Craig Rothenberg

Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL)

Study objective We describe current hospital‐level performance for the Centers for Medicare & Medicaid Services’ Severe Sepsis/Septic Shock Early Management Bundle (SEP‐1) quality measure and qualitatively assess emergency department (ED) sepsis quality improvement best practice implementation. Methods Using a standardized Web‐based submission portal, we surveyed quality improvement data from volunteer hospital‐based EDs participating in the Emergency Quality Network Sepsis Initiative. Each hospital submitted preliminary SEP‐1 local chart review data, using existing Centers for Medicare & Medicaid Services definitions. We report descriptive statistics of SEP‐1 data availability and performance. The primary outcome for this study was SEP‐1 bundle compliance, defined as the proportion of all severe sepsis and septic shock cases receiving all required bundle elements, and secondary outcomes included conditional compliance on reported SEP‐1 numerator components and ED implementation of sepsis quality improvement best practices. Results A total of 50 EDs participated in the survey; 74% were nonteaching sites and 26% were affiliated with academic centers. Of all participating EDs, 80% were in regions with relatively high population density. The mean hospital SEP‐1 bundle compliance was 54% (interquartile range 30% to 75%). Bundle compliance improved during fiscal year 2016 from 39% to 57%. Broad variation existed for each bundle component, with intravenous fluid resuscitation and repeated lactate bundle elements having the widest variation and largest gaps in quality. At least one consensus sepsis quality improvement best practice implementation occurred in 92% of participating sites. Conclusion Preliminary data on SEP‐1 performance suggest wide hospital‐level variation in performance, with modest improvement during the first year of data collection.

Systematic review of emergency medicine clinical practice guidelines: Implications for research and policy

Introduction Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence. Methods Systematic review of clinical practice guidelines (Clinical Policies) published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies. Results A total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent. Conclusions Emergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality standards.

Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications.

OBJECTIVES Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. METHODS We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims-based definition, 2) facility claims-based definition, and 3) CMS Research Data Assistance Center (ResDAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. RESULTS Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other definitions including 17% more ED visits than the provider definition and 2% fewer visits than the ResDAC definition. Differences in ED visitation counts between each definition occurred for several reasons including the inclusion of critical care or observation services in the ED, discrepancies between facility and provider billing regulations, and operational decisions of each definition. CONCLUSION Current operational definitions of ED visitation using administrative claims produce different estimates of ED visitation based on the underlying assumptions applied to billing data and data set availability. Future analyses using administrative claims data should seek to validate specific definitions and inform the development of a consistent, consensus ED visitation definitions to standardize research reporting and the interpretation of policy interventions.

Trends and Variation in the Utilization and Diagnostic Yield of Chest Imaging for Medicare Patients With Suspected Pulmonary Embolism in the Emergency Department

OBJECTIVE The purpose of this study is to assess trends and variation in chest CT utilization in the emergency department (ED) and its diagnostic yield for suspected pulmonary embolism (PE) among a national sample of Medicare beneficiaries. The relationship between hospital and provider characteristics is also discussed. MATERIALS AND METHODS We conducted an observational analysis of Medicare beneficiaries evaluated in the ED for suspected PE from 2000 to 2009. Standard Medicare analytic files representing a 20% sample of fee-for-service beneficiaries were linked to the American Hospital Association Annual Survey of Hospitals, American Medical Association Physician Masterfile, Medicare Physician Identification and Eligibility Registry, and Dartmouth Atlas Project to calculate geographic- and physician-level chest CT utilization (i.e., the proportion of ED visits involving chest CT examination for suspected PE) and diagnostic yield (i.e., the proportion of chest CT examinations with a positive PE diagnosis). RESULTS Of 2.5 million ED visits, 2.5% (n = 164,274) included chest CT for suspected PE; 6.2% visits (n = 10,121) resulted in positive findings for PE. Between 2000 and 2009, chest CT utilization increased fivefold. Geographic variation in CT utilization (median, 2.38%; interquartile range [IQR], 1.91-2.92%) and diagnostic yield (median, 6.31%; IQR, 5.11-7.66%) was observed between 306 hospital referral regions. Physician use of imaging was explained by greater experience (lower utilization and higher yield) and emergency medicine board certification (lower utilization and equivalent yield). CONCLUSION CT utilization in the ED for suspected PE has steadily risen, whereas diagnostic yields have declined over time. Wide variation in practice is observed at the physician and geographic levels and is explained by several physician and hospital characteristics. Taken together, our findings suggest a substantial inefficiency of chest CT use and substantial opportunities for improvement.

