Stephanie J. Gravenor

Geriatric emergency department innovations: preliminary data for the geriatric nurse liaison model

Older adults account for a large and growing segment of the emergency department (ED) population. They are often admitted to the hospital for nonurgent conditions such as dementia, impaired functional status, and gait instability. The aims of this geriatric ED innovations (GEDI) project were to develop GEDI nurse liaisons by training ED nurses in geriatric assessment and care coordination skills, describe characteristics of patients that these GEDI nurse liaisons see, and measure the admission rate of these patients. Four ED nurses participated in the GEDI training program, which consisted of 82 hours of clinical rotations in geriatrics and palliative medicine, 82 hours of didactics, and a pilot phase for refinement of the GEDI consultation process. Individuals were eligible for GEDI consultation if they had an Identification of Seniors At Risk (ISAR) score greater than 2 or at ED clinician request. GEDI consultation was available Monday through Friday from 9:00 a.m. to 8:00 p.m. An extensive database was set up to collect clinical outcomes data for all older adults in the ED before and after GEDI implementation. The liaisons underwent training from January through March 2013. From April through August 2013, 408 GEDI consultations were performed in 7,213 total older adults in the ED (5.7%, 95% confidence interval (CI) = 5.2–6.2%), 2,124 of whom were eligible for GEDI consultation (19.2%, 95% CI = 17.6–20.9%); 34.6% (95% CI = 30.1–39.3%) received social work consultation, 43.9% (95% CI = 39.1–48.7) received pharmacy consultation, and more than 90% received telephone follow‐up. The admission rate for GEDI patients was 44.9% (95% CI = 40.1–49.7), compared with 60.0% (95% CI = 58.8–61.2) non‐GEDI. ED nurses undergoing a 3‐month training program can develop geriatric‐specific assessment skills. Implementation of these skills in the ED may be associated with fewer admissions of older adults.

Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program

Introduction Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model. Methods Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. Results Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%). Conclusion The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.

Characterizing Teamwork in Cardiovascular Care Outcomes: A Network Analytics Approach

Background—The nature of teamwork in healthcare is complex and interdisciplinary, and provider collaboration based on shared patient encounters is crucial to its success. Characterizing the intensity of working relationships with risk-adjusted patient outcomes supplies insight into provider interactions in a hospital environment. Methods and Results—We extracted 4 years of patient, provider, and activity data for encounters in an inpatient cardiology unit from Northwestern Medicine’s Enterprise Data Warehouse. We then created a provider–patient network to identify healthcare providers who jointly participated in patient encounters and calculated satisfaction rates for provider–provider pairs. We demonstrated the application of a novel parameter, the shared positive outcome ratio, a measure that assesses the strength of a patient-sharing relationship between 2 providers based on risk-adjusted encounter outcomes. We compared an observed collaboration network of 334 providers and 3453 relationships to 1000 networks with shared positive outcome ratio scores based on randomized outcomes and found 188 collaborative relationships between pairs of providers that showed significantly higher than expected patient satisfaction ratings. A group of 22 providers performed exceptionally in terms of patient satisfaction. Our results indicate high variability in collaboration scores across the network and highlight our ability to identify relationships with both higher and lower than expected scores across a set of shared patient encounters. Conclusions—Satisfaction rates seem to vary across different teams of providers. Team collaboration can be quantified using a composite measure of collaboration across provider pairs. Tracking provider pair outcomes over a sufficient set of shared encounters may inform quality improvement strategies such as optimizing team staffing, identifying characteristics and practices of high-performing teams, developing evidence-based team guidelines, and redesigning inpatient care processes.

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

To examine the effect of an emergency department (ED)‐based transitional care nurse (TCN) on hospital use.

An Outcome-Weighted Network Model for Characterizing Collaboration

Shared patient encounters form the basis of collaborative relationships, which are crucial to the success of complex and interdisciplinary teamwork in healthcare. Quantifying the strength of these relationships using shared risk-adjusted patient outcomes provides insight into interactions that occur between healthcare providers. We developed the Shared Positive Outcome Ratio (SPOR), a novel parameter that quantifies the concentration of positive outcomes between a pair of healthcare providers over a set of shared patient encounters. We constructed a collaboration network using hospital emergency department patient data from electronic health records (EHRs) over a three-year period. Based on an outcome indicating patient satisfaction, we used this network to assess pairwise collaboration and evaluate the SPOR. By comparing this network of 574 providers and 5,615 relationships to a set of networks based on randomized outcomes, we identified 295 (5.2%) pairwise collaborations having significantly higher patient satisfaction rates. Our results show extreme high- and low-scoring relationships over a set of shared patient encounters and quantify high variability in collaboration between providers. We identified 29 top performers in terms of patient satisfaction. Providers in the high-scoring group had both a greater average number of associated encounters and a higher percentage of total encounters with positive outcomes than those in the low-scoring group, implying that more experienced individuals may be able to collaborate more successfully. Our study shows that a healthcare collaboration network can be structurally evaluated to characterize the collaborative interactions that occur between healthcare providers in a hospital setting.

ED opioid prescribing is not associated with higher patient satisfaction scores

Despite the popular belief that providing an opioid prescription increases patient satisfaction [1], this association has not been well studied in the emergency department (ED) setting. Although a prior study found no association between patient satisfaction scores and opioid analgesics administered in the ED [2], providing an opioid prescription may reasonably differ. Prescription opioids may serve as physical tokens of the index ED visit at the time of survey response and may increase patient satisfaction similarly to the provision of an antibiotic prescription [3]. The potential association between opioid prescribing and patient satisfaction is worthy of investigation. Although not all opioid prescriptions result in misuse, the potential harm of indiscriminate prescribing practices is becoming increasingly evident, as unintentional opioid overdoses have now surpassed motor vehicle accidents as the leading cause of injury [4]. In a recent national survey of ED providers, 12% of respondents reported prescribing an opioid analgesic to improve patient satisfaction [5]. We conducted an institutional review board–approved retrospective cohort study of adult patients completing a Press Ganey survey relating to an ED visit in 2010 to a single urban academic ED in Chicago, IL (85 000 annual visits). Per institutional protocol, 30% of discharged patients are randomly selected to receive a survey bymail. ED providers at this institution do not receive financial incentives for patient satisfaction scores. We stratified patients into 1 of 3 exposure groups (no analgesic prescription, nonopioid analgesic prescription, or any opioid prescription) based on Multum coding of prescribed medications and investigated the association between prescription type and Press Ganey survey scores. The patient satisfaction survey is composed of 38 individual questions, each scored on a 5-point Likert scale (1 = very poor, 5= very good), and organized into 8 domains: Arrival, Nurses, Doctors, Tests, Family/Friends, Personal/Insurance Information, Personal

Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department

Introduction Emergency department (ED) crowding is associated with detrimental effects on ED quality of care. Triage liaison providers (TLP) have been used to mitigate the effects of crowding. Prior studies have evaluated attending physicians and advanced practice providers as TLPs, with limited data evaluating resident physicians as TLPs. This study compares operational performance outcomes between resident and attending physicians as TLPs. Methods This retrospective cohort study compared aggregate operational performance at an urban, academic ED during pre- and post-TLP periods. The primary outcome was defined as cost-effectiveness based upon return on investment (ROI). Secondary outcomes were defined as differences in median ED length of stay (LOS), median door-to-provider (DTP) time, proportion of left without being seen (LWBS), and proportion of “very good” overall patient satisfaction scores. Results Annual profit generated for physician-based collections through LWBS capture (after deducting respective salary costs) equated to a gain (ROI: 54%) for resident TLPs and a loss (ROI: −31%) for attending TLPs. Accounting for hospital-based collections made both profitable, with gains for resident TLPs (ROI: 317%) and for attending TLPs (ROI: 86%). Median DTP time for resident TLPs was significantly lower (p<0.0001) than attending or historical control. Proportion of “very good” patient satisfaction scores and LWBS was improved for both resident and attending TLPs over historical control. Overall median LOS was not significantly different. Conclusion Resident and attending TLPs improved DTP time, patient satisfaction, and LWBS rates. Both resident and attending TLPs are cost effective, with residents having a more favorable financial profile.

Electronic medication complete communication strategy for opioid prescriptions in the emergency department: Rationale and design for a three-arm provider randomized trial

BACKGROUND Thousands of people die annually from prescription opioid overdoses; however there are few strategies to ensure patients receive medication risk information at the time of prescribing. OBJECTIVES To compare the effectiveness of the Emergency Department (ED) Electronic Medication Complete Communication (EMC2) Opioid Strategy (with and without text messaging) to promote safe medication use and improved patient knowledge as compared to usual care. METHODS The ED EMC2 Opioid Strategy consists of 5 automated components to promote safe medication use: 1) physician reminder to counsel, 2) inbox message sent on to the patients primary care physician, 3) pharmacist message on the prescription to counsel, 4) MedSheet supporting prescription information, and 5) patient-centered Take-Wait-Stop wording of prescription instructions. This strategy will be assessed both with and without the addition of text messages via a three-arm randomized trial. The study will take place at an urban academic ED (annual volume>85,000) in Chicago, IL. Patients being discharged with a new prescription for hydrocodone-acetaminophen will be enrolled and randomized (based on their prescribing physician). The primary outcome of the study is medication safe use as measured by a demonstrated dosing task. Additionally actual safe use, patient knowledge and provider counseling will be measured. Implementation fidelity as well as costs will be reported. CONCLUSIONS The ED EMC2 Opioid Strategy embeds a risk communication strategy into the electronic health record and promotes medication counseling with minimal workflow disruption. This trial will evaluate the strategys effectiveness and implementation fidelity as compared to usual care. TRIAL REGISTRATION This trial is registered on clinicaltrials.gov with identifier NCT02431793.

Measuring the Correlation Between Emergency Medicine Resident and Attending Physician Patient Satisfaction Scores Using Press Ganey

The purpose of this study was to assess the relationship between emergency medicine (EM) resident and attending physician patient satisfaction scores.