Richard T. Griffey

A compilation of strategies for implementing clinical innovations in health and mental health

Efforts to identify, develop, refine, and test strategies to disseminate and implement evidence-based treatments have been prioritized in order to improve the quality of health and mental health care delivery. However, this task is complicated by an implementation science literature characterized by inconsistent language use and inadequate descriptions of implementation strategies. This article brings more depth and clarity to implementation research and practice by presenting a consolidated compilation of discrete implementation strategies, based on a review of 205 sources published between 1995 and 2011. The resulting compilation includes 68 implementation strategies and definitions, which are grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. This consolidated compilation can serve as a reference to stakeholders who wish to implement clinical innovations in health and mental health care and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.

Review of modeling approaches for emergency department patient flow and crowding research.

Emergency department (ED) crowding is an international phenomenon that continues to challenge operational efficiency. Many statistical modeling approaches have been offered to describe, and at times predict, ED patient load and crowding. A number of formula-based equations, regression models, time-series analyses, queuing theory-based models, and discrete-event (or process) simulation (DES) models have been proposed. In this review, we compare and contrast these modeling methodologies, describe the fundamental assumptions each makes, and outline the potential applications and limitations for each with regard to usability in ED operations and in ED operations and crowding research.

Physician and Nurse Acceptance of Technicians to Screen for Geriatric Syndromes in the Emergency Department

Introduction The objective of this study was to evaluate emergency medicine physician and nurse acceptance of nonnurse, nonphysician screening for geriatric syndromes. Methods This was a single-center emergency department (ED) survey of physicians and nurses after an 8-month project. Geriatric technicians were paid medical student research assistants evaluating consenting ED patients older than 65 years for cognitive dysfunction, fall risk, or functional decline. The primary objective of this anonymous survey was to evaluate ED nurse and physician perceptions about the geriatric screener feasibility and barriers to implementation. In addition, as a secondary objective, respondents reported ongoing geriatric screening efforts independent of the research screeners. Results The survey was completed by 72% of physicians and 33% of nurses. Most nurses and physicians identified geriatric technicians as beneficial to patients without impeding ED throughput. Fewer than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluated for fall risk significantly more often than physicians, but no other significant differences were noted in ongoing screening efforts. Conclusion Dedicated geriatric technicians are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. Most nurses and physicians are not currently screening for any geriatric syndromes.

An Empirical Assessment of Boarding and Quality of Care: Delays in Care Among Chest Pain, Pneumonia, and Cellulitis Patients

BACKGROUND As hospital crowding has increased, more patients have ended up boarding in the emergency department (ED) awaiting their inpatient beds. To the best of our knowledge, no study has compared the quality of care of boarded and nonboarded patients. OBJECTIVES This study sought to examine whether being a boarded patient and boarding longer were associated with more delays, medication errors, and adverse events among ED patients admitted with chest pain, pneumonia, or cellulitis. METHODS This study was a retrospective cohort design in which data collection was accomplished via medical record review from two urban teaching hospitals. Patients admitted with chest pain, pneumonia, or cellulitis between August 2004 and January 2005 were eligible for inclusion. Our outcomes measures were: 1) delays in administration of home medications, cardiac enzyme tests, partial thromboplastin time (PTT), and antibiotics; 2) medication errors; and 3) adverse events or near misses. Primary independent variables were boarded status, boarding time, and boarded time interval. Multiple logistic regression models controlling for patient, ED, and hospital characteristics were used. RESULTS A total of 1,431 patient charts were included: 811 with chest pain, 387 with pneumonia, and 233 with cellulitis. Boarding time was associated with an increased odds of home medication delays (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] = 1.05 to 1.10), as were boarded time intervals of 12, 18, and 24 hours. Boarding time also was associated with lower odds of having a late cardiac enzyme test (AOR = 0.93, 95% CI = 0.88 to 0.97). CONCLUSIONS Boarding was associated with home medication delays, but fewer cardiac enzyme test delays. Boarding was not associated with delayed PTT checks, antibiotic administration, medication errors, or adverse events/near misses. These findings likely reflect the inherent resources of the ED and the inpatient units.

An Emergency Department Patient Flow Model Based on Queueing Theory Principles

OBJECTIVES The objective was to derive and validate a novel queuing theory-based model that predicts the effect of various patient crowding scenarios on patient left without being seen (LWBS) rates. METHODS Retrospective data were collected from all patient presentations to triage at an urban, academic, adult-only emergency department (ED) with 87,705 visits in calendar year 2008. Data from specific time windows during the day were divided into derivation and validation sets based on odd or even days. Patient records with incomplete time data were excluded. With an established call center queueing model, input variables were modified to adapt this model to the ED setting, while satisfying the underlying assumptions of queueing theory. The primary aim was the derivation and validation of an ED flow model. Chi-square and Students t-tests were used for model derivation and validation. The secondary aim was estimating the effect of varying ED patient arrival and boarding scenarios on LWBS rates using this model. RESULTS The assumption of stationarity of the model was validated for three time periods (peak arrival rate = 10:00 a.m. to 12:00 p.m.; a moderate arrival rate = 8:00 a.m. to 10:00 a.m.; and lowest arrival rate = 4:00 a.m. to 6:00 a.m.) and for different days of the week and month. Between 10:00 a.m. and 12:00 p.m., defined as the primary study period representing peak arrivals, 3.9% (n = 4,038) of patients LWBS. Using the derived model, the predicted LWBS rate was 4%. LWBS rates increased as the rate of ED patient arrivals, treatment times, and ED boarding times increased. A 10% increase in hourly ED patient arrivals from the observed average arrival rate increased the predicted LWBS rate to 10.8%; a 10% decrease in hourly ED patient arrivals from the observed average arrival rate predicted a 1.6% LWBS rate. A 30-minute decrease in treatment time from the observed average treatment time predicted a 1.4% LWBS. A 1% increase in patient arrivals has the same effect on LWBS rates as a 1% increase in treatment time. Reducing boarding times by 10% is expected to reduce LWBS rates by approximately 0.8%. CONCLUSIONS This novel queuing theory-based model predicts the effect of patient arrivals, treatment time, and ED boarding on the rate of patients who LWBS at one institution. More studies are needed to validate this model across other institutions.

Guided medication dosing for elderly emergency patients using real-time, computerized decision support

OBJECTIVE To evaluate the impact of a real-time computerized decision support tool in the emergency department that guides medication dosing for the elderly on physician ordering behavior and on adverse drug events (ADEs). DESIGN A prospective controlled trial was conducted over 26 weeks. The status of the decision support tool alternated OFF (7/17/06-8/29/06), ON (8/29/06-10/10/06), OFF (10/10/06-11/28/06), and ON (11/28/06-1/16/07) in consecutive blocks during the study period. In patients ≥65 who were ordered certain benzodiazepines, opiates, non-steroidals, or sedative-hypnotics, the computer application either adjusted the dosing or suggested a different medication. Physicians could accept or reject recommendations. MEASUREMENTS The primary outcome compared medication ordering consistent with recommendations during ON versus OFF periods. Secondary outcomes included the admission rate, emergency department length of stay for discharged patients, 10-fold dosing orders, use of a second drug to reverse the original medication, and rate of ADEs using previously validated explicit chart review. RESULTS 2398 orders were placed for 1407 patients over 1548 visits. The majority (49/53; 92.5%) of recommendations for alternate medications were declined. More orders were consistent with dosing recommendations during ON (403/1283; 31.4%) than OFF (256/1115; 23%) periods (p≤0.0001). 673 (43%) visits were reviewed for ADEs. The rate of ADEs was lower during ON (8/237; 3.4%) compared with OFF (31/436; 7.1%) periods (p=0.02). The remaining secondary outcomes showed no difference. LIMITATIONS Single institution study, retrospective chart review for ADEs. CONCLUSION Though overall agreement with recommendations was low, real-time computerized decision support resulted in greater acceptance of medication recommendations. Fewer ADEs were observed when computerized decision support was active.

Assessment of Medicare's imaging efficiency measure for emergency department patients with atraumatic headache.

STUDY OBJECTIVE Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging efficiency measure (Outpatient Measure 15 [OP-15]) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15. METHODS This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measures validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Associations Physician Consortium for Performance Improvement. RESULTS On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval [CI] 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measures validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measures accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication (r=-0.11; P=.63). CONCLUSION The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.

The impact of teach-back on comprehension of discharge instructions and satisfaction among emergency patients with limited health literacy: A randomized, controlled study

Abstract Objective Recommended as a ‘universal precaution’ for improving provider–patient communication, teach-back has a limited evidence base. Discharge from the emergency department (ED) to home is an important high-risk transition of care with potential for miscommunication of critical information. We examined whether teach-back improves: comprehension and perceived comprehension of discharge instructions and satisfaction among patients with limited health literacy (LHL) in the ED. Methods We performed a randomized, controlled study among adult patients with LHL, randomized to teach-back or standard discharge instructions. Patients completed an audio-recorded structured interview evaluating comprehension and perceived comprehension of (1) diagnosis, (2) ED course, (3) post-ED care, and (4) reasons to return and satisfaction using four Consumer Assessment of Healthcare Providers and Systems questions. Concordance with the medical record was rated using a five-level scale. We analyzed differences between groups using multivariable ordinal logistic regression. Results Patients randomized to receive teach-back had higher comprehension of post-ED care areas: post-ED medication (P < 0.02), self-care (P < 0.03), and follow-up instructions (P < 0.0001), but no change in patient satisfaction or perceived comprehension. Conclusion Teach-back appears to improve comprehension of post-ED care instructions but not satisfaction or perceived comprehension. Our data from a randomized, controlled study support the effectiveness of teach-back in a busy clinical setting. Further research is needed to test the utility and feasibility of teach-back for routine use including its impacts on distal outcomes.

Effect of cognitive dysfunction on the relationship between age and health literacy.

OBJECTIVE Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood. METHODS We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction. RESULTS Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r=-0.16, p=0.001 vs. r=-0.35, p<0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups. CONCLUSION Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults. PRACTICE IMPLICATIONS Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.

Use of a Computerized Forcing Function Improves Performance in Ordering Restraints

STUDY OBJECTIVE We evaluate the effect of a computerized order entry system forcing function on improving timely renewal of restraint orders. METHODS In this prospective study of 2 successive interventions, physicians received computerized reminders to renew or discontinue restraint orders before their expiration. The initial intervention allowed acknowledgement of this reminder without further consequence, changing at 6 months to deny computer access until addressed. We performed chart review on emergency department visits with restraint orders in 3 consecutive 6-month periods (A, B, C) separated by these 2 interventions, determining time to order renewal, number of restraint orders, renewal orders per hour in restraints, and time in restraints and evaluating variability in these values across study intervals. Statistical analysis for our primary outcome used the Mann-Whitney and variance ratio tests. RESULTS Median time to order renewal decreased in periods B and C versus A by 64 and 56 minutes, respectively, with variability in this measure decreasing across all periods. Mean number of restraint orders in periods B and C significantly increased versus those in A (1.46 to 1.89 to 2.34), with corresponding increases in variability. Mean renewal orders per hour in restraint significantly increased in period C versus A and B, from 0.08 to 0.23 to 0.89, with increasing variability across all periods. Decreases in median time spent in restraints observed in periods B and C versus A of 45 and 105 minutes, respectively, trended toward but did not achieve significance, with significantly decreasing variability compared with baseline. CONCLUSION The forcing function improved restraint reordering and variability in practice and may have contributed to nonsignificant reductions observed in time in restraint.