Christopher Fee

Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.

Improving health care quality depends on having valid ways to measure quality. Unfortunately, there are few validated quality outcome measurements, because valid and feasible case-mix adjustors are lacking and patients are difficult to follow over time for clinically important outcomes, such as death. Processes of care are easier to identify and measure, but some of these measures will be proven invalid or inappropriate because their scientific rationale was flawed from the start, unanticipated consequences emerge after implementation, or later studies undermine them. We review how these issues played out in the measure of time to first antibiotic dose (TFAD), also called door-to-needle time, for patients presenting to the hospital with community-acquired pneumonia (CAP). We also propose lessons that can be learned from the experience. TFAD as a Quality Measure Community-acquired pneumonia is one of the most common admitting diagnoses in U.S. hospitals, accounting for more than 1 million hospitalizations yearly (1), with short-term mortality rates ranging from 0.5% to 27.1% (2). Given its risk, frequency, and perceived outcome variations, CAP was an obvious candidate for quality measurement and improvement initiatives. Because outcome measurement in CAP was problematic for the usual reasons (data collection burden, case-mix adjustment, and need for posthospital follow-up), investigators sought process measures associated with higher quality. During the 1990s, the notion of time-based quality measures gained favor because evidence emerged that rapid treatment of myocardial infarction, and later trauma, stroke, and sepsis, improved outcomes (37). Naturally, investigators began to examine whether rapid administration of antibiotics might improve CAP outcomes. In 1997, a retrospective study of 14069 Medicare patients hospitalized for CAP found that, after adjustment for severity (2) and demographic factors, administration of antibiotics within 8 hours was associated with a lower 30-day mortality rate (odds ratio [OR], 0.85 [95% CI, 0.75 to 0.96]) (8). Patients were included if they had chest radiography results within 2 days of admission consistent with pneumonia and an initial working diagnosis of pneumonia. In 2004, a second retrospective study of 13771 Medicare patients (age 65 years) hospitalized for CAP (9) also found that, among the 75% of patients without evidence of prehospital receipt of antibiotics, administration of antibiotics within 4 hours was associated with a lower 30-day mortality rate (OR, 0.85 [CI, 0.76 to 0.95]). Extrapolating these data to a hypothetical national Medicare sample, the authors estimated that achieving TFAD by 4 hours after presentation to the hospital would save more than 1200 lives yearly. The 2 studies reported that patients who received their first dose of antibiotics in the first hour of their emergency department stay had a higher mortality rate than those who received antibiotics later; however, this finding was attributed to incomplete adjustment for severity of CAP and was therefore not felt to challenge the main conclusion about TFAD (8, 9). Two smaller studies of CAP found no association between early antibiotic administration and outcomes (10, 11). Nevertheless, the authors of the 2004 study (9) editorialized that the 4-hour TFAD quality measure was still valid (12, 13). Translation into a Performance Standard Almost exclusively on the basis of results from the 1997 study, the Medicare National Pneumonia Project endorsed first antibiotics within 8 hours of hospital arrival as a CAP quality measure in 1998. The Medicare National Pneumonia Project tightened its TFAD window to 4 hours in 2002 on the basis of the prepublication results of the 2004 study by Houck and colleagues (9, 12). In 2003, the Infectious Diseases Society of America (IDSA) also endorsed a 4-hour timeframe (14). With support from the Medicare National Pneumonia Project and IDSA and subsequent endorsement by the National Quality Forum, The Joint Commission and The Centers for Medicare & Medicaid Services (CMS) chose the 4-hour TFAD measure as 1 of their initial core measures of quality (measure PN-5b). Since 2002, this measure has been publicly reported for all U.S. hospitals. In 2006, it became part of a measure set tied to additional payments under several pilot pay-for-performance programs (15). The Response from Emergency Medicine The emergency medicine community began raising red flags about the TFAD measure soon after its formulation, and complaints from this community markedly increased after TFAD was publicly reported and became the subject of pay-for-performance programs (16). Published studies challenging the measure soon followed. Although some questioned the association itself, most focused on the issue of diagnostic uncertainty. One study found that 22% of 86 randomly selected patients with pneumonia had uncertain presentations and often lacked infiltrates