Stephen K. Epstein

Emergency department crowding and risk of preventable medical errors

The objective of the study is to determine the association between emergency department (ED) crowding and preventable medical errors (PME). This was a retrospective cohort study of 533 ED patients enrolled in the National ED Safety Study (NEDSS) in four Massachusetts EDs. Individual patients’ average exposure to ED crowding during their ED visit was compared with the occurrence of a PME (yes/no) for the three diagnostic categories in NEDSS: acute myocardial infarction, asthma exacerbation, and dislocation requiring procedural sedation. To accommodate site-to-site differences in available administrative data, ED crowding was measured using one of three previously validated crowding metrics (ED Work Index, ED Workscore, and ED Occupancy). At each site, the continuous measure was placed into site-specific quartiles, and these quartiles then were combined across sites. We found that 46 (8.6%; 95% confidence interval, 6.4–11.3%) of the 533 patients experienced a PME. For those seen during higher levels of ED crowding (quartile 4 vs. quartile 1), the occurrence of PMEs was more than twofold higher, both on unadjusted analysis and adjusting for two potential confounders (diagnosis, site). The association appeared non-linear, with most PMEs occurring at the highest crowding level. We identified a direct association between high levels of ED crowding and risk of preventable medical errors. Further study is needed to determine the generalizability of these results. Should such research confirm our findings, we would suggest that mitigating ED crowding may reduce the occurrence of preventable medical errors.

The National Report Card on the State of Emergency Medicine: Evaluating the Emergency Care Environment State by State 2009 Edition

Becher • Editorial E this year, the American College of Emergency Physicians (ACEP) released its first-ever National Report Card on the State of Emergency Medicine with the intention of bringing the critical issues confronting emergency care in the United States before the public eye. The ACEP Report Card is an assessment of the support that each state provides for its emergency medicine system. The January 2006 report card is the first in a proposed series that the ACEP plans to issue, and it will serve as a baseline measure for comparison with future changes as data become available from state government offices. It is hoped that the results of the ACEP Report Card will serve as a much-needed wake-up call to state legislators and the public that the system they depend on for lifesaving emergency care is itself in critical condition. For the first time, the public saw the support—or lack of support—provided by the states to their local emergency care systems. The ACEP Report Card analyzed 2500 data points, all directly related to the financial support provided by the individual states. This was the first definitive look at the entire range of issues confronting the provision of emergency care. Fifty objective and quantifiable criteria were used to measure the performance of each state and the District of Columbia. These measurements were weighted and aggregated, and grades were assigned based on comparison to the best state’s performance (ie, a “sliding scale”). Each state received an overall grade as well as individual grades in each of four specific categories. Recognizing that not all categories or criteria were of equal importance, the task force assigned weighted scores to reflect “real world” priorities: ▫ access to emergency care, 40%; ▫ quality and patient safety, 25%; ▫ public health and injury/crisis prevention, 10%; and ▫ medical liability environment, 25%. It is important to note that these grades are not evaluations of the quality of care provided by emergency physicians, residency programs, or hospital emergency departments. Rather, the grades in the ACEP Report Card show the overall effort of states to support effective emergency medicine systems. Local emergency departments are at the front line of a national healthcare crisis. They are increasingly crowded— often to the point that ambulances en route must be diverted to another hospital.1,2 A key cause of emergency department crowding is the lack of staffed inpatient beds.1,2 Another cause of crowding is the high cost of medical liability insurance, which has led some specialty physicians to leave the practice of medicine or to be less willing to be “on-call” for emergency situations, aggravating hospitals’ difficulties in providing emergency care.3 The ACEP Report Card indicates that the national emergency healthcare system is in serious condition, with many states in critical condition. While no state received an overall failing grade, many have serious deficiencies, and almost all states have areas in which there is substantial room for improvement. Currently, emergency care is this country’s safety net for the entire healthcare system.2 The growing number of uninsured citizens, the lack of participation in preventive health programs, and the relentless demographic shift that accompanies the baby-boom generation all contribute to the increasing burden on the emergency medicine system.2,4,5 No state received an overall grade of A, and only California, Connecticut, Massachusetts, and Washington, DC, earned a solid B. A summary of the grades for the states with the highest number of hospitals accredited by the American Osteopathic Association (AOA) is provided in Table. Clearly, in those states with the worst environment for medical liability reform, the effects of a low score for that portion of the formula (25%) would have a negative impact on the overall grade. Therefore, those states in which emergency departments have closed because medical specialists such as neurosurgeons, obstetricians, and orthopedists could not obtain medical liability insurance would be inclined toward lower overall scores than states with more reformfriendly environments. States with hospitals that do not have critical on-call specialists available because of a fear of lawsuits would be similarly affected. The AOA, American Medical Association, and ACEP advocate several possible solutions to the crisis in emergency medicine, including: The National Report Card on the State of Emergency Medicine

The Effect of an Ambulance Diversion Ban on Emergency Department Length of Stay and Ambulance Turnaround Time