Reducing Unnecessary Blood Chemistry Testing in the Emergency Department

Point of care (POC) laboratory testing is used to improve emergency department (ED) throughput but often overuses resources by duplicating formal laboratory testing. This study sought to evaluate the effect of a multimodal intervention on duplicate chemistry testing. This pre-post analysis included all visits to 2 urban EDs between June 2014 and June 2016. The multimodal intervention including provider education, signage, electronic health record redesign, and audit and feedback focused on reducing duplicate chemistry testing. The primary outcome was the number of duplicate chemistry tests per 100 visits. Autoregressive integrated moving-average models were used to account for secular changes. A total of 299 701 ED visits were included. The daily number of duplicate chemistry and POC chemistry tests significantly decreased following the intervention (3.3 fewer duplicates and 10.2 fewer POC per 100 ED visits, P < .0001). This implementation of a multimodal quality improvement intervention yielded substantial reductions in the overuse of blood chemistry testing in the ED.

Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies:

Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate. Risks to patient safety during the transfer process were reported by 1 in 3 of respondents. Perceived risks were reported more frequently by nurses (44%) than physicians/advanced practice providers (28%). Real-time survey methodology appears to be a feasible and valuable, albeit resource intensive, tool to identify safety risks, expose barriers to communication, and reveal challenges not captured by traditional approaches to inform multidisciplinary quality improvement efforts.

Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service

Objective: Overcrowding in the emergency department (ED) has been associated with patient harm, yet little is known about the association between ED boarding and adverse hospitalization outcomes. We sought to examine the association between ED boarding and three common adverse hospitalization outcomes: rapid response team activation (RRT), escalation in care, and mortality. Method: We conducted an observational analysis of consecutive patient encounters admitted from the ED to the general medical service between February 2013 and June 2015. This study was conducted in an urban, academic hospital with an annual adult ED census over 90,000. We defined boarding as patients with greater than 4 h from ED bed order to ED departure to hospital ward. The primary outcome was a composite of adverse outcomes in the first 24 h of admission, including RRT activation, care escalation to intensive care, or in‐hospital mortality. Results: A total of 31,426 patient encounters were included of which 3978 (12.7%) boarded in the ED for 4 h or more. Adverse outcomes occurred in 1.92% of all encounters. Comparing boarded vs. non‐boarded patients, 41 (1.03%) vs. 244 (0.90%) patients experienced a RRT activation, 53 (1.33%) vs. 387 (1.42%) experienced a care escalation, and 1 (0.03%) vs.12 (0.04%) experienced unanticipated in‐hospital death, within 24 h of ED admission. In unadjusted analysis, there was no difference in the composite outcome between boarding and non‐boarding patients (1.91% vs. 1.91%, p = 0.994). Regression analysis adjusted for patient demographics, acuity, and comorbidities also showed no association between boarding and the primary outcome. A sensitivity analysis showed an association between ED boarding and the composite outcome inclusive of the entire inpatient hospital stay (5.8% vs. 4.7%, p = 0.003). Conclusion: Within the first 24 h of hospital admission to a general medicine service, adverse hospitalization outcomes are rare and not associated with ED boarding.

Patient centered medical homes did not improve access to timely follow-up after ED visit

Background: Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow‐up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow‐up appointment with practice access improvements, including patient‐centered medical home (PCMH) designations or extended‐hours appointments. Methods: We performed a secret‐shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow‐up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements. Results: Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7 days. Practices with PCMH designation were less likely to offer appointments within 7 days (23.4% vs. 33.1%, p = 0.03). However, callers were more likely to obtain an appointment in 7 days from practices offering after‐hour appointments (36.3% vs. 27.8%, p = 0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7‐day appointment availability or appointment wait time. Conclusion: PCMH designation and extended‐hours appointments were not associated with improved availability of timely primary care follow‐up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices.

Quality of Septic Shock Care in the Emergency Department: Perceptions Versus Reality

I the United States, more than a million patients are diagnosed with severe sepsis per year, of whom 25% die of septic shock.1 Early recognition of septic patients facilitates expedited implementation of evidence-based interventions that prevent delays in treatment of septic shock linked to mortality and morbidity.2 Widespread efforts have been made to improve provider awareness of quality gaps in sepsis care,3 including implementation of national quality measures by the Centers for Medicare & Medicaid Services, yet little is known about actual provider perceptions of sepsis care quality compared to actual quality measure performance.4 Previous work has shown that providers have limited ability to accurately self-assess their clinical performance.5 However, assessing gaps in knowledge and understanding the inadequacies of clinical performance are integral components of quality improvement (QI). Accurate clinician self-assessment is a necessary foundation for effective QI measured by provider competence and patient outcomes in various clinical contexts, including the emergency department (ED).6 Accordingly, as part of an institutional QI intervention, our objective was to examine ED clinician perceptions of septic shock care performance in comparison to actual performance on several nationally recognized metrics of sepsis care quality.