on chest radiography, which could have appropriately led to delayed antibiotic administration (17). Another study documented cases that were labeled poor-quality care, in which delayed use of antibiotics was clinically appropriate (18), whereas still another found that maneuvers to improve TFAD were not very cost-effective (19). In fact, many eligible patients with a working diagnosis of CAP who did not receive antibiotics within 4 hours had no radiographic evidence of pneumonia in the emergency department and did not have a final emergency department diagnosis of CAP (20, 21). Moreover, other studies showed that TFAD measurement led to administration of antibiotics in many patients who proved not to have pneumonia or another infectious disease (22, 23). Finally, a recent systematic review concluded that evidence from observational studies fails to confirm decreased mortality with early administration of antibiotics in stable patients with [CAP] (24). On the basis of these studies, analyses, and considerable anecdotal evidence, editorials in the emergency medicine literature argued vigorously for relaxing the TFAD standards (25, 26), pointing out that the measure was skewing emergency department triage priorities and promoting unnecessary antibiotic use (18). The Response from Payers, Regulators, and Professional Societies Within months of the critical publications, The Joint Commission and CMS revisited measure PN-5b. In October 2006, patients eligible for the measure had to have a final emergency department diagnosis of pneumonia (rather than an initial working diagnosis) and objective radiographic findings sometime during the hospitalization. Unfortunately, although the revised criteria solved some of the problems associated with PN-5b, they created new ones. For example, Fee and colleagues (27) worried that the new measures would generate pressure to administer antibiotics before patients were sent for computed tomography to rule out pulmonary embolism (even in the face of nondiagnostic chest radiographs) or to avoid writing pneumonia as the final emergency department diagnosis. In March 2007, IDSA and the American Thoracic Society issued joint guidelines that abolished time-specific goals for CAP treatment, now recommending that patients receive their first dose of antibiotics as soon as possible after a definitive diagnosis of CAP, preferably in the emergency department (28). One month later, The Joint Commission created a test measure (PN-5c) that relaxed the antibiotic administration window to 6 hours. That same month, the National Quality Forum withdrew its endorsement of measure PN-5b and endorsed PN-5c, which became the publicly reported measure in April 2008. In addition, The Joint Commission created a new data element, diagnostic uncertainty, which may exclude patients from TFAD measurement (29, 30). Whether all of these revisions will solve the problems associated with measure PN-5b is unknown; no study has yet shown a benefit from a 6-hour rule, and the diagnostic uncertainty construct has not, to our knowledge, been field-tested and validated. Unanticipated Consequences of TFAD Measurement and Reporting Prompt administration of antibiotics to patients with documented pneumonia makes sense, and seeking ironclad evidence to prove its value might seem to be analogous to requiring proof of the value of parachutes (31). Moreover, a randomized trial that withheld early antibiotic treatment in some patients with CAP would be unethical. It was therefore inevitable that decisions about the timing of antibiotic administration in CAP would be based on imperfect retrospective studies, out of necessity (8, 9). However, the TFAD measure was enacted largely on the evidence derived from 2 large studies, in which conditions (retrospective review of patients with working diagnoses of pneumonia) replicate only in part the predicament that busy emergency medicine physicians face daily: evaluating scores of patients with cough, fever, dyspnea, weakness, dizziness, confusion, or abdominal pain. As Pines (26) has written, Most ED [emergency department] patients do not present at triage with a sign on their forehead that reads, I have pneumonia; give me antibiotics now! Unlike myocardial infarction, in which there is palpable clinical urgency to confirm the diagnosis and a series of tests (cardiac biomarker measurement and electrocardiography) available to reliably do so, no gold standard test for pneumonia exists. Although a triage rule of obtaining an electrocardiogram in any patient whose symptoms, signs, or risk factors make myocardial infarction even a remote possibility makes perfect sense, a similar strategy for chest radiography would be resource intensive, often confusing (given the relatively poor sensitivity and specificity of the test in CAP [32]), impractical, and even potentially harmful (because of radiation exposure). In the days before measurement of TFAD, patients with uncertain diagnoses would continue to be evaluated until th

How common is MRSA in adult septic arthritis

STUDY OBJECTIVE We determine the proportion of methicillin-resistant Staphylococcus aureus (MRSA) in adult septic arthritis patients presenting to the emergency department (ED). METHODS This was a cross-sectional retrospective review in 2 urban academic EDs in northern California, one tertiary care and one public. Subjects included patients who underwent arthrocentesis in the ED from April 2006 through July 2007. We queried the microbiology laboratory databases for synovial fluid cultures sent from the ED. We reviewed synovial fluid culture results and corresponding synovial fluid analyses and then classified positive culture results as true septic arthritis or likely contaminant. For septic arthritis cases, we reviewed medical records and abstracted presenting features. We report our findings with descriptive statistics. RESULTS One hundred nine synovial fluid cultures were sent from the EDs. Twenty-three results (21%; 95% confidence interval [CI] 14% to 30%) were positive, of which 9 were likely contaminants; 1 was from a soft tissue abscess and 1 was from bursitis. Of 12 septic arthritis cases, 6 cultures (50%; 95% CI 21% to 78%) grew MRSA, 4 (33%; 95% CI 7% to 60%) methicillin-susceptible S aureus, and 1 each (8%; 95% CI 0% to 24%) Streptococcus pneumoniae, Enterococcus faecalis, and Pseudomonas aeruginosa. Of the 6 MRSA cases, 4 were in male patients; median age of patients was 47.5 years, 3 patients had previously diseased joints, 2 patients injected drugs, 2 patients were febrile, 3 patients had previously diseased joints, median synovial fluid leukocyte count was 15,184 cells/microL (range 3,400 to 34,075 cells/microL), and 5 patients received appropriate ED antibiotics. CONCLUSION In this 2-ED population from a single geographic region, MRSA was the most common cause of community-onset adult septic arthritis. Synovial fluid cell counts were unexpectedly low in MRSA septic arthritis cases.

The HCAP Gap: Differences between Self-Reported Practice Patterns and Published Guidelines for Health Care-Associated Pneumonia

BACKGROUND Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. METHODS An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. RESULTS Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. CONCLUSIONS In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.

Association of Emergency Department Length of Stay With Safety-Net Status

CONTEXT Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. OBJECTIVE To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status. DESIGN, SETTING, AND PARTICIPANTS The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance. MAIN OUTCOME MEASURES Emergency Department length-of-stay measure compliance by disposition and safety-net status. RESULTS Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non-safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non-safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]). CONCLUSION Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non-safety-net hospitals.

Strategies for success: A PDSA analysis of three QI initiatives in critical care.

BACKGROUND Implementation of evidence-based quality improvement (QI) initiatives is not without its challenges. Recent experience in the design, implementation, and evaluation of three QI initiatives at the University of California, San Francisco Medical Center (UCSF) suggests lessons learned that may be generalizable to other QI initiatives. INITIATIVES: Between December 2002 and May 2006, a ventilator bundle of care and a tight glycemic control (TGC) protocol were implemented in the intensive care units (ICUs), and early goal-directed therapy (EGDT) for patients with severe sepsis or septic shock was implemented in the ICUs and emergency department. The initiatives were selected on the basis of the magnitude of the problem, strength of the evidence regarding associated reductions in morbidity and mortality in the critically ill, and cost-effectiveness. LESSONS LEARNED A number of challenges in QI processes and strategies for success were identified via retrospective analysis within the construct of the Plan-Do-Study-Act model, representing a novel use of the model. Pitfalls most commonly occurred in the planning stage. Suggested strategies for success include using an interdisciplinary team, selecting a champion, securing additional resources, identifying specific goals and providing feedback on progress, using work-flow analyses and stepwise implementation and/or pilot testing, creating standard work, eliciting feedback from staff, and celebrating successes. The knowledge gained from these initiatives has been disseminated at UCSF, and the initiatives have helped to raise general awareness regarding the importance of quality. CONCLUSIONS The ventilator bundle of care, TGC, and EGDT are still in use at UCSF, with modification of the initiatives occurring as new evidence becomes available.

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

Abstract Objective: Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods: A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. Results: A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). Conclusion: A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments

INTRODUCTION Boarding, especially among psychiatric patients, has been characterized as a significant cause of ED crowding, but no quantitative analysis has described boarding nationally. This study determines the incidence, duration, and factors associated with ED boarding in the United States. METHODS 2008 National Hospital Ambulatory Medical Care Survey ED data were stratified by visit type (psychiatric vs. non-psychiatric), boarding status, and patient and hospital characteristics. Boarding was defined as a visit with an ED length of stay >6 hours, and boarding time as ED length of stay minus 6 hours. Pearsons chi-square tests describe hospital and patient characteristics stratified by boarding status. Multilevel multivariable logistic and linear regressions determine associations with boarding and boarding time. RESULTS While 11% of all ED patients boarded, 21.5% of all psychiatric ED patients boarded. Boarding was also more prolonged for psychiatric ED patients. Controlling for confounders, odds of boarding for psychiatric patients were 4.78 (2.63-8.66) times higher than non-psychiatric, and psychiatric patients boarded 2.78 (1.91-3.64) hours longer than non-psychiatric. DISCUSSION US EDs experienced high proportions and durations of boarding with psychiatric patients disproportionately affected. Additional research concerning mental health care services and legislation may be required to address ED psychiatric patient boarding.

Effect of an electronic medical record alert for severe sepsis among ED patients.

BACKGROUND Severe sepsis and septic shock are a major health concern worldwide. The objective of this study is to determine if Severe Sepsis Best Practice Alert (SS-BPA) implementation was associated with improved processes of care and clinical outcomes among patients with severe sepsis or septic shock presenting to the emergency department (ED). METHODS This is a single-center, before-and-after observational study. The intervention group (n = 103) consisted of adult patients presenting to the ED with severe sepsis or septic shock during a 7-month period after implementation of the SS-BPA. The control group (n = 111) consisted of patients meeting the same criteria over a prior 7-month period. The SS-BPA primarily acts by automated, real-time, algorithm-based detection of severe sepsis or septic shock via the electronic medical record system. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (LOS), time to antibiotic administration, and proportion of patients who received antibiotics within the target 60 minutes. RESULTS Time to antibiotics was significantly reduced in the SS-BPA cohort (29 vs 61.5 minutes, P < .001). In addition, there was a higher proportion of patients who received antibiotics within 60 minutes (76.7 vs 48.6%; P < .001). On multivariable analysis, in-hospital mortality was not significantly reduced in the intervention group (odds ratio, 0.64; 95% confidence interval, 0.26-1.57). Multivariable analysis of LOS indicated a significant reduction among patients in the SS-BPA cohort (geometric mean ratio, 0.66; 95% confidence interval, 0.53-0.82). CONCLUSION Implementation of the SS-BPA for severe sepsis or septic shock among ED patients is associated with significantly improved timeliness of antibiotic administration and reduced hospital LOS.

Many emergency department patients with severe sepsis and septic shock do not meet diagnostic criteria within 3 hours of arrival.

STUDY OBJECTIVE Proposed national performance measures for severe sepsis or septic shock include interventions within 3 hours of emergency department (ED) arrival rather than from time of first meeting diagnostic criteria. We aim to determine the percentage of ED patients who first meet criteria greater than 3 hours after arrival. METHODS We conducted a retrospective analysis of adult patients with severe sepsis or septic shock in 2 EDs (university hospital [September 2012 to June 2013] and public trauma center [December 2012 to May 2013]). Times of ED arrival and first meeting clinical criteria were collected for quality assurance programs, which differed between institutions. At the university hospital, patients with admission diagnoses consistent with infection were included. Clinical presentation was defined as time meeting 2 or more systemic inflammatory response syndrome criteria and evidence of end-organ dysfunction. At the trauma center, only patients with hospital discharge diagnoses consistent with infection were included. Clinical presentation was defined by time of end-organ dysfunction. RESULTS Three hundred seventy-two patients met inclusion criteria at the university hospital and 133 at the trauma center. Median times from ED arrival to first meeting criteria were 68 minutes (interquartile range 34 to 130 minutes) and 31 minutes (interquartile range 8 to 73 minutes), respectively; 15.3% (95% confidence interval 11.9% to 19.3%) and 9.8% (95% confidence interval 5.5% to 15.7%) first met criteria greater than 3 hours from ED arrival, respectively. CONCLUSION Compliance with a performance metric for severe sepsis and septic shock within 3 hours of ED arrival would require application of this measure to patients who do not meet diagnostic criteria, potentially resulting in unnecessary interventions. Measure developers should consider these findings.

Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma.

Objective This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. Methods This was a retrospective study of pediatric (age ⩽ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. Results Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19–4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10–3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33–5.83), or tachypneic (OR, 1.52; 95% CI, 1.05–2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65–164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11–3.27) or tachypnea (OR, 1.82; 95% CI, 1.17–2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07–0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67–0.94) were less likely to receive timely steroids. Conclusions In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.