published a survey documenting the frequency of aspirin and heparin administration during hospitalization for acute stroke and found a 44% and 10% rate, respectively. To our knowledge, there has been no study published that surveys the frequency of aspirin and heparin use in the management of acute stroke in a tertiary emergency department (ED). Our study characterizes the frequency of aspirin and heparin use by emergency physicians in managing stroke to determine whether recent evidence has affected clinical practice. We determine the use of aspirin and heparin for treatment of acute stroke in an urban tertiary ED from 2000 to 2001. Methods: We performed a retrospective medical record review for aspirin and heparin use in patients with a primary ED diagnosis of cerebral vascular accident from January 2000 to May 2001. Review methodology recommended by Gilbert and Lowenstein was implemented and included a single record reviewer who used a standardized abstraction form. Additionally, a second reviewer reabstracted a sample of charts to measure interpreter reliability. Computerized order entry charts and physician dictations were reviewed to quantify the rate of aspirin and heparin use (accounting for allergies and contraindications). Results: Five hundred eighty-five patients were evaluated for aspirin and heparin administration in the ED. Two hundred fifty-one patients received aspirin, which represented 43% (95% confidence interval [CI] 39% to 47%) of patients who were candidates for aspirin therapy. Fifty-nine patients (10%; 95% CI 8% to 12%) received heparin. Conclusion: We found that aspirin is underused and heparin is overused in the early management of acute stroke in a tertiary ED in the 21st century. Efforts should be made to increase awareness of the beneficial effects of aspirin and the lack of beneficial effects of heparin in the early management of stroke patients.
141
The Effect of Template Charting on Chest Pain Documentation by Attending Physicians and Physicians in Training
Brooks CB, Wilmas JH, Youdelman BA/Washington University School of Medicine, St. Louis, MO; Westchester Medical Center, Valhalla, NY Study objectives: We compare the documentation of critical items by attending physicians and physicians in training when evaluating patients with nontraumatic chest pain (NTCP) before and after the implementation of a chest pain evaluation form (CPEF) in a university hospital emergency department (ED). Methods: Using the American College of Emergency Physicians Clinical Policy for Adults Presenting with Chest Pain, a CPEF was designed and implemented in the ED to document the evaluation of patients presenting with NTCP. The CPEF contained critical documentation items (CDIs) listed as questions on the form with boxes for a response. After approval from the institutional review board, the records of 250 patients presenting with NTCP were retrospectively reviewed before and after the implementation of the CPEF for the presence of 28 CDIs and the identity of the primary documenter (attending physician versus physician in training, a senior student, or rotating resident). Overall and individual comparisons of the CDI documented by the 2 groups with and without the CPEF were analyzed using 2-sample z tests. Results: Using the CPEF, a significant increase in the percentage of items documented occurred for both the attending physician and physician in training groups compared with the blank form (attending physician without CPEF, n=60, CDI=36%, SD=24%; attending physician with CPEF, n=78, CDI=89%, SD=8%; physician in training without CPEF, n=186, CDI=39%, SD=23%; physician in training with CPEF, n=167, CDI=91%, SD=8%). Each CDI was documented significantly more often with the CPEF by both groups, with the exception of chest radiograph results, which were documented at a high level by the attending physician group before the implementation of the CPEF. Overall, there was not a significant difference between the attending physician and physician in training
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004
cautery, the use of antibiotics, and the presence of subsequent complications. A complication was defined as a return to the ED for any reason. Results: The study cohort included 234 patients with anterior epistaxis. Eighty patients (34%) received anterior nasal packing; 154 patients (66%) did not. Seventynine (34%) patients received chemical cautery. Forty-nine (61%) of the patients who underwent nasal packing were placed on antibiotics. Of the 80 nasal packing patients who underwent nasal packing, 22 (28%) developed complications. In all instances, the complication was a recurrence of bleeding. Twenty-seven of the 154 (18%) patients who did not receive packing also returned with recurrence of bleeding. There was no significant difference in complication rates between patients who were packed, cauterized, or received no intervention. No patient returned to the ED with an infectious complication. Conclusion: Approximately one third of anterior epistaxis patients presenting to this ED received nasal packing. A high percentage of return ED visits was noted in patients discharged with and without packing, all for recurrence of anterior epistaxis. Regardless of antibiotic use, no infectious complications were cited in this cohort.
