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Mitigating Threats to Quality in Emergency Care Caused By Crowding

Mitigating Threats to Quality in Emergency Care Caused By Crowding. The US Experience Ellen J. Weber MD Professor of Emergency Medicine University of California, San Francisco. Death in Brooklyn Psychiatric ED Waiting Room

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Mitigating Threats to Quality in Emergency Care Caused By Crowding

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  1. Mitigating Threats to Quality in Emergency Care Caused By Crowding The US Experience Ellen J. Weber MD Professor of Emergency Medicine University of California, San Francisco

  2. Death in Brooklyn Psychiatric ED Waiting Room Chest pain death in Vista Medical Center became a homicide case Bowel perforation death in LA as patient calls for ambulance to another ED Crowding in the Public Eye .

  3. Achieving Quality “Between the health care that we now have and the health care that we could have lies not just a gap, but a chasm. Institute of Medicine, 2001”

  4. Quality Metrics: Disease-Based • Pneumonia • 4 hrs to antibiotics • Correct antibiotics • Smoking cessation counseling • Vaccination • Acute Coronary Syndrome • Aspirin on arrival • time to ecg • time to reperfusion • beta blocker at discharge • CHF, Sepsis • Safety: med errors, hospital-acquired infection • ED is a part of the continuum

  5. The $takes • Accreditation • Payment • Public • Insurer choice • Patient choice www.hospitalscompare.gov

  6. Impact of ED crowding • Lower likelihood of getting antibiotics in ≤ 4 hrs • Fee, Weber, Maak, Ann Emerg Med, 2007 • Lower likelihood of meeting quality measures for ACS. • Diercks, Roe Chen, et al, Ann Emerg Med 2007

  7. Crowding Due to Admitted Patients Nov 10, 2011 07:00

  8. Why hospitals don’t address crowding • Economic triage • Operating room vs. ED • Simply expect EDs to prioritize. • Why can’t you have triage nurse order chest xray on patients with cough?

  9. What have regulators done about crowding? • Ignored it, mostly • Policy (?) – Pay for reporting (2014!) • length of stay • time to MD • No target, no penalties for long times

  10. Who uses the emergency department? Weber, Showstack, Hunt et al. Ann Emerg Medicine, 2005

  11. Addressing Quality Despite Crowding Timely Safe Patient-centered Efficient Effective Equitable

  12. Challenging Dogma Weber, McAalpine, Grimes, Ann Emerg Med 2011

  13. Door to Doctor Banner Health System • “Quick Look” by MD/Nurse Team • Patients assigned 3 streams: 1) Home 2) Waiting 3) Main ED

  14. Diagnostic Waiting Room Bannock, Idaho

  15. Diagnostic Waiting Room University of New Mexico

  16. Pharmacy oversight (safety)

  17. Medication Reconciliation (safety) • Patients must have a full list of current meds, what’s being discontinued and what’s new, at each care transition.

  18. Hand Hygiene (safety)

  19. Senior Physician Oversight 24/7 attending (Consultant) coverage An accident of billing rules Must document “key portion” of H&P Effective, ? inefficient

  20. Protocols/Pathways/Care Plans • Quality goals: Efficient, safe, effective • Evidence-based • Uniform approach • Nurses familiar with the drugs • Avoids errors/omissions from cognitive overload • Avoids disparate treatment • Physicians object to being told how to practice • Many hospitals will not allow protocols to be initiated by nurses.

  21. Information technology • Quality goals: Safety, efficacy • Guidance for ordering • Alerts to allergies, drug interactions • Legibility • History, immunizations, meds, readily available. • Few rigorous studies of benefit, even though billions being spent on it. • Slower for physicians

  22. Regionalization (efficacy) • Designated EDs • Trauma • Stroke • ST elevation MI • Issues • Pre-hospital recognition • Need for timely transfer • Evidence

  23. Patient-centered • Patient surveys • Press-Ganey

  24. Patient-centered

  25. Characteristics of High Quality Performers - University Health Consortium Shared sense of purpose Passionate, hands-on leadership style Accountability system for service quality and safety A focus on results Collaboration

  26. Physicians must be more involved • Hospital quality scores are approximately 25% higher in physician-run hospitals than those whose CEO’s are managers • Goodall, Social Science and Medicine, 2011

  27. Thank you ellen.weber@ucsf.edu

  28. Chart 3.9: Percent of Hospitals Reporting Emergency Department Capacity Issues by Type of Hospital, March 2010 Source: American Hospital Association 2010 Rapid Response Survey: Telling the Hospital Story.

  29. Controversy over OP -15 Appropriateness of head CT for headache in patients >65

  30. Studies on Crowding Done in the US • Timeliness: • Delay to pain management • Effective: • Delay to appropriate antibiotics • Less adherence to practice guidelines for acute coronary syndrome • Equitable: • Elderly suffer in crowded ED's • LWBS greater in communities with lower insurance, poverty, immigrants • Safe • More errors in crowding

  31. Geriatric EDs (patient-centered)

  32. Ventilator acquired pneumonia

  33. TelemedicineTriage • Decrease Unnecessary Trips to ED • Begin Treatment at Facility • Ready for High Acuity Patients • Medical College of Georgia • Linked to 5 Nursing Homes

  34. ED expansion: venous capacitance • If you build it, they will stay • Flow considerations, separating populations • Computer modeling • Observation units • If you build it, they will stay. • Strong Memorial (Rochester, NY) • 120 Beds • 44 nightly boarders

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