Disclosures What s New in Patient Safety & Quality Improvement? No financial relationships with any corporate entities to disclose Steven K. Polevoi, MD Clinical Professor of Emergency Medicine UCSF Emergency Department A literature review Overview Top articles last 5 years Issues relevant to EM practice Focus on systems of care NEJM; 363, 2010. 1
Trends in Harm-Methods Retrospective chart review Random sample: 10 hospitals, North Carolina 100 admissions per quarter, Jan 02-Dec 07 Trigger tool utilized to identify adverse events Primary and secondary reviews conducted for all harms Reviewers: good inter and intra rater reliability Trends in Harm-Results 588 total harms identified 56.5 harms per 1000 patient-days 25.1 harms per 100 admissions Majority were procedures and medications 2
Trends in Harm-Conclusion Harms are common in NC hospitals Harm reduction is difficult to achieve Recommend more evidence-based practices to improve safety Relevance to EM: likely similar obstacles NEJM; 366, 2012. P4P-Methods 253 hospitals participating in Premier demo 3363 control hospitals (paid for reporting only) Outcomes: 30-day mortality, 2003-09 AMI CHF PNA CABG Controlled for patient and hospital characteristics P4P-Results More than 6 million patients Premier hospitals Larger More likely teaching facilities More likely non-profit Premier patients Older More men More African-American 3
P4P-Conclusions No evidence that Premier P4P lead to a decrease in mortality Process improvements may not be directly proportional to outcomes Incentives may not be large enough Expectations should be modest Annals of EM; 49, 2007. 4
Death after Discharge-Methods Retrospective cohort design Linked databases from hospital and ME Patients treated and discharged from UNM ED and died within 7 days of discharge 10 year period 1994-2004 Cases reviewed and themes identified Death after Discharge-Results 387,334 visits during study period 149 deaths identified 117 underwent detailed review 59 deaths were unrelated or expected 58 deaths were related and unexpected 60% possible medical error identified Death after Discharge-Results Themes identified Abnormal vital signs (83%) Decompensated chronic disease (60%) Atypical presentation of rare disease (38%) Mental illness/substance abuse (41%) Death after Discharge-Conclusion Death shortly after ED discharge is rare 50% were unexpected and related Abnormal vital signs: most common theme identified An opportunity to intervene to prevent bad outcomes 5
LOS and Mortality-Methods BMJ; 342, 2011. Retrospective cohort study, Ontario Canada ED patients seen and discharged or LWBS April 2003-March 2008 Exposure: mean length of stay for like patients, same shift, same ED Outcome: risk of admission or death within 7 days of index visit Multiple linked databases utilized LOS and Mortality-Results Higher Risk at Triage 13,934,542 patients were seen and discharged 617,011 left without being seen Controlled for sociodemographics, triage acuity, month, time of day, number of ED visits in previous year, and chief complaint 6
Lower Risk at Triage LOS and Mortality-Conclusion No increase in adverse events for LWBS Adverse events are associated with increasing length of stay for discharged patients Clinical justification for time targets (Canada, Australia, England) Efforts to improve timeliness of care likely have positive impact on outcomes for all patients CPOE-Methods Sample: 62 US hospitals with CPOE/decision support 63%: teaching hospitals Frequency that common ADEs can be averted Test orders on fictitious patients Multiple vendors included Basic: Drug-drug, drug-allergy, duplication, inappropriate dose/route Complex: contraindications due to renal status, age, weight, or diagnosis Health Affairs, 29. 2010. 7
CPOE-Results Individual site results: 10-82% detection rate Best performers: 71-82% Worst performers: 10-18% Fatal orders: 47% not detected CPOE-Conclusions Great variability in ADE detection among sites Vendor did not explain all variability Refinement of decision support is critical for higher risk ADEs Recommend: libraries of decision support rules Arch Intern Med, 172; 2012 8
Patient Satisfaction-Methods Prospective cohort; 2000-2007 MEPS: Annual national survey, self-administered questionnaire Results validated by medical record review Comparing patient satisfaction in year 1 to utilization and expenditures in year 2 and mortality through 2006 Satisfaction with outpatient physician communication assessed at the midpoint of the study years (CAHPS) Covariates: sociodemographics, health behaviors, access, propensity to use health care, and health status Patient Satisfaction-Results Sample: 51,946 respondents 58% female 75% white 29% college graduate 87% had a usual source of care 9
Patient Satisfaction-Conclusion Association of higher patient satisfaction with Decreased ED utilization Increased inpatient utilization Increased health care expenditures (Rx) Increased mortality (most satisfied quartile) Possible explanation: physicians doing more discretionary care to improve satisfaction Journal of Patient Safety, 7; 2011 DC Instructions-Methods Prospective cohort study; June-October 2007 Telephone interviews Patients 65 years or older (or their proxies) within 72 hours of ED discharge Assessing understanding of 4 areas: ED diagnosis Expected course of illness Self-care instructions Return precautions Adverse events: repeat ED visits, hospitalizations, or deaths within 90 days of ED discharge DC instructions-results 92 respondents Mean age 75 years, 60% female 41% were ESI 2 on arrival 91% got written and verbal instructions 16-63% did not understand one aspect of DC instructions 10
DC instructions-conclusion Substantial portion elderly didn t understand DC instructions Trend toward higher risk of adverse events New strategies are needed to improve communication in this population Summary Slow progress in quality and safety efforts Some assumptions haven t been borne out Unintended consequences are inevitable EM physicians can make changes in practice that can improve chances for favorable outcomes References Landrigan C, Parry G, Bones C et al. Temporal trends in rates of patient harm resulting from medial care. NEJM 2010; 363: 2124-34. Jha A, Joynt K, Orav E, Epstein A. The long-term effect of premier pay for performance on patient outcomes. NEJM 2012; 366: 1606-15. Sklar D, Crandall C, Loellger E et al. Unanticipated death after discharge home from the emergency department. Ann Emerg Med 2007; 49: 735-45. Guttmann A, Schull M, Vermeulen M, Stuke T. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011; 342: d2983. Metzger J, Welebob E, Bates D et al. Mixed results in the safety performance of computerized physician order entry. Health Aff 2010; 29 (4): 655-63. Fenton J, Jerant A, Bertakis K, Franks P. The cost of satisfaction. A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012; 172 (5): 405-11. Hastings, Barrett A, Weinberger M et al. Older patients understanding of emergency department discharge information and its relationship with adverse outcomes. J Patient Saf 2011; 7: 19-25. 11