139
Automating Revenue Reconciliation Through Development of an Open-Source Tool
Nielson JA, Barton ED, Leiker T/University of Utah, Salt Lake City, UT Study objectives: The complexity of medical billing leads to errors and potential lost revenues. The errors constitute a breakdown in the billing cycle. When a breakdown in the billing cycle has occurred, the potential governmental and commercial payers do not receive accurate invoices, and, predictably, reimbursement is not actualized. The billing process for emergency department (ED) visits often relies on multiple complicated computer systems from individual vendors, as well as cooperation between many organizations, departments, and other third parties. At each step in the process, there exists a potential for omission of charges, and this is represented by discrepancies in the data between systems. Reconciling of data to other sources reveals process errors within the billing system, which range from omission of patients to incomplete or incorrect billing. Although there exist manual methods for completing this process, they are time-consuming and repetitive and require close attention to detail. We present EDReconciler, an open-source, freely distributed application designed to reconcile data from the individual data sources that represent the billing cycle pathway. Methods: The application was designed to import and process billing data from the author’s institution, and it can be extended to function in other institutions and other reconciliation settings. Each step in the billing cycle is subject to reconciliation. We found 6 useful data formats from 5 computer systems, and each was imported for reconciliation: (1) ED admission data from hospital admission system; (2) patient tracking data from clinical system; (3) HL7 data received from medical record coding service; (4) demographic information from patient research information system; (5) physician billing records; and (6) hospital facility billing records. The tool imports patient records and calculates daily census according to data from each data source. When discrepancies arise, the user may use the tool to discover names and information about patient encounters that may not have completed the billing cycle. Dollar estimates of the unbilled encounters can be computed (according to average charges per patient), which can be useful to demonstrate the need for administrative financial support of further inquiries. Global queries can be made to search for problem items such as specific billing codes or unbilled accounts. Results: The errors discovered in this analysis resulted from omitted patient records, incomplete clinical documentation, and lost charges from automatic data transfers. Early estimates show a value of $195,000 during the 4-month period studied at our institution, which is based on 650 noninvoiced patients, 60% specificity, and $500 per patient. We expect the final number to be higher with improvement of imported data reports, as well as indications that lost charges tend to come from complicated, higherbilled patients. Current work includes finalizing an estimate of losses to justify continued auditing and submission of invoices for services that remain billable. Also, implementation of long-term control procedures that include the developed application are under way. Conclusion: Reconciliation of the billing cycle using reliable data from other sources is essential to ensure appropriate revenue capture. Automated reconciliation can estimate errors, discover lost revenue, and most important, recognize process errors that cause the issues.
S 4 4
140
Use of Aspirin and Heparin for Treatment of Stroke in a Tertiary Hospital Emergency Department in the 21st Century
Hendrickson M, O’Malley M, Brooks KL/Cedars-Sinai Medical Center, Los Angeles, CA Study objectives: Stroke is the third leading cause of death in the United States and the leading cause of adult disability. The International Stroke Trial and Chinese Acute Stroke Trial demonstrated decreases in mortality, disability, and recurrent stroke for patients who received early administration of aspirin. A systematic review by the Cochrane Collaboration and the Heparin Acute Embolic Stroke Trial found no benefit in mortality for acute stroke patients who received heparin. Anderson et al published a survey documenting the frequency of aspirin and heparin administration during hospitalization for acute stroke and found a 44% and 10% rate, respectively. To our knowledge, there has been no study published that surveys the frequency of aspirin and heparin use in the management of acute stroke in a tertiary emergency department (ED). Our study characterizes the frequency of aspirin and heparin use by emergency physicians in managing stroke to determine whether recent evidence has affected clinical practice. We determine the use of aspirin and heparin for treatment of acute stroke in an urban tertiary ED from 2000 to 2001. Methods: We performed a retrospective medical record review for aspirin and heparin use in patients with a primary ED diagnosis of cerebral vascular accident from January 2000 to May 2001. Review methodology recommended by Gilbert and Lowenstein was implemented and included a single record reviewer who used a standardized abstraction form. Additionally, a second reviewer reabstracted a sample of charts to measure interpreter reliability. Computerized order entry charts and physician dictations were reviewed to quantify the rate of aspirin and heparin use (accounting for allergies and contraindications). Results: Five hundred eighty-five patients were evaluated for aspirin and heparin administration in the ED. Two hundred fifty-one patients received aspirin, which represented 43% (95% confidence interval [CI] 39% to 47%) of patients who were candidates for aspirin therapy. Fifty-nine patients (10%; 95% CI 8% to 12%) received heparin. Conclusion: We found that aspirin is underused and heparin is overused in the early management of acute stroke in a tertiary ED in the 21st century. Efforts should be made to increase awareness of the beneficial effects of aspirin and the lack of beneficial effects of heparin in the early management of stroke patients.
141
The Effect of Template Charting on Chest Pain Documentation by Attending Physicians and Physicians in Training
Brooks CB, Wilmas JH, Youdelman BA/Washington University School of Medicine, St. Louis, MO; Westchester Medical Center, Valhalla, NY Study objectives: We compare the documentation of critical items by attending physicians and physicians in training when evaluating patients with nontraumatic chest pain (NTCP) before and after the implementation of a chest pain evaluation form (CPEF) in a university hospital emergency department (ED). Methods: Using the American College of Emergency Physicians Clinical Policy for Adults Presenting with Chest Pain, a CPEF was designed and implemented in the ED to document the evaluation of patients presenting with NTCP. The CPEF contained critical documentation items (CDIs) listed as questions on the form with boxes for a response. After approval from the institutional review board, the records of 250 patients presenting with NTCP were retrospectively reviewed before and after the implementation of the CPEF for the presence of 28 CDIs and the identity of the primary documenter (attending physician versus physician in training, a senior student, or rotating resident). Overall and individual comparisons of the CDI documented by the 2 groups with and without the CPEF were analyzed using 2-sample z tests. Results: Using the CPEF, a significant increase in the percentage of items documented occurred for both the attending physician and physician in training groups compared with the blank form (attending physician without CPEF, n=60, CDI=36%, SD=24%; attending physician with CPEF, n=78, CDI=89%, SD=8%; physician in training without CPEF, n=186, CDI=39%, SD=23%; physician in training with CPEF, n=167, CDI=91%, SD=8%). Each CDI was documented significantly more often with the CPEF by both groups, with the exception of chest radiograph results, which were documented at a high level by the attending physician group before the implementation of the CPEF. Overall, there was not a significant difference between the attending physician and physician in training
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004