Daniel A. Handel

Using information technology to improve the quality and safety of emergency care

With the 2010 federal health care reform passage, a renewed focus has emerged for the integration of electronic health records (EHRs) into the U.S. health care system. A consensus conference in October 2009 met to discuss the future research agenda with regard to using information technology (IT) to improve the future quality and safety of emergency department (ED) care. The literature is mixed as to how the use of computerized provider order entry (CPOE), clinical decision support (CDS), EHRs, and patient tracking systems has improved or degraded the safety and quality of ED care. Such mixed findings must be considered in the national push for rapid implementation of health IT. We present a research agenda addressing the major questions that are posed by the introduction of IT into ED care; these questions relate to interoperability, patient flow and integration into clinical work, real-time decision support, handoffs, safety-critical computing, and the interaction between IT systems and clinical workflows.

Implementing Electronic Health Records in the Emergency Department

BACKGROUND The increasing presence of electronic health records (EHRs) in health care presents interesting and unique challenges in the Emergency Department (ED) setting. Unfortunately, scant literature exists addressing the implementation of EHRs in this setting. OBJECTIVES The authors, both involved in the implementation of such systems at their respective institutions, review the challenges and benefits that exist with such implementation, and the steps that EDs can take to facilitate this process. DISCUSSION Unlike ambulatory and inpatient settings, where patient volume can be adjusted to help with this transition, EDs are unable to alter their volume and must maximize their efficiency during this process. CONCLUSIONS Understanding and anticipating the EHRs impact on workflow is critical to successful implementation.

The use of sleep aids among Emergency Medicine residents: a web based survey

BackgroundSleepiness is a significant problem among residents due to chronic sleep deprivation. Recent studies have highlighted medical errors due to resident sleep deprivation. We hypothesized residents routinely use pharmacologic sleep aids to manage their sleep deprivation and reduce sleepiness.MethodsA web-based survey of US allopathic Emergency Medicine (EM) residents was conducted during September 2004. All EM residency program directors were asked to invite their residents to participate. E-mail with reminders was used to solicit participation. Direct questions about use of alcohol and medications to facilitate sleep, and questions requesting details of sleep aids were included.ResultsOf 3,971 EM residents, 602 (16%) replied to the survey. Respondents were 71% male, 78% white, and mean (SD) age was 30 (4) years, which is similar to the entire EM resident population reported by the ACGME. There were 32% 1st year, 32% 2nd year, 28% 3rd year, and 8% 4th year residents. The Epworth Sleepiness Scale (ESS) showed 38% of residents were excessively sleepy (ESS 11–16) and 7% were severely sleepy (ESS>16). 46% (95 CI 42%–50%) regularly used alcohol, antihistamines, sleep adjuncts, benzodiazepines, or muscle relaxants to help them fall or stay asleep. Study limitations include low response and self-report.ConclusionEven with a low response rate, sleep aid use among EM residents may be common. How this affects performance, well-being, and health remains unknown.

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

The Financial Impact of Ambulance Diversion on Inpatient Hospital Revenues and Profits

OBJECTIVES The objective was to study the association between ambulance diversion and weekly inpatient hospital revenues and profits. METHODS This was a retrospective review of administrative data from one academic medical center from July 1, 2003, to December 31, 2006. Given the high amount of daily variability, inpatient hospital revenues and profits were collapsed by week and evaluated in four categories: no diversion, mild diversion (from >0 and <10 hours), moderate diversion (>10 and <20 hours), and high diversion (>20 hours). Revenues and profits for two categories of patients admitted to the hospital were calculated: 1) patients admitted from the emergency department (ED; i.e., those arriving by ambulance and by other means) and 2) electively admitted patients. RESULTS A total of 166,460 ED patients were included in the analysis. Inpatient hospital revenues were included from 85,111 patients, 28,665 of which were admissions from the ED (33.7%). For patients admitted from the ED, the average weekly revenues during periods of high diversion were

