Lori N. Scanlan-Hanson

Sustaining Improvement in Door-to-Balloon Time Over 4 Years The Mayo Clinic ST-Elevation Myocardial Infarction Protocol

Background—American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) <90 minutes for nontransferred patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention. Systems of care to achieve and sustain this DTB performance over several years have not been previously reported. Methods and Results—The Mayo Clinic STEMI protocol was implemented in April 2004 and included activation of the cardiac catheterization laboratory by the emergency medicine physician; a single call system to activate the catheterization laboratory; catheterization laboratory staff arrival within 20 to 30 minutes of activation; and real-time performance feedback within 24 to 48 hours. Data were collected on nontransferred STEMI patients. The preimplementation group (June 2002 to March 2004) comprised 96 patients with a median DTB of 97 (interquartile range, 82, 130) minutes, and 40% had a DTB <90 minutes. The postimplementation group (May 2004 to March 2008) comprised 322 patients with a median DTB of 67 (interquartile range, 55, 82) minutes, and 81% had a DTB <90 minutes. Postimplementation DTB was significantly shorter than preimplementation DTB (P<0.001). In the 4-year follow-up after protocol implementation, the DTB performance remained stable over time (P=0.41). Conclusions—The Mayo Clinic STEMI protocol implemented strategies to reduce DTB for nontransferred patients with STEMI. DTB was significantly reduced, and the results were sustained over the 4-year follow-up period. Our experience demonstrates the effectiveness and durability of process changes targeting timeliness of primary percutaneous coronary intervention.

A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department.

BACKGROUND Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. OBJECTIVE To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence. METHODS A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated. RESULTS The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit. CONCLUSIONS Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

Effect of a Physician Assistant as Triage Liaison Provider on Patient Throughput in an Academic Emergency Department

OBJECTIVES Overcapacity issues plague emergency departments (EDs). Studies suggest that triage liaison providers (TLPs) may shorten patient length of stay (LOS) and reduce the proportion of patients who leave without being seen (LWBS), but these results are not universal. Previous studies used physicians as TLPs. We evaluated whether a physician assistant (PA), acting as a TLP, would shorten LOS and decrease LWBS rates. METHODS The authors used an observational cohort controlled before-and-after study design with predefined outcome measures, comparing 8 pilot days to 8 control days. The TLP evaluated all Emergency Severity Index (ESI) level 3, 4, and 5 patients, excluding pediatric and behavioral health patients. RESULTS A total of 353 patients were included on pilot days and 371 on control days. LOS was shorter on pilot days than control days (median [interquartile range {IQR}] = 229 [168 to 303] minutes vs. 270 [187 to 372] minutes, p < 0.001). Waiting room times were similar between pilot and control days (median [IQR] = 69 [20 to 119] minutes vs. 70 [19 to 137] minutes, p = 0.408), but treatment room times were shorter (median [IQR] = 151 [92 to 223] minutes vs. 187 [110 to 254] minutes, p < 0.001). Finally, a lower proportion of patients LWBS on pilot days (1.4% vs. 9.7%, p < 0.001). CONCLUSIONS The addition of a PA as a TLP was associated with a 41-minute decrease in median total LOS and a lower proportion of patients who LWBS. The decrease in total LOS is likely attributable to the addition of the TLP, with patients having shorter duration in treatment rooms on pilot days compared to control days.

Commentary on "primer in health information exchange for the emergency physician: benefits and barriers".

Patients seek emergency care for a variety of reasons. Where a health information exchange (HIE) exists, emergency medical providers have access to clinical information that may otherwise represent a void. The general trend toward greater treatment intensity in the nation’s emergency departments reinforces the importance of research on the design and implementation of HIEs and the policies that seek to promote their effective use. Indeed, the experience of practitioners suggests that the most complicated patients who present in the emergency setting may benefit most from expanded access to information from their caregivers. The increasing intensity of patient conditions, the current epidemic of overcrowding in emergency departments, and the need to find cost-effective improvement information suggest that HIEs represent a timely policy and research agenda. In this issue of the Southern Medical Journal, Saef and colleagues correctly emphasize the literature supporting the role of HIEs in reducing the cost of care for patients seeking emergency services. Other authors have reviewed advantages in primary care; however, research on the impact on emergency medicine has not kept pace with the rate of interest and investment. Fontaine et al have rightly identified that the potential for HIEs to reduce cost and improve quality of care in ambulatory primary care practices is well recognized but needs further empiric study. The same holds true for HIEs and emergency medicine. Future policy and investment require an evidencebased approach. Access to more complete records for an HIE becomes most important for acute disease presentation (eg, chest pain) rather than less acute presentation (eg, ankle sprain). The complexity of multiple medications and complicated health histories challenges both patients and families to provide a complete picture even under the best of circumstances. Patients arrive with implanted devices, complications of postorgan transplant, and complex oncology regimes. These patients historically have required the highest resource allocation when they present to emergency services. Although achieving time efficiencies represents an important policy objective, HIEs address several quality concerns. When viewed through the lens of the Institute of Medicine’s six aims for safe, effective, patient-centered, timely, efficient, and equitable care, the concept of HIEs offers significant potential for improvements in care. A complete and an accurate medical history provides the basis for safe, effective, timely care in emergency medicine. In terms of safe and effective care, common sense would argue that the potential for overtreatment or undertreatment increases when basic medical histories are incomplete. Patient safety increaseswhen the risk of overprescribing a medication and the potential for drug interactions are reduced. Timely access to diagnostic test results increases efficiency by avoiding unnecessary or duplicative testing. It also may be that expanded use of HIEs provides new insights into the quality of emergency medicine, including the potential for evaluating what does and does not represent overly aggressive care. Furthermore, the potential uses of HIEs go beyond the initial encounter; depending on how HIEs are structured, the information in them enhances retrospective quality review and allows for longitudinal study of patient outcomes. The gaps among interest, investment, and appropriate evidence-based evaluation may reflect the local nature of HIE initiatives. As the authors make clear, although policy may be driven at the federal and state level, adoption and implementation of HIEs are by nature a local and regional endeavor. The American Recovery and Reinvestment Act of 2009 (Public Law 111-5) acknowledges the local nature of initiatives by providing state grants to promote health information technology. It is impossible to discuss the benefits and barriers in the creation of HIEs without examining the specifics of local politics, economics, healthcare networks, technological resources, and Invited Commentary

Improving Community Resilience through Disaster Simulation: How Simulation-based Education Augments Emergency Management Exercises

Abstract Increased interest among leaders and practitioners in the field of emergency preparedness in the concept of whole community resilience can create new ways reaching the community. This paper explores one approach to community-engaged preparedness education. By drawing on the fields of emergency management and simulation–based instructional design, we describe an approach to preparedness events with broad community participation. We describe the education methodology used to plan the event and the core concepts related to simulation-based education. We offer key principles for event planners to engage a diverse group of participants ranging from youth, pre-professional healthcare students, practicing healthcare professionals, and staff from local community organizations. Our experience through seven years of events offers a proof of concept available to local communities; community organizational leaders concerned with the resilience for their own organizations; and academic organizations preparing our citizens to deal with the challenges of living and serving in a world of increasing risk of disaster.

Clinical care review systems in healthcare: a systematic review

BackgroundClinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review.MethodsA librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction.ResultsWe found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review.ConclusionWhile guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation.