Michael Hocker

Evidence-Based Perspectives on Pay for Performance and Quality of Patient Care and Outcomes in Emergency Medicine

Pay for performance is gaining momentum as a means to improve the quality of clinical care. Recently, the Centers for Medicare & Medicaid Services has expanded pay for performance initiatives to incorporate 9 emergency care metrics, including indicators for cardiac, pneumonia, and stroke care. The American College of Cardiology and American Heart Association (ACC/AHA) have published methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. The purpose of this study is to grade each of the 9 Physician Quality Reporting Initiative emergency medicine process measures according to the ACC/AHA criteria related to clinical evidence (yes, no, indeterminate). Five of the 9 recently selected metrics in emergency medicine do not appear to meet all of the ACC/AHA criteria for measurement selection. Several of the metrics, including aspirin for acute myocardial infarction (mean hospital adherence 94.7%; SD 6.7%) and pulse oximetry for community-acquired pneumonia (mean 99.4%; SD 2.0%), already have high levels of performance nationally, which raises uncertainty about the overall cost-effectiveness of quality improvement interventions for these measures. Formal methodology needs to be established for future selection of performance measures for quality improvement programs in emergency care. These performance measures should focus on unique aspects of emergency and acute care, including recognition and treatment of time-sensitive life-threatening conditions, assessment of patients with undifferentiated signs and symptoms, and care of all-inclusive geographically based patient populations. In key emergency therapeutic areas, the evidence linking treatment and improved patient outcomes will require additional study before inclusion in pay for performance programs. New research initiatives are needed to assess the effect of timely administration of emergency department interventions on patient outcomes.

Analysis of traumatic injuries presenting to a referral hospital emergency department in Moshi, Tanzania

BackgroundInjuries represent a significant and growing public health concern in the developing world, yet their impact on patients and the emergency health-care system in the countries of East Africa has received limited attention. This study evaluates the magnitude and scope of injury related disorders in the population presenting to a referral hospital emergency department in northern Tanzania.MethodsA retrospective chart review of patients presenting to the emergency department at Kilimanjaro Christian Medical Centre was performed. A standardized data collection form was used for data abstraction from the emergency department logbook and the complete medical record for all injured patients. Patient demographics, mechanism of injury, location, type and outcomes were recorded.ResultsTen thousand six hundred twenty-two patients presented to the emergency department for evaluation and treatment during the 7-month study period. One thousand two hundred twenty-four patients (11.5%) had injuries. Males and individuals aged 15 to 44 years were most frequently injured, representing 73.4% and 57.8%, respectively. Road traffic injuries were the most common mechanism of injury, representing 43.9% of injuries. Head injuries (36.5%) and extremity injuries (59.5%) were the most common location of injury. The majority of injured patients, 59.3%, were admitted from the emergency department to the hospital wards, and 5.6%, required admission to an intensive care unit. Death occurred in 5.4% of injured patients.ConclusionsThese data give a detailed and more robust picture of the patient demographics, mechanisms of injury, types of injury and patient outcomes from similar resource-limited settings.

Road Traffic Injury Prevention Initiatives: A Systematic Review and Metasummary of Effectiveness in Low and Middle Income Countries

Background Road traffic injuries (RTIs) are a growing but neglected global health crisis, requiring effective prevention to promote sustainable safety. Low- and middle-income countries (LMICs) share a disproportionately high burden with 90% of the world’s road traffic deaths, and where RTIs are escalating due to rapid urbanization and motorization. Although several studies have assessed the effectiveness of a specific intervention, no systematic reviews have been conducted summarizing the effectiveness of RTI prevention initiatives specifically performed in LMIC settings; this study will help fill this gap. Methods In accordance with PRISMA guidelines we searched the electronic databases MEDLINE, EMBASE, Scopus, Web of Science, TRID, Lilacs, Scielo and Global Health. Articles were eligible if they considered RTI prevention in LMICs by evaluating a prevention-related intervention with outcome measures of crash, RTI, or death. In addition, a reference and citation analysis was conducted as well as a data quality assessment. A qualitative metasummary approach was used for data analysis and effect sizes were calculated to quantify the magnitude of emerging themes. Results Of the 8560 articles from the literature search, 18 articles from 11 LMICs fit the eligibility and inclusion criteria. Of these studies, four were from Sub-Saharan Africa, ten from Latin America and the Caribbean, one from the Middle East, and three from Asia. Half of the studies focused specifically on legislation, while the others focused on speed control measures, educational interventions, enforcement, road improvement, community programs, or a multifaceted intervention. Conclusion Legislation was the most common intervention evaluated with the best outcomes when combined with strong enforcement initiatives or as part of a multifaceted approach. Because speed control is crucial to crash and injury prevention, road improvement interventions in LMIC settings should carefully consider how the impact of improvements will affect speed and traffic flow. Further road traffic injury prevention interventions should be performed in LMICs with patient-centered outcomes in order to guide injury prevention in these complex settings.

Exploring Patterns of Health Service Use in Older Emergency Department Patients

OBJECTIVES Study objectives were to identify groups of older patients with similar patterns of health care use in the 12 months preceding an index outpatient emergency department (ED) visit and to identify patient-level predictors of group membership. METHODS   Subjects were adults ≥ 65 years of age treated and released from an academic medical center ED. Latent cluster analysis (LCA) models were estimated to identify groups with similar numbers of primary care (PC), specialist, and outpatient ED visits and hospital days within 12 months preceding the index ED visit. RESULTS   In this sample (n = 308), five groups with distinct patterns of health service use emerged. Low Users (35%) had fewer visits of all types and fewer hospital days compared to sample means. Low Users were more likely to be female and had fewer chronic health conditions relative to the overall sample (p < 0.05). The ED to Supplement Primary Care Provider (PCP) (23%) group had more PCP visits, but also significantly more ED visits. Specialist Heavy (22%) group members had twice as many specialist visits, but no difference in PCP visits. Members of this class were more likely to be white and male (p < 0.05). High Users (15%) received more care in all categories and had more chronic baseline health conditions (p < 0.05) but no differences in demographic characteristics relative to the whole sample. The ED and Hospital as Substitution Care (6%) group had fewer PC and specialist visits, but more ED visits and hospital days. CONCLUSIONS   In this sample of older ED patients, five groups with distinct patterns of health service use were identified. Further study is needed to determine whether identification of these patient groups can add important information to existing risk-assessment methods.

A prospective registry evaluating the epidemiology and clinical care of traumatic brain injury patients presenting to a regional referral hospital in Moshi, Tanzania: challenges and the way forward.

Traumatic brain injury (TBI) is the most common cause of death and disability globally disproportionately affecting low- and middle-income countries where increasing injury rates are compounded by limited quality care. The objective of this study is to describe quality of care for TBI patients who presented to Kilimanjaro Christian Medical Center, Moshi, Tanzania. We evaluated a prospective quality improvement TBI registry that enrolled consecutive patients with acute TBI. Descriptive statistics and qualitative comparative analysis was performed. Overall, 893 TBI patients were enrolled during the study period, with a mean age of 32.1 years and who were mostly (80%) male. 12.9% suffered severe TBI (GCS < 9). Most injuries were road traffic (66%) especially motorcyclists (49%) and 26.8% were alcohol related. One intubation occurred, and 22.9% of hypoxic patients received oxygen. Severe TBI mortality was 47%. TBI affects men 15–45 years old in traffic crashes with high mortality for severe TBI (47%) patients. Care addressing secondary injury, hypoxemia, and hypotension is limited.

An observation unit may help improve an institution's Press Ganey satisfaction score.

BACKGROUND : Hospitals measure patient satisfaction through Press Ganey (PG) surveys. The impact of an emergency department observation unit (EDOU) on patient satisfaction has not been reported to date. We hypothesize that an EDOU has a positive impact on patient satisfaction results as measured by PG surveys. METHODS : This is a retrospective observational analysis of PG scores collected for 8 quarters before the opening of a 13-bed EDOU in January 2002 and compared with 6 quarters post-EDOU opening, starting April 1, 2003, at a tertiary care, academic, urban hospital. The facility, physician staffing, nursing, and wait times all remained the same during this period. Mean values and a 95% confidence interval (CI) are reported and statistical significance is calculated using a t test. Significance is defined as a P < 0.05. RESULTS : The mean overall PG scores pre-EDOU was 75.2 (95% CI: 74.2-76.2) and post-EDOU was 80.2 (95% CI: 78.9-82.6), which is statistically significant (P = 0.00005). Of 9 scoring categories, 9 increased post-EDOU. Other than the category for physician scores, all other mean values were higher for the EDOU in the subcategories. CONCLUSION : The introduction of an observation unit appears to be associated with a statistical improvement in patient satisfaction scores as reported by PG, in the setting of same facility, physician staffing, and nursing staffing.

Health care utilization before and after an outpatient ED visit in older people.

BACKGROUND Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population. OBJECTIVES The goals of this study were to examine the relationships between health care use before and after an ED visit among older adults. METHODS This retrospective cohort study examined health care use among 308 patients 65 years or older discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician [PCP], specialist, ED, and hospital) and risk of return ED visits. RESULTS Older ED patients in this study had visited other types of providers frequently in the previous year (median number of PCP and specialist visits, 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits, 7.0 vs 4.0; P < .001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (hazard ratio, 2.20; 95% confidence interval, 1.15-4.21), in models adjusted for demographics and health status. CONCLUSION Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals.

Systematic review and metasummary of attitudes toward research in emergency medical conditions

Emergency departments are challenging research settings, where truly informed consent can be difficult to obtain. A deeper understanding of emergency medical patients’ opinions about research is needed. We conducted a systematic review and meta-summary of quantitative and qualitative studies on which values, attitudes, or beliefs of emergent medical research participants influence research participation. We included studies of adults that investigated opinions toward emergency medicine research participation. We excluded studies focused on the association between demographics or consent document features and participation and those focused on non-emergency research. In August 2011, we searched the following databases: MEDLINE, EMBASE, Google Scholar, Scirus, PsycINFO, AgeLine and Global Health. Titles, abstracts and then full manuscripts were independently evaluated by two reviewers. Disagreements were resolved by consensus and adjudicated by a third author. Studies were evaluated for bias using standardised scores. We report themes associated with participation or refusal. Our initial search produced over 1800 articles. A total of 44 articles were extracted for full-manuscript analysis, and 14 were retained based on our eligibility criteria. Among factors favouring participation, altruism and personal health benefit had the highest frequency. Mistrust of researchers, feeling like a ‘guinea pig’ and risk were leading factors favouring refusal. Many studies noted limitations of informed consent processes in emergent conditions. We conclude that highlighting the benefits to the participant and society, mitigating risk and increasing public trust may increase research participation in emergency medical research. New methods for conducting informed consent in such studies are needed.

Noninvasive Ventilation in Severe Acute Asthma

Noninvasive ventilation (NIV) in severe acute asthma is controversial but may benefit this population by preventing intubation. We report on a 35-year-old male asthma patient who presented to our emergency department via emergency medical services. The patient was responsive, diaphoretic, and breathing at 35 breaths/min on 100% oxygen with bag-mask assistance, with SpO2 88%, heart rate 110–120 beats/min, blood pressure 220/110 mm Hg, and temperature 35.8°C. NIV at 12/5 cm H2O and FIO2 0.40 was applied, and albuterol at 40 mg/h was initiated. Admission arterial blood gas revealed a pH of 6.95, PaCO2 126 mm Hg, and PaO2 316 mm Hg. After 90 min of therapy, PaCO2 was 63 mm Hg. Improvement continued, and NIV was stopped 4 h following presentation. NIV tolerance was supported with low doses of lorazepam. The patient was transferred to the ICU, moved to general care the next morning, and discharged 3 days later. We attribute our success to close monitoring in a critical care setting and the titration of lorazepam.

Evaluation of a Novel Wound Closure Device: A Multicenter Randomized Controlled Trial

OBJECTIVES A novel wound closure device combining a mesh tape and octylcyanoacrylate (OCA) topical skin adhesive (TSA) was developed to facilitate wound closure and enhance the adhesives strength. The objective of this study was to determine whether the incidence of wound dehiscence after laceration repair with the new device was equivalent to that after use of a high-viscosity OCA. We hypothesized that the rate of complete wound edge apposition would be equivalent for the two closure devices. METHODS This was a multicenter, randomized clinical trial in nine academic and community emergency departments (EDs) and urgent care centers. Patients with simple traumatic lacerations were included. Lacerations were randomly closed with a high-viscosity OCA or mesh tape-OCA combination. The rate of complete wound edge apposition at 14 days, rates of wound infection at 14 and 30 days, and the percentage of optimally appearing scars at 30 days after closure were assessed. Assuming a maximal clinically acceptable difference for equivalence of 8% in the rate of completely apposed wound edges, a sample of at least 138 patients in the tape-OCA group and at least 69 in the OCA-only group would give 80% power and a one-sided significance level of 5%. RESULTS During the study period the investigators enrolled 216 subjects, of whom 143 were randomized to the tape-OCA combination and 73 to the OCA-only group. Most wounds were located on the face and the upper extremities. Mean laceration length was similar in patients in both groups (tape-OCA 2.1 cm vs. OCA-only 2.0 cm; difference 0.1 cm, 95% confidence interval [CI] = -0.45 to 0.58 cm). The rate of complete wound edge apposition at 14 days was higher in wounds treated with the tape-OCA combination than in wounds treated with OCA alone (86.0% vs. 78.1%). The upper bound of the one-sided CI was 1.0% for the intention-to-treat population, which was less than the predetermined acceptable difference of less than 8%. There were no between-group differences in rates of infection and optimally appearing scars. CONCLUSIONS When compared with OCA alone, the novel tape-OCA combination is equivalent with regard to complete wound edge apposition and cosmetic appearance.