Emergency Department Patient Volume and Troponin Laboratory Turnaround Time

265K higher than periods of no diversion. For patients admitted on an elective basis, revenues were significantly higher when comparing periods of mild divert to high diversion (an additional

Is all pain is treated equally? A multicenter evaluation of acute pain care by age

415K weekly). The overall increase in profitability was significant for periods of severe divert compared to no divert (

Associations Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in an Adult Population

119K per week). CONCLUSIONS Periods of greater diversion are associated with higher inpatient revenues and profits for ED, electively admitted patients, and the overall inpatient hospital population. Therefore, no financial disincentive exists from an inpatient perspective for the boarding of admitted patients in the ED and increasing periods of diversion. Efforts to decrease ambulance diversion must therefore be based on other rationales, like patient safety, quality of care, and improving access to care, or new models of reimbursement that reward hospitals for reducing ambulance diversion.

The future of emergency medicine: an evolutionary perspective.

OBJECTIVES Increases in emergency department (ED) visits may place a substantial burden on both the ED and hospital-based laboratories. Studies have identified laboratory turnaround time (TAT) as a barrier to patient process times and lengths of stay. Prolonged laboratory study results may also result in delayed recognition of critically ill patients and initiation of appropriate therapies. The objective of this study was to determine how ED patient volume itself is associated with laboratory TAT. METHODS This was a retrospective cohort review of patients at five academic, tertiary care EDs in the United States. Data were collected on all adult patients seen in each ED with troponin laboratory testing during the months of January, April, July, and October 2007. Primary predictor variables were two ED patient volume measures at the time the troponin test was ordered: 1) number of all patients in the ED/number of beds (occupancy) and 2) number of admitted patients waiting for beds/beds (boarder occupancy). The outcome variable was troponin turnaround time (TTAT). Adjusted covariates included patient characteristics, triage severity, season (month of the laboratory test), and site. Multivariable adjusted quantile regression was carried out to assess the association of ED volume measures with TTAT. RESULTS At total of 9,492 troponin tests were reviewed. Median TTAT for this cohort was 107 minutes (interquartile range [IQR] = 73-148 minutes). Median occupancy for this cohort was 1.05 patients (IQR = 0.78-1.38 patients) and median boarder occupancy was 0.21 (IQR = 0.11-0.32). Adjusted quantile regression demonstrated a significant association between increased ED patient volume and longer times to TTAT. For every 100% increase in census, or number of boarders over the number of ED beds, respectively, there was a 12 (95% confidence interval [CI] = 9 to 14) or 33 (95% CI = 24 to 42)-minute increase in TTAT. CONCLUSIONS Increased ED patient volume is associated with longer hospital laboratory processing times. Prolonged laboratory TAT may delay recognition of conditions in the acutely ill, potentially affecting clinician decision-making and the initiation of timely treatment. Use of laboratory TAT as a patient throughput measure and the study of factors associated with its prolonging should be further investigated.

Association of Emergency Department and Hospital Characteristics with Elopements and Length of Stay

Summary Older patients receive less analgesics than younger patients, yet had greater reductions in acute pain scores. These differences may be driven by type of pain. ABSTRACT Pain is highly prevalent in health care settings; however, disparities continue to exist in pain care treatment. Few studies have investigated if differences exist based on patient‐related characteristics associated with aging. The objective of this study was to determine if there are differences in acute pain care for older vs younger patients. This was a multicenter, retrospective, cross‐sectional observation study of 5 emergency departments across the United States evaluating the 2 most commonly presenting pain conditions for older adults, abdominal and fracture pain. Multivariable adjusted hierarchical modeling was completed. A total of 6,948 visits were reviewed. Older (≥65 years) and oldest (≥85 years) were less likely to receive analgesics compared to younger patients (<65 years), yet older patients had greater reductions in final pain scores. When evaluating pain treatment and final pain scores, differences appeared to be based on type of pain. Older patients with abdominal pain were less likely to receive pain medications, while older patients with fracture were more likely to receive analgesics and opioids compared to younger patients. Differences in pain care for older patients appear to be driven by the type of presenting pain.