Steven J. Davidson

Emergency Department Operational Metrics, Measures and Definitions: Results of the Second Performance Measures and Benchmarking Summit

There is a growing mandate from the public, payers, hospitals, and Centers for Medicare & Medicaid Services (CMS) to measure and improve emergency department (ED) performance. This creates a compelling need for a standard set of definitions about the measurement of ED operational performance. This Concepts article reports the consensus of a summit of emergency medicine experts tasked with the review, expansion, and update of key definitions and metrics for ED operations. Thirty-two emergency medicine leaders convened for the Second Performance Measures and Benchmarking Summit on February 24, 2010. Before arrival, attendees were provided with the original definitions published in 2006 and were surveyed about gaps and limitations in the original work. According to survey responses, a work plan to revise and update the definitions was developed. Published definitions from key stakeholders in emergency medicine and health care were reviewed and circulated. At the summit, attendees discussed and debated key terminology and metrics and work groups were created to draft the revised document. Workgroups communicated online and by teleconference to reach consensus. When possible, definitions were aligned with performance measures and definitions put forth by the CMS, the Emergency Nurses Association Consistent Metrics Document, and the National Quality Forum. The results of this work are presented as a reference document.

Hazardous materials preparedness in the emergency department.

INTRODUCTION This study was conducted to examine the preparedness of emergency departments (EDs) to safely receive, decontaminate, and treat chemically contaminated patients. METHODS The safety officers of all 58 acute-care hospitals in the five-county philadelphia metropolitan region were surveyed by mail, with a repeat mailing to nonresponders followed by telephone contact. The 16 survey questions addressed the ability of EDs to safely decontaminate and treat chemically contaminated patients. RESULTS Thirty-eight of 58 hospitals (66%) returned usable surveys. Of these, 24 (63%) have a written plan for decontamination and treatment of chemically contaminated patients in the ED, and 19 (50%) have a hospital-wide disaster plan that includes contingencies for decontamination and treatment of one or more chemically contaminated patients. Thirteen hospitals (34%) conducted a drill of either of these plans in 1994. Twenty (53%) EDs have a specific treatment area for chemically contaminated patients. A stock of supplies for protecting the ED from secondary contamination is maintained by 16 (42%). While 24 (63%) store personal protective equipment, most of these involve only gowns, gloves, and surgical masks; only 13 provide any type of respiratory protection. Nine respondents were certain that patients brought in by local EMS would have been adequately decontaminated in the field, eight stated that they believed or felt decontamination would be adequate, and 12 were concerned that field decontamination might not be adequate. Eighteen hospitals (47%) reported treating one or more chemically contaminated patients in 1994. The authors believe the return rate reflects reluctance to commit hospital policies to paper. This was confirmed during telephone follow-up of nonrespondents when, for example, one safety officer discussed hazardous materials (hazmat) principles for 40 minutes, but refused to complete the survey. CONCLUSIONS Hospital hazmat preparedness in this area varies tremendously. A significant proportion of hospitals lack a written plan and equipment to allow the ED to safely and effectively handle the chemically contaminated patient. There is reluctance to discuss this topic.

Exploring New Intake Models for the Emergency Department

The objective of this article was to explore new intake models for processing patients into the emergency department (ED) and disseminate these new ideas. In the fall of 2008, the Board of Directors of the Emergency Department Benchmarking Alliance (EDBA) identified intake as an area of focus and asked its members to submit new intake strategies alternative to traditional triage. All EDBA members were invited to participate via an e-mail survey. New models could be of their own design or developed by another organization and presented with permission. In all, 25 departments provided information on intake innovations. These submissions were collated into a document that outlines some of the new models. Collaborative methodology promoted the diffusion of innovation in this organization. The results of the project are presented here as an original article that outlines some of the new and mostly unpublished work occurring to improve the intake process into the ED.

Failure to Notify Reportable Test Results: Significance in Medical Malpractice

BACKGROUND Diagnostic physicians generally acknowledge their responsibility to notify referring clinicians whenever examinations demonstrate urgent or unexpected findings. During the past decade, clinicians have ordered dramatically greater numbers of diagnostic examinations. One study demonstrated that between 1996 and 2003, malpractice payments related to diagnosis increased by approximately 40%. Communication failures are a prominent cause of action in medical malpractice litigation. The aims of this study were to (1) define the magnitude of malpractice costs related to communication failures in test result notification and (2) determine if these costs are increasing significantly. EVALUATION Linear regression analysis of National Practitioner Data Bank claims data from 1991 to 2009 suggested that claims payments increased at the national level by an average of

Emergency Department Operations Dictionary: Results of the Second Performance Measures and Benchmarking Summit

4.7 million annually (95% confidence interval,

Quality in Clinical Practice

2.98 million to

Legislative and regulatory description of ems medical direction: A survey of states

6.37 million). Controlled Risk Insurance Company/Risk Management Foundation claims data for 2004 to 2008 indicate that communication failures played a role, accounting for 4% of cases by volume and 7% of the total cost. DISCUSSION Faile communication of clinical data constitutes an increasing proportion of medical malpractice payments. The increase in cases may reflect expectations of more reliable notification of medical data. Another explanation may be that the remarkable growth in diagnostic test volume has led to a corresponding increase in reportable results. If notification reliability remained unchanged, this increased volume would predict more failed notifications. CONCLUSIONS There is increased risk for malpractice litigation resulting from diagnostic test result notification. The advent of semiautomated critical test result management systems may improve notification reliability, improve workflow and patient safety, and, when necessary, provide legal documentation.

The Performance Limits of Traditional Triage

The public, payers, hospitals, and Centers for Medicare and Medicaid Services (CMS) are demanding that emergency departments (EDs) measure and improve performance, but this cannot be done unless we define the terms used in ED operations. On February 24, 2010, 32 stakeholders from 13 professional organizations met in Salt Lake City, Utah, to standardize ED operations metrics and definitions, which are presented in this consensus paper. Emergency medicine (EM) experts attending the Second Performance Measures and Benchmarking Summit reviewed, expanded, and updated key definitions for ED operations. Prior to the meeting, participants were provided with the definitions created at the first summit in 2006 and relevant documents from other organizations and asked to identify gaps and limitations in the original work. Those responses were used to devise a plan to revise and update the definitions. At the summit, attendees discussed and debated key terminology, and workgroups were created to draft a more comprehensive document. These results have been crafted into two reference documents, one for metrics and the operations dictionary presented here. The ED Operations Dictionary defines ED spaces, processes, patient populations, and new ED roles. Common definitions of key terms will improve the ability to compare ED operations research and practice and provide a common language for frontline practitioners, managers, and researchers.

H1N1: Communication patterns among emergency department staff during the H1N1 outbreak, April 2009

This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine. It is important to note that this is not intended to be a comprehensive review of this extensive topic, but instead is designed to report the discussion that occurred at this session of the consensus conference.

Emergency Ventilation Volumes: A Comparison of Commonly Used Ventilators During Two-Person Cardiac Resuscitation

OBJECTIVE To assess regulatory trends in EMS medical direction by examining state EMS legislation and regulations, and legal qualifications for medical direction. METHODS A two-page survey was mailed to all 50 state EMS directors, with a repeat mailing to nonresponders and telephone follow-up as needed. Copies of EMS legislation and regulations were requested to assist in the interpretation of answers to survey questions. The questions focused on two physician roles in the oversight of the practice of paramedics; off-line ALS service medical director (ASMD) and on-line medical command (OLMC). RESULTS Thirty-nine surveys were returned (78%). Only one state (IL) requires that ASMDs be board-certified in emergency medicine. Thirteen others (33%) permit physicians with primary care specialization or various ACLS/ATLS certifications to serve as ASMDs. Twenty-two states (56%) require only that the ASMD be a physician; three states (8%) have no requirements at all. Eight states (21%) have no requirements for personnel providing OLMC, and another 25 (64%) require only physician licensure. Six states (15%) require various ACLS/ATLS certifications. Several states do not differentiate between the two physician roles. Twenty-four states (62%) provide some type of Good Samaritan protection for medical direction, but in two of these only unpaid medical directors are protected. CONCLUSIONS There is tremendous variation in regulatory requirements for physician participation in EMS medical direction activities at the ALS level. Few states have specific training or background requirements for the provision of OLMC, and a requirement for board certification in emergency medicine is the exception, not the rule.