STUDY OBJECTIVE Massachusetts became the first state in the nation to ban ambulance diversion in 2009. It was feared that the diversion ban would lead to increased emergency department (ED) crowding and ambulance turnaround time. We seek to characterize the effect of a statewide ambulance diversion ban on ED length of stay and ambulance turnaround time at Boston-area EDs. METHODS We conducted a retrospective, pre-post observational analysis of 9 Boston-area hospital EDs before and after the ban. We used ED length of stay as a proxy for ED crowding. We compared hospitals individually and in aggregate to determine any changes in ED length of stay for admitted and discharged patients, ED volume, and turnaround time. RESULTS No ED experienced an increase in ED length of stay for admitted or discharged patients or ambulance turnaround time despite an increase in volume for several EDs. There was an overall 3.6% increase in ED volume in our sample, a 10.4-minute decrease in length of stay for admitted patients, and a 2.2-minute decrease in turnaround time. When we compared high- and low-diverting EDs separately, neither saw an increase in length of stay, and both saw a decrease in turnaround time. CONCLUSION After the first statewide ambulance diversion ban, there was no increase in ED length of stay or ambulance turnaround time at 9 Boston-area EDs. Several hospitals actually experienced improvements in these outcome measures. Our results suggest that the ban did not worsen ED crowding or ambulance availability at Boston-area hospitals.

Forecasting Emergency Department Crowding: An External, Multicenter Evaluation

STUDY OBJECTIVE We apply a previously described tool to forecast emergency department (ED) crowding at multiple institutions and assess its generalizability for predicting the near-future waiting count, occupancy level, and boarding count. METHODS The ForecastED tool was validated with historical data from 5 institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n=52,560) at 4 sites and 10 months (n=44,064) at the fifth. Three outcome measures-the waiting count, occupancy level, and boarding count-were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared with observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured with the median absolute error. RESULTS The tool was successfully used for 5 different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at 4 of 5 sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the median absolute error of the waiting count ranged between 0.6 and 3.1 patients, the median absolute error of the occupancy level ranged between 9.0% and 14.5% of beds, and the median absolute error of the boarding count ranged between 0.9 and 2.8 patients. CONCLUSION The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at 5 external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems.

The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.

Overdose of Rogaine ® Extra Strength for Men Topical Minoxidil Preparation

CASE REPORT Minoxidil is a potent arterial vasodilator used in the treatment of hypertension. A side effect, hypertrichosis, has prompted the marketing of a topical preparation, Rogaine, for the treatment of male-pattern baldness. Recently, a 5% solution of minoxidil became available over-the-counter as Rogaine Extra Strength For Men Hair Regrowth Treatment. We describe an oral overdose of minoxidil 3 g as the Rogaine Extra Strength preparation. Toxicity manifested as profound hypotension, requiring vasopressor support, intubation, prolonged tachycardia, and fluid overload with pleural effusions, requiring several days of therapy with furosemide. This is the largest reported ingestion of minoxidil and the first reported overdose of the extra strength 5% solution.

The effect of a CT and MR preauthorization program on ED utilization

OBJECTIVES To determine if a new outpatient preauthorization process for radiologic studies was associated with a change in emergency department (ED) CT and MRI utilization rates. METHODS This was a retrospective study set in an urban tertiary teaching hospital. Subjects included all nonadmitted ED patients who had either a CT or MRI during a control or preauthorization period. The study group consisted of those patients whose insurance required preauthorization. The control group consisted of those patients for whom preauthorization was not required. We used a multiple regression with autoregressive error adjusting for seasonal and monthly variation to obtain the rates of change of CT and MRI usage over time for the control and preauthorization periods. RESULTS The control period consisted of 29,303 ED visits over 54 weeks not resulting in hospital admission. The preauthorization period contained 33,858 patients over 64 weeks. The baseline ordering of CT and MRI was not significantly different between the groups. After controlling for seasonal and monthly variation, our results demonstrated that while both insurance groups demonstrated an increase in use of CT and MRI from the control to preauthorization periods, there is a statistically significant increase only in the rate of MRI utilization in the study group during the preauthorization period. CONCLUSION A telephone preauthorization process for radiological studies produced a statistically significant change in the rate of ordering MRI studies, but not CT, in the study group. We conclude that this preauthorization process may have resulted in additional ED visits for outpatient MR scans.

America's Emergency Care Environment, A State-by-State Report Card:2014 Edition

Jon Mark Hirshon, MD, MPH, PhD, FACEP Report Card Task Force Chair Roy L. Alson, MD, PhD, FACEP David Blunk Douglas P. Brosnan, MD, JD, FACEP Stephen K. Epstein, MD, MPP, FACEP Angela F. Gardner, MD, FACEP Donald L. Lum, MD, FACEP Joshua B. Moskovitz, MD, MPH, FACEP Lynne D. Richardson, MD, FACEP Jennifer L. Stankus, MD, JD Paul D. Kivela, MD, FACEP, ACEP Board of Directors Liaison to the Task Force ACEP Staff

Regionalization Findings in the National Report Card of the State of Emergency Medicine

The National Report Card on the State of Emergency Medicine (2009 edition) evaluated the conditions under which emergency care is delivered in each of the 50 states and compared those conditions between the states. The Report Card ranked states in five major categories: access to emergency care, quality and patient safety environment, public health and injury prevention, liability environment, and disaster preparedness. Three of those categories are particularly relevant to regionalization: access to emergency care, quality and patient safety environment, and disaster-preparedness. Within these categories, there was great variability between states in the distribution, planning, infrastructure, and available personnel for emergency care. Effective regionalization may require additional resources or a redistribution of existing resources within and among the states.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study

Study objective: We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. Methods: An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs—from departmental resources to physician incentives—to help achieve accountable care organization goals of decreasing spending and improving quality. Results: Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost‐reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self‐reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. Conclusion: The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals.