Margarita E. Pena

Effect of establishing guidelines on appropriate urinary catheter placement.

OBJECTIVES Avoiding placement of unnecessary urinary catheters (UCs) in the emergency department (ED) affects UC utilization during hospitalization. The authors sought to evaluate the effect of establishing institutional guidelines for appropriate UC placement coupled with emergency physician (EP) education on UC utilization. METHODS Urinary catheter utilization was measured before and after the establishment of guidelines and EP education. Data collected included the presence of a UC on ED arrival, placement of a UC in the ED, documentation of a physician order for UC placement, reasons for placement, and compliance with the guidelines. Chi-square analyses were used to study the association between pre- and postintervention time periods and catheter use. RESULTS A total of 377 (15%) patients had UCs; only 151 (47%) UCs initially placed in the ED had a physician order documented. UC placement was appropriately indicated in 75.5% of patients with a documented physician order, but in only 52% of cases without a documented physician order (p<0.001). The physician intervention was associated with an overall reduction in UC utilization from 16.4% to 13% (p=0.018). Physicians ordered 40% fewer UCs postintervention compared to preintervention. Preintervention, a physician order for UC placement was found indicated in 72.6% patients, compared to 82.2% patients with UC placed postintervention (p=0.21). CONCLUSIONS Establishing guidelines for UC placement and physician education in the ED were associated with a marked reduction in utilization. However, addressing appropriate UC utilization may require evaluating other factors such as nursing influence on utilization.

Urinary catheters in the emergency department: Very elderly women are at high risk for unnecessary utilization

BACKGROUND Many of the urinary catheters (UCs) placed in the emergency department (ED) might not be necessary. We evaluated compliance with our institutional UC utilization guidelines and assessed factors influencing utilization. METHODS We conducted a 12-week retrospective observational study evaluating UC utilization in all admissions from the ED. Data included reason for placement, presence of a physicians order for placement, resident physician involvement, and patient age and sex. RESULTS Out of 4521 patients evaluated, 532 (11.8%) had a UC placed. Of these UCs, 371 (69.7%) were indicated, and 312 (58.6%) had a physicians order documented. The mean age of the patients who had a UC placed without an indication was 71.3 ± 18.8 years, that of patients with an indication was 60.0 ± 22.4 years (P < .0001), and that of patients who did not have a UC placed was 56.2 ± 22.6 years (P < .0001). Half of the women aged ≥80 years who had a UC placed did not have an indication according to our institutional guidelines. Multivariate logistic regression showed that women were 1.9 times more likely than men, and those age ≥80 years were 2.9 times more likely than those age ≤50 years, to have a UC placed without an indication. CONCLUSION Very elderly women are at high risk for inappropriate UC utilization in the ED. Interventions are needed to address this vulnerable population.

Sustained reductions in urinary catheter use over 5 years: Bedside nurses view themselves responsible for evaluation of catheter necessity

BACKGROUND Multiple approaches are needed to improve urinary catheter use and sustain compliance with the appropriate indications for catheter use. METHODS We evaluated the effect of 3 interventions over 5 years: a nurse-driven multidisciplinary effort for early urinary catheter removal, an intervention in an emergency department to promote appropriate placement, and twice-weekly assessment of urinary catheter prevalence with periodic feedback on performance for nonintensive care units. We also assessed the views of bedside nurses, case managers, and nurse managers with respect to appropriate catheter use, how often need is assessed, and who they consider responsible for the evaluation of urinary catheter need. RESULTS There was a significant reduction in urinary catheter use from 17.3%-12.7% during the 5-year period (linear regression with time as independent variable, R(2), 0.61; P < .0001). Of bedside nurses responding to the questionnaire, 222 of 227 (97.8%) identified themselves as responsible or as sharing the responsibility for catheter necessity evaluation, 223 of 229 (97.4%) were confident in their knowledge, and 166 of 222 (74.8%) viewed physicians as receptive to their requests for catheter removal >70% of the time. CONCLUSIONS A multifaceted approach to promote appropriate urinary catheter use is associated with sustained reductions in catheter use. Bedside nurses view themselves responsible for the evaluation of catheter presence and need.

The effect of resident peer-to-peer education on compliance with urinary catheter placement indications in the emergency department.

Objective This study aims to evaluate the effect of resident peer-to-peer education on knowledge of appropriate urinary catheter (UC) placement in the emergency department (ED) and to determine if this translates into further reduction in UC utilisation. Background Instituting guidelines for appropriate UC placement reduces UC utilisation in the ED. No study has explored if resident education in a teaching hospital would further reduce UC utilisation. Methods An educational intervention implemented in February 2009 consisted of a lecture, distribution of pocket cards and a peer-administered weekly review of institutional UC guidelines. A 12-question multiple-choice test was given to residents prelecture and postlecture, and the 12-question test was repeated 3 months later. Retrospective chart review was performed to evaluate UC utilisation before, immediately after and 3 months after the educational intervention. Results 30 residents completed all three tests. Significant differences were found between the mean test score pre-education and the mean test score immediately after education (9.43±1.17 vs 10.87±1.46, p<0.001) and between the mean test score pre-education and the mean test score 3 months posteducation (9.43±1.17 vs 10.43±1.28, p<0.001). There was no significant difference in UC utilisation or in the proportion of indicated UCs placed by residents within the three study periods. Conclusions Resident peer-to-peer education was associated with improvement of knowledge but did not result in decreased UC utilisation. A more active approach must be taken and other factors need to be further explored to reduce unnecessary placement of UC by residents in the ED.

Decreasing troponin turnaround time in the emergency department using the central laboratory: A process improvement study.

OBJECTIVES To implement collaborative process improvement measures to reduce emergency department (ED) troponin turnaround time (TAT) to less than 60min using central laboratory. DESIGN AND METHODS This was an observational, retrospective data study. A multidisciplinary team from the ED and laboratory identified opportunities and developed a new workflow model. Process changes were implemented in ED patient triage, staffing, lab collection and processing. Data collected included TAT of door-to-order, order-to-collect, collect-to-received, received-to-result, door-to-result, ED length of stay, and hemolysis rate before (January-August, 2011) and after (September 2011-June 2013) process improvement. RESULTS After process improvement and implementation of the new workflow model, decreased median TAT (in min) was seen in door-to-order (54 [IQR43] vs. 11 [IQR20]), order-to-collect (15 [IQR 23] vs. 10 [IQR12]), collect-to-received (6 [IQR8] vs. 5 [IQR5]), received-to-result (30 [IQR12] vs. 24 [IQR11]), and overall door-to-result (117 [IQR60] vs. 60 [IQR40]). A troponin TAT of <60min was realized beginning in May 2012 (59 [IQR39]). Hemolysis rates decreased (14.63±0.74 vs. 3.36±1.99, p<0.0001), as did ED length of stay (5.87±2.73h vs. 5.15±2.34h, p<0.0001). Conclusion Troponin TAT of <60min using a central laboratory was achieved with collaboration between the ED and the laboratory; additional findings include a decreased ED length of stay.

Effect on efficiency and cost-effectiveness when an observation unit is managed as a closed unit vs an open unit

OBJECTIVE To compare efficiency and cost-effectiveness of an observation unit (OU) when managed as a closed unit vs an open unit. METHODS This observational, retrospective study of a 30-bed OU compared three time periods: Nov 2007 to Aug 2008 (period 1), Nov 2008 to Aug 2009 (period 2) and Nov 2010 to Aug 2011 (period 3). The OU was managed and staffed by non-emergency department physicians as an open unit during period 1, and a closed unit by emergency department physicians during periods 2 and 3. RESULTS OU volume was greatest in period 3 (1 vs 3, 95% CI -235.8 to -127.9; 2 vs 3, 95% CI -191.9 to -84.095%). Periods 2 and 3 had shorter lengths of stay for discharged (1 vs 2, 95% CI -6.6 to 1.7; 1 vs 3, 95% CI -8.1 to -3.1) and admitted (1 vs 2, 95% CI -11.4 to -8.6; 1 vs 3, 95% CI -11.8 to -9.0) patients, less admission rates (P < .001), and less 30-day all cause admission rates after discharge (P < .0001). Cost was less during periods 2 and 3 for direct (1 vs 2, 95% CI -392.5 to -305.9; 1 vs 3, 95% CI -471.4 to -388.4), indirect (1 vs 2, 95% CI -249.5 to - 199.8; 1 vs 3, 95% CI -187 to-139.4) and total cost (1 vs 2, 95% CI -640.7 to -507; 1 vs 3, 95% CI -657.2 to -529). CONCLUSION The same OU was more efficient and cost-effective when managed as a closed unit vs an open unit.

Ethical considerations for emergency care providers during pandemic influenza--ready or not...

When an infectious pandemic occurs in the United States, emergency care providers (ECPs) will be on the frontlines caring for infected, potentially infected, and non-infected patients. Logistically, the current emergency care system is not ready for a pandemic, but are the providers ethically ready? Some of the most difficult and challenging issues that will be raised during a pandemic will be ethical in nature. An ECP likely will be confronted with ethical values and value conflicts underlying restriction of liberty, duty to care, and resource allocation. This report summarizes the ethical concerns and challenges that ECPs face during an infectious pandemic, and raises ethical questions that may arise related to the role of an ECP as a healthcare provider and stakeholder.

Cost-effectiveness of noninvasive ventilation for chronic obstructive pulmonary disease-related respiratory failure in Indian hospitals without ICU facilities

Introduction: The majority of Indian hospitals do not provide intensive care unit (ICU) care or ward-based noninvasive positive pressure ventilation (NIV). Because no mechanical ventilation or NIV is available in these hospitals, the majority of patients suffering from respiratory failure die. Objective: To perform a cost-effective analysis of two strategies (ward-based NIV with concurrent standard treatment vs standard treatment alone) in chronic obstructive pulmonary disease (COPD) respiratory failure patients treated in Indian hospitals without ICU care. Materials and Methods: A decision-analytical model was created to compare the cost-effectiveness for the two strategies. Estimates from the literature were used for parameters in the model. Future costs were discounted at 3%. All costs were reported in USD (2012). One-way, two-way, and probabilistic sensitivity analysis were performed. The time horizon was lifetime and perspective was societal. Results: The NIV strategy resulted in 17.7% more survival and was slightly more costly (increased cost of

Care of Respiratory Conditions in an Observation Unit

101 (USD 2012) but resulted in increased quality-adjusted life-years (QALYs) (1.67 QALY). The cost-effectiveness (2012 USD)/QALY in the standard and NIV groups was

Reduction in Radiation Exposure through a Stress Test Algorithm in an Emergency Department Observation Unit

78/QALY (