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Leisman DE, Deng H, Lee AH, Flynn MH, Rutkey H, Copenhaver MS, Gay EA, Dutta S, McEvoy DS, Dunham LN, Mort EA, Lucier DJ, Sonis JD, Aaronson EL, Hibbert KA, Safavi KC. Effect of Automated Real-Time Feedback on Early-Sepsis Care: A Pragmatic Clinical Trial. Crit Care Med 2024; 52:210-222. [PMID: 38088767 DOI: 10.1097/ccm.0000000000006057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To determine if a real-time monitoring system with automated clinician alerts improves 3-hour sepsis bundle adherence. DESIGN Prospective, pragmatic clinical trial. Allocation alternated every 7 days. SETTING Quaternary hospital from December 1, 2020 to November 30, 2021. PATIENTS Adult emergency department or inpatients meeting objective sepsis criteria triggered an electronic medical record (EMR)-embedded best practice advisory. Enrollment occurred when clinicians acknowledged the advisory indicating they felt sepsis was likely. INTERVENTION Real-time automated EMR monitoring identified suspected sepsis patients with incomplete bundle measures within 1-hour of completion deadlines and generated reminder pages. Clinicians responsible for intervention group patients received reminder pages; no pages were sent for controls. The primary analysis cohort was the subset of enrolled patients at risk of bundle nonadherent care that had reminder pages generated. MEASUREMENTS AND MAIN RESULTS The primary outcome was orders for all 3-hour bundle elements within guideline time limits. Secondary outcomes included guideline-adherent delivery of all 3-hour bundle elements, 28-day mortality, antibiotic discontinuation within 48-hours, and pathogen recovery from any culture within 7 days of time-zero. Among 3,269 enrolled patients, 1,377 had reminder pages generated and were included in the primary analysis. There were 670 (48.7%) at-risk patients randomized to paging alerts and 707 (51.3%) to control. Bundle-adherent orders were placed for 198 intervention patients (29.6%) versus 149 (21.1%) controls (difference: 8.5%; 95% CI, 3.9-13.1%; p = 0.0003). Bundle-adherent care was delivered for 152 (22.7%) intervention versus 121 (17.1%) control patients (difference: 5.6%; 95% CI, 1.4-9.8%; p = 0.0095). Mortality was similar between groups (8.4% vs 8.3%), as were early antibiotic discontinuation (35.1% vs 33.4%) and pan-culture negativity (69.0% vs 68.2%). CONCLUSIONS Real-time monitoring and paging alerts significantly increased orders for and delivery of guideline-adherent care for suspected sepsis patients at risk of 3-hour bundle nonadherence. The trial was underpowered to determine whether adherence affected mortality. Despite enrolling patients with clinically suspected sepsis, early antibiotic discontinuation and pan-culture negativity were common, highlighting challenges in identifying appropriate patients for sepsis bundle application.
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Affiliation(s)
- Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Hao Deng
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Andy H Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Micah H Flynn
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Hayley Rutkey
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Martin S Copenhaver
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, MA
| | - Elizabeth A Gay
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
- Mass General Brigham Digital, Mass General Brigham Health System, Sommerville, MA
| | - Dustin S McEvoy
- Mass General Brigham Digital, Mass General Brigham Health System, Sommerville, MA
| | - Lisette N Dunham
- Mass General Brigham Digital, Mass General Brigham Health System, Sommerville, MA
| | - Elizabeth A Mort
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - David J Lucier
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Kyan C Safavi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, MA
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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D. Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Berlyand Y, Black L, Lee AHY, Aaronson EL, Copenhaver MS, Filbin MR, Mort EA, Dutta S, Rhee C, Hibbert KA, Turno DJC, Durocher KE, Aristizabal ME, Sonis JD. A successful campaign to increase use of the sepsis order set in the emergency department. Am J Emerg Med 2023; 72:216-218. [PMID: 37598023 DOI: 10.1016/j.ajem.2023.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/21/2023] Open
Affiliation(s)
- Yosef Berlyand
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA; The Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI, USA
| | - Lauren Black
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | - Andy Hung-Yi Lee
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Martin S Copenhaver
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Healthcare Systems Engineering, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Elizabeth A Mort
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Chanu Rhee
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA
| | - Kathryn A Hibbert
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | | | - Kara E Durocher
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | - Maria E Aristizabal
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | - Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA.
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4
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Ouchi K, Lee RS, Block SD, Aaronson EL, Hasdianda MA, Wang W, Rossmassler S, Lopez RP, Berry D, Sudore R, Schonberg MA, Tulsky JA. An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study. Palliat Med 2023; 37:730-739. [PMID: 36380515 PMCID: PMC10183478 DOI: 10.1177/02692163221136641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations. AIM To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses. DESIGN A pre-/post-intervention study. SETTINGS/PARTICIPANTS In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations. RESULTS Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit. CONCLUSION A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Serious Illness Care Program, Ariadne Labs, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachel S. Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Susan D. Block
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Emily L. Aaronson
- Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wei Wang
- Harvard Medical School, Boston, MA, USA
- Division of Circadian and Sleep Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sarah Rossmassler
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
- Division of Geriatrics and Palliative Care, Baystate Medical Center, Springfield, MA, USA
| | - Ruth Palan Lopez
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Rebecca Sudore
- Division of Geriatrics Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mara A. Schonberg
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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5
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Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Lee RS, Santangelo I, Hasdianda MA, Wang W, George N, Liu SW, Kennedy M, Schonberg MA, Block SD, Tulsky JA, Ouchi K. Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians. J Pain Symptom Manage 2023; 65:58-65. [PMID: 36265695 PMCID: PMC9790029 DOI: 10.1016/j.jpainsymman.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training. OBJECTIVES To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training. METHODS A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals. RESULTS Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups. CONCLUSION Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (T.P.), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Emily L Aaronson
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Serious Illness Care Program (J.R.L., K.O.), Ariadne Labs, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Palliative Care and Geriatric Medicine (M.H.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachel S Lee
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammad A Hasdianda
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA
| | - Wei Wang
- Department of Medicine and Neurology, Brigham and Women's Hospital (W.W.), Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine `(N.G.), Division of Critical Care, University of New Mexico, Albuquerque, New Mexico, USA
| | - Shan W Liu
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mara A Schonberg
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Medicine (M.A.S.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Susan D Block
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Departments of Medicine (S.D.B., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James A Tulsky
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Departments of Medicine (S.D.B., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Serious Illness Care Program (J.R.L., K.O.), Ariadne Labs, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Bowman JK, Aaronson EL, Petrillo LA, Jacobsen JC. Goals of Care Conversations Documented by an Embedded Emergency Department-Palliative Care Team during COVID. J Palliat Med 2022; 26:662-666. [PMID: 36378862 DOI: 10.1089/jpm.2022.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.
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Affiliation(s)
- Jason K. Bowman
- Department of Emergency Medicine and Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily L. Aaronson
- Department of Emergency Medicine and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura A. Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet C. Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Lund University Institute for Palliative Care, Lund, Sweden
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7
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Aaronson EL, Wright RJ, Ritchie CS, Grudzen CR, Ankuda CK, Bowman JK, Kuntz JG, Ouchi K, George N, Jubanyik K, Bright LE, Bickel K, Isaacs E, Petrillo LA, Carpenter C, Goett R, LaPointe L, Owens D, Manfredi R, Quest T. Mapping the future for research in emergency medicine palliative care: A research roadmap. Acad Emerg Med 2022; 29:963-973. [PMID: 35368129 DOI: 10.1111/acem.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
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Affiliation(s)
- Emily L. Aaronson
- Department of Emergency Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | | | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Mongan Institute Center for Aging and Serious Illness Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine NYU Grossman School of Medicine, NYU Langone Health/Bellevue Hospital Center New York New York USA
| | - Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York New York USA
| | - Jason K. Bowman
- Department of Emergency Medicine Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Joanne G. Kuntz
- Department of Palliative and Supportive Care Emory University Hospital Midtown, Emory University School of Medicine Atlanta Georgia USA
| | - Kei Ouchi
- Department of Emergency Medicine Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Naomi George
- Department of Emergency Medicine and Division of Adult Critical Care University of New Mexico School of Medicine Albuquerque New Mexico USA
| | - Karen Jubanyik
- Emergency Department Yale University School of Medicine New Haven Connecticut USA
| | - Leah E. Bright
- Department of Emergency Medicine Johns Hopkins Hospital Baltimore Maryland USA
| | - Kathleen Bickel
- Hospice and Palliative Medicine in the Division of General Internal Medicine University of Colorado Anschutz Medical Campus Aurora Colorado USA
| | - Eric Isaacs
- Emergency Department Zuckerberg San Francisco General Hospital, University of California at San Francisco San Francisco California USA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | - Christopher Carpenter
- Washington University School of Medicine in St. Louis St. Louis Missouri USA
- Department of Emergency Medicine Rutgers New Jersey Medical School Newark New Jersey USA
| | - Rebecca Goett
- Department of Emergency Medicine Rutgers New Jersey Medical School Newark New Jersey USA
| | - Lauren LaPointe
- Department of Social Work Massachusetts General Hospital Boston Massachusetts USA
| | - Darrell Owens
- University of Washington Medical Center, UW School of Medicine Seattle Washington USA
| | - Rita Manfredi
- Department of Emergency Medicine The George Washington University School of Medicine Washington DC USA
| | - Tammie Quest
- Department of Palliative and Supportive Care Emory University Hospital Midtown, Emory University School of Medicine Atlanta Georgia USA
- Department of Family and Preventive Medicine, Department of Emergency Medicine Emory University School of Medicine Atlanta Georgia USA
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8
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Rubin BR, Chung M, Hasdianda MA, Gray TF, Aaronson EL, Dundin A, Egorova NA, Revette AC, Berry D, Ouchi K. Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Nurses. J Palliat Med 2022; 25:650-655. [PMID: 35100041 PMCID: PMC8982111 DOI: 10.1089/jpm.2021.0398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.
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Affiliation(s)
- Batsheva R Rubin
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Chung
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mohammad Adrian Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew Dundin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha A Egorova
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, Washington, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
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9
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Michelson KA, Williams DN, Dart AH, Mahajan P, Aaronson EL, Bachur RG, Finkelstein JA. Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis. Diagnosis (Berl) 2021; 8:219-225. [PMID: 32589599 PMCID: PMC7759568 DOI: 10.1515/dx-2020-0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Using case review to determine whether a patient experienced a delayed diagnosis is challenging. Measurement would be more accurate if case reviewers had access to multi-expert consensus on grading the likelihood of delayed diagnosis. Our objective was to use expert consensus to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS Case vignettes were constructed for each condition. In each vignette, a patient has the condition and had a previous emergency department (ED) visit within 7 days. Condition-specific multi-specialty expert Delphi panels reviewed the case vignettes and graded the likelihood of a delayed diagnosis on a five-point scale. Delayed diagnosis was defined as the condition being present during the previous ED visit. Consensus was defined as ≥75% agreement. In each Delphi round, panelists were given the scores from the previous round and asked to rescore. A case scoring guide was created from the consensus scores. RESULTS Eighteen expert panelists participated. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes. We reached consensus on 23/30 (77%) DKA vignettes. A case review guide was created from the consensus scores. CONCLUSIONS Multi-specialty expert reviewers can agree on the likelihood of a delayed diagnosis for cases of appendicitis and sepsis, and for most cases of DKA. We created a guide that can be used by researchers and quality improvement specialists to allow for objective case review to determine when delayed diagnoses have occurred for appendicitis, DKA, and sepsis.
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Affiliation(s)
| | - David N. Williams
- Division of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Arianna H. Dart
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
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10
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA .,Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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11
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Sonis JD, Berlyand Y, Yun BJ, Aaronson EL, Raja AS, Brown DFM, Pestka SB, White BA. Patient Experiences With Transfer for Community Hospital Inpatient Admission From an Academic Emergency Department. J Patient Exp 2021; 7:946-950. [PMID: 33457526 PMCID: PMC7786737 DOI: 10.1177/2374373520949168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Emergency department (ED) crowding continues to be a major challenge and has important ramifications for patient care quality. One strategy to decrease ED crowding has been to implement alternative pathways to traditional hospital admission. Through a survey-based retrospective cohort study, we aimed to assess the patient experience for those who agreed to transfer and admission to an affiliated community hospital from a large, academic center’s ED. In all, 85% of participants rated their overall experience as either great or good, 92% did not find it hard to make the decision to be transferred, and 95% found the transfer process itself to be easy.
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Affiliation(s)
- Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yosef Berlyand
- Harvard Medical School, Boston, MA, USA.,Harvard-Affiliated Emergency Medicine Residency, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Steven B Pestka
- Division of Adult Inpatient Medicine, Department of Medicine, Newton-Wellesley Hospital, Newton, MA, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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12
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Baugh JJ, Sonis JD, Wittbold KA, White BA, Raja AS, Aaronson EL, Biddinger PD, Yun BJ. Keeping pace: An ED communications strategy for COVID-19. Am J Emerg Med 2020; 38:2735-2736. [PMID: 32305156 PMCID: PMC7195306 DOI: 10.1016/j.ajem.2020.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 11/25/2022] Open
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13
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Aaronson EL, Petrillo L, Stoltenberg M, Jacobsen J, Wilson E, Bowman J, Ouchi K, Traeger L, Daubman BR, Ritchie CS, Jackson V. The Experience of Emergency Department Providers With Embedded Palliative Care During COVID. J Pain Symptom Manage 2020; 60:e35-e43. [PMID: 32882358 PMCID: PMC7456836 DOI: 10.1016/j.jpainsymman.2020.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Although the importance of palliative care (PC) integration in the emergency department (ED) has long been recognized, few formalized programs have been reported, and none have evaluated the experience of ED clinicians with embedded PC. OBJECTIVES We evaluate the experience of ED clinicians with embedded PC in the ED during the coronavirus disease pandemic. METHODS ED clinicians completed a survey about their perceptions of embedded PC in the ED. We summarized responses to closed-ended items using descriptive statistics and analyzed open-ended items using thematic analysis. RESULTS There were 134 ED clinicians surveyed. About 101 replied (75% response rate). Of those who had interacted with PC, 100% indicated a benefit of having PC involved. These included freeing up ED clinicians for other tasks (89%), helping them feel more supported (84%), changing the patients care trajectory (67%), and contributing to clinician education (57%) and skills (49%). Among barriers related to engaging PC were difficulty locating them (8%) and lack of time to consult because of ED volume (5%). About 98% of respondents felt that having PC in the ED was either valuable or very valuable. Open-ended responses reflected a positive impact on clinician wellness and improvement in access to high-quality goal-concordant care. Clinicians expressed gratitude for having PC in the ED and noted the importance of having readily available and easily accessible PC in the ED. CONCLUSION ED clinicians' perception of embedded PC was overall positive, with an emphasis on the impact related to task management, enrichment of PC skills, providing support for the team, and improved care for ED patients.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Laura Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark Stoltenberg
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erica Wilson
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany-Rose Daubman
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine S Ritchie
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Abstract
BACKGROUND Identifying characteristics of malpractice claims involving emergency medicine (EM) physicians allows leaders to develop patient safety initiatives to prevent future harm events. METHODS A retrospective study was performed of paid/unpaid claims closed 2007 to 2016 from Comparative Benchmarking System. Claims were identified by physician specialty involved (EM, internal medicine, general surgery). Various characteristics were compared by physician specialty. Multivariable regression was performed to identify factors associated with claim payment, in which (1) physician specialty was included as a predictor and (2) only the subset involving EM physicians was analyzed. RESULTS Of 54,772 claims, 2760 involved EM physicians, 5886 involved internists, and 3207 involved surgeons. Death was the most common severity among EM claims (34%). Diagnosis-related allegations accounted for 58%, higher than 42% and 11% of claims involving internists and surgeons, respectively (P < 0.0001). Thirty-one percent was paid. The median indemnity paid on behalf of any defendant was $206,261 (interquartile range $55,065-527,651). The most common final diagnoses were myocardial infarction (2%), pulmonary embolus (2%), and cardiac arrest (2%). Procedure-related claims were associated with increased payment likelihood (odds ratio 1.21, 95% confidence interval 1.10-1.34). CONCLUSION Malpractice claims in EM are often diagnosis- or procedure related. Our findings suggest that diagnostic accuracy and procedural competency should shape future quality improvement work.
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Affiliation(s)
- Laura C Myers
- Division of Pulmonary/Critical Care Medicine, Massachusetts General Hospital, Boston, MA, 02114
- Harvard Medical School, Boston, MA, 02115
| | - Jonathan Einbinder
- Harvard Medical School, Boston, MA, 02115
- Controlled Risk Insurance Company, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, 02115
| | - Carlos A Camargo
- Harvard Medical School, Boston, MA, 02115
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, 02114
| | - Emily L Aaronson
- Harvard Medical School, Boston, MA, 02115
- Controlled Risk Insurance Company, Boston, MA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, 02114
- Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, 02114
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15
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Donovan AL, Aaronson EL, Black L, Fisher SA, Bird SA, Benzer T, Temin ES. Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach. Jt Comm J Qual Patient Saf 2020; 47:S1553-7250(20)30215-4. [PMID: 32962905 DOI: 10.1016/j.jcjq.2020.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing numbers of patients with psychiatric illness are boarding in emergency departments (EDs) for longer periods. Many patients are at high risk of harm to self, and maintaining their safety is critical. The objectives of this study are to describe the development and implementation of a comprehensive safety precautions protocol for ED patients at risk for self-harm and to report the observed changes in rates of self-harm. METHODS A multidisciplinary team developed comprehensive safety precautions, including the creation of safe bathrooms, increasing the number and training of observers, protocols to manage access to belongings and for clothing search or removal, and additional interventions for exceptionally high-risk patients. Events of attempted self-harm were measured for 12 months before and after new safety precautions were enacted. RESULTS In the 12 months prior to the protocol initiation, among 4,408 at-risk patients, there were 13 episodes of attempted self-harm (2.95 per 1,000 at-risk patients), and 6 that resulted in actual self-harm (1.36 per 1,000 at-risk patients). In the 12 months after the protocol was introduced, among the 4,523 at-risk patients, there were 6 episodes of attempted self-harm (1.33 per 1,000 at-risk patients, p = 0.11) and only 1 that resulted in actual self-harm (0.22 per 1,000 at-risk patients, p = 0.07). There were no deaths. CONCLUSION Comprehensive safety precautions can be successfully developed and implemented in the ED. These precautions correlated with lower, although not statistically significant, rates of self-harm. Further study of similar interventions with adequately powered samples could be beneficial.
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16
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Affiliation(s)
- Jason K. Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Tammie E. Quest
- Emory Palliative Care Center, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- American Academy of Hospice and Palliative Medicine, Chicago, Illinois
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17
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Aaronson EL, Yun BJ. Emergency department shifts and decision to admit: is there a lever to pull to address crowding? BMJ Qual Saf 2020; 29:443-445. [DOI: 10.1136/bmjqs-2019-010554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 11/03/2022]
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18
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Sonis JD, Kennedy M, Aaronson EL, Baugh JJ, Raja AS, Yun BJ, White BA. Humanism in the Age of COVID-19: Renewing Focus on Communication and Compassion. West J Emerg Med 2020; 21:499-502. [PMID: 32421497 PMCID: PMC7234721 DOI: 10.5811/westjem.2020.4.47596] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/17/2020] [Indexed: 11/11/2022] Open
Abstract
The global COVID-19 pandemic has become one of the largest clinical and operational challenges faced by emergency medicine, and our EDs continue to see increased volumes of infected patients, many of whom are not only ill, but acutely aware and fearful of their circumstances and potential mortality. Given this, there may be no more important time to focus on staff-patient communication and expression of compassion.
However, many of the techniques usually employed by emergency clinicians to provide comfort to patients and their families are made more challenging or impossible by the current circumstances. Geriatric ED patients, who are at increased risk of severe disease, are particularly vulnerable to the effects of isolation.
Despite many challenges, emergency clinicians have at their disposal a myriad of tools that can still be used to express compassion and empathy to their patients. Placing emphasis on using these techniques to maximize humanism in the care of COVID-19 patients during this crisis has the potential to bring improvements to ED patient care well after this pandemic has passed.
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Affiliation(s)
- Jonathan D Sonis
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Maura Kennedy
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Emily L Aaronson
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Joshua J Baugh
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Ali S Raja
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Bryan J Yun
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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19
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Sonis JD, Black L, Baugh J, Benzer TI, Hayes BD, Raja AS, White BA, Wilcox SR, Yun BJ, Aaronson EL. Leveraging existing quality improvement communication strategies during the COVID-19 crisis. Am J Emerg Med 2020; 38:1523-1524. [PMID: 32312576 PMCID: PMC7151532 DOI: 10.1016/j.ajem.2020.04.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jonathan D Sonis
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America.
| | - Lauren Black
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Joshua Baugh
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Theodore I Benzer
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Bryan D Hayes
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Ali S Raja
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Benjamin A White
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Brian J Yun
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America; Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, United States of America
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20
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Jansson PS, Schuur JD, Baker O, Hagan SC, Nadel ES, Aaronson EL. Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference. J Patient Saf 2020; 15:e86-e89. [PMID: 30444742 DOI: 10.1097/pts.0000000000000555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. METHODS We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. RESULTS Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. CONCLUSIONS We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.
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Affiliation(s)
- Paul S Jansson
- From the Department of Emergency Medicine, Massachusetts General Hospital.,Department of Emergency Medicine, Brigham and Women's Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women's Hospital
| | - Sean C Hagan
- Department of Emergency Medicine, Brigham and Women's Hospital
| | - Eric S Nadel
- From the Department of Emergency Medicine, Massachusetts General Hospital.,Department of Emergency Medicine, Brigham and Women's Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emily L Aaronson
- From the Department of Emergency Medicine, Massachusetts General Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Aaronson EL, Wittels K, Dwyer R, Nadel E, Gallahue F, Baker O, Fee C, Tubbs R, Schuur J. The Impact of Anonymity in Emergency Medicine Morbidity and Mortality Conferences: Findings from a National Survey of Resident Physicians. West J Emerg Med 2019; 21:127-133. [PMID: 31913832 PMCID: PMC6948693 DOI: 10.5811/westjem.2019.10.44497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/11/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. Methods We conducted a national survey at 33 emergency medicine residency programs evaluating residents’ perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified. Results There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity’s impact on punitive response to error, the ability to learn from cases, and professional responsibility. Conclusion Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.
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Affiliation(s)
- Emily L Aaronson
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Kathleen Wittels
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Richard Dwyer
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Eric Nadel
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Fiona Gallahue
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christopher Fee
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Robert Tubbs
- Warren Alpert Medical School at Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Jeremiah Schuur
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
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22
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Aaronson EL, Kim J, Hard GA, Yun BJ, Kaafarani HMA, Rao SK, Weilburg JB, Lee J. Emergency department visits by patients with an internal medicine specialist: understanding the role of specialists in reducing ED crowding. Intern Emerg Med 2019; 14:777-782. [PMID: 30796698 DOI: 10.1007/s11739-019-02051-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
As emergency department (ED) crowding continues to worsen, many visits are at academic referral hospitals. As a result, engaging specialty services will be essential to decompressing the ED. To do this, it will be important to understand which specialties to focus interventions on for the greatest impact. To characterize the ED utilization of non-surgical adult patients with an ambulatory specialist who were seen and discharged from the ED. Retrospective cohort study of all consecutive patients currently under the care from a specialist presenting to an urban, university affiliated hospital between 01 January 2015 and 31 December 2016. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. Only patients who were discharged directly from the ED were included in the analysis. There were 29,853 ED visits by patients currently under the care of a specialist during the study period. 17.76% of these visits were related to the medical specialty of the specialist. Of these visits, 41.73% occurred during office hours, and 24.81% occurred during weekends. The specialties with the largest proportion of ED visits related to their specialty was cardiology, gastroenterology, and pulmonary, respectively. Nearly 18% of all patients that have a specialist and are treated and discharged from the ED present with a diagnosis related to their specialist's practice. This may indicate that there is a role for specialty service to play in decreasing some ED utilization that may be appropriate for the out-patient clinical setting. By focusing attention on specific specialties and interventions targeted during office hours, there may be an opportunity to decrease ED utilization.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gregory A Hard
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham M A Kaafarani
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Sandhya K Rao
- Department of Primary Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffery B Weilburg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
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23
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Aaronson EL, Quinn GR, Wong CI, Murray AM, Petty CR, Einbinder J, Schiff GD. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag 2019; 39:19-29. [PMID: 31338938 DOI: 10.1002/jhrm.21385] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In the ambulatory setting, missed cancer diagnoses are leading contributors to patient harm and malpractice risk; however, there are limited data on the malpractice case characteristics for these cases. OBJECTIVE The aim of this study was to examine key features and factors identified in missed cancer diagnosis malpractice claims filed related to primary care and evaluate predictors of clinical and claim outcomes. METHODS We analyzed 2155 diagnostic error closed malpractice claims in outpatient general medicine. We created multivariate models to determine factors that predicted case outcomes. RESULTS Missed cancer diagnoses represented 980 (46%) cases of primary care diagnostic errors, most commonly from lung, colorectal, prostate, or breast cancer. The majority (76%) involved errors in clinical judgment, such as a failure or delay in ordering a diagnostic test (51%) or failure or delay in obtaining a consult or referral (37%). These factors were independently associated with higher-severity patient harm. The majority of these errors were of high severity (85%). CONCLUSIONS Malpractice claims involving missed diagnoses of cancer in primary care most often involve routine screening examinations or delays in testing or referral. Our findings suggest that more reliable closed-loop systems for diagnostic testing and referrals are crucial for preventing diagnostic errors in the ambulatory setting.
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Affiliation(s)
- Laura A Dean
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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25
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Griffey RT, Schneider RM, Todorov AA, Yaeger L, Sharp BR, Vrablik MC, Aaronson EL, Sammer C, Nelson A, Manley H, Dalton P, Adler L. Critical Review, Development, and Testing of a Taxonomy for Adverse Events and Near Misses in the Emergency Department. Acad Emerg Med 2019; 26:670-679. [PMID: 30859666 DOI: 10.1111/acem.13724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/29/2019] [Accepted: 02/15/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g., hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g., "communication error"). We set out to create a patient-centered, emergency department (ED)-specific framework for describing AEs and near misses to advance quality and safety in the acute care setting. METHODS We performed a critical review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified AEs and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our criterion standard. RESULTS Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems AE taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories, and up to three modifiers to further describe events. On testing, overall reviewer agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55 of 59 scenarios (93%) and all four concurred in 46 of 59 scenarios (78%). At the subcategory level, there was complete agreement in 40 of 59 (68%) scenarios and majority agreement in 55 of 59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level. CONCLUSIONS We developed a taxonomy of AEs and near misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good inter-rater reliability. This taxonomy can be adapted and modified by EDs seeking to enhance their quality and safety reviews and characterize harm occurring in their EDs for quality improvement purposes.
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Affiliation(s)
- Richard T. Griffey
- Division of Emergency Medicine Washington University School of Medicine St. Louis MO
| | - Ryan M. Schneider
- Division of Emergency Medicine Washington University School of Medicine St. Louis MO
| | | | - Lauren Yaeger
- Washington University School of Medicine St. Louis MO
| | - Brian R. Sharp
- Department of Emergency Medicine University of Wisconsin School of Medicine and Public Health Madison WI
| | | | | | | | | | - Holly Manley
- Department of Clinical Patient Safety AdventHealth Altamonte FL
| | - Patricia Dalton
- Department of Clinical Patient Safety AdventHealth Altamonte FL
| | - Lee Adler
- Department of Clinical Patient Safety AdventHealth Altamonte FL
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26
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Aaronson EL, George N, Ouchi K, Zheng H, Bowman J, Monette D, Jacobsen J, Jackson V. The Surprise Question Can Be Used to Identify Heart Failure Patients in the Emergency Department Who Would Benefit From Palliative Care. J Pain Symptom Manage 2019; 57:944-951. [PMID: 30776539 PMCID: PMC6713219 DOI: 10.1016/j.jpainsymman.2019.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Heart failure (HF) is associated with symptom exacerbations and risk of mortality after an emergency department (ED) visit. Although emergency physicians (EPs) treat symptoms of HF, often the opportunity to connect with palliative care is missed. The "surprise question" (SQ) "Would you be surprised if this patient died in the next 12 months?" is a simple tool to identify patients at risk for 12-month mortality. OBJECTIVES The objective of this study was to assess the accuracy of the SQ when used by EPs to assess patients with HF. METHODS We conducted a prospective cohort study in which clinicians applied the SQ to patients presenting to the ED with symptoms of HF. Chart review and review of death records were completed. The primary outcome was accuracy of the surprise question to predict 12-month mortality. A univariate analysis for potential predictors of 12-month mortality was performed. RESULTS During the study period, 199 patients were identified, and complete data were available for 97% of observations (n = 193). The one-year mortality was 29%. EPs reported that "they would not be surprised" if the patient died within the next 12 months in 53% of cases. 42.7% of these patients died within 12 months compared to 13.3% in the "would be surprised" group. There was a strong association with death in the "not surprised" group (odds ratio 4.85, 95% CI 2.34-9.98, P < 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of the SQ were 78.6%, 56.9%, 42.7%, and 86.7%, respectively, with c-statistic = 0.68. CONCLUSION The SQ screening tool can assist ED providers in identifying HF patients that would benefit from early palliative care involvement.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Naomi George
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Zheng
- Biostatistic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Derek Monette
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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27
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Natsui S, Aaronson EL, Joseph TA, Goldsmith AJ, Sonis JD, Raja AS, White BA, Luciani-Mcgillivray I, Mort E. Calling on the Patient's Perspective in Emergency Medicine: Analysis of 1 Year of a Patient Callback Program. J Patient Exp 2018; 6:318-324. [PMID: 31853488 PMCID: PMC6908991 DOI: 10.1177/2374373518805542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patient-centered approaches in the evaluation of patient experience are increasingly important priorities for quality improvement in health-care delivery. Our objective was to investigate common themes in patient-reported data to better understand areas for improvement in the emergency department (ED) experience. Methods: A large urban, tertiary-care ED conducted phone interviews with 2607 patients who visited the ED during 2015. Patients were asked to identify one area that would have significantly improved their visit. Transcripts were analyzed using content analysis, and the results were summarized with descriptive statistics. Results: The most commonly cited themes for improvement in the patient experience were wait time (49.4%) and communication (14.6%). Related, but more nuanced, themes emerged around the perception of ED crowding and compassionate care as additional important contributors to the patient experience. Other frequently cited factors contributing to a negative experience were the discharge process and inability to complete follow-up plan (8.0%), environmental factors (7.9%), perceived competency of providers in the evaluation or treatment (7.4%), and pain management (7.4%). Conclusions: Wait times and perceptions of ED crowding, as well as provider communication and compassionate care, are significant factors identified by patients that affect their ED experience.
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Affiliation(s)
- Shaw Natsui
- Harvard Affiliated Emergency Medicine Residency Program, Harvard Medical School, Boston, MA, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA, USA
| | - Tony A Joseph
- Harvard Affiliated Emergency Medicine Residency Program, Harvard Medical School, Boston, MA, USA
| | - Andrew J Goldsmith
- Harvard Affiliated Emergency Medicine Residency Program, Harvard Medical School, Boston, MA, USA
| | - Jonathan D Sonis
- Harvard Affiliated Emergency Medicine Residency Program, Harvard Medical School, Boston, MA, USA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ines Luciani-Mcgillivray
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Mort
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA, USA
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28
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Bowman JK, Aaronson EL, George NR, Alexander Cole C, Ouchi K. Effect of Brief Educational Intervention on Emergency Medicine Resident Physicians' Comfort with Goals-of-Care Conversations. J Palliat Med 2018; 21:1378-1379. [DOI: 10.1089/jpm.2018.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jason K. Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Affiliated Emergency Medicine Residency (Resident), Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Affiliated Emergency Medicine Residency (Faculty), Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Naomi R. George
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Corinne Alexander Cole
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Internal Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Affiliated Emergency Medicine Residency (Faculty), Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
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Aaronson EL, White BA, Black L, Brown DF, Benzer T, Castagna A, Raja AS, Sonis J, Mort E. Training to Improve Communication Quality: An Efficient Interdisciplinary Experience for Emergency Department Clinicians. Am J Med Qual 2018; 34:260-265. [PMID: 30235933 DOI: 10.1177/1062860618799936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-provider communication has been recognized as a critical area of focus for improved health care quality, with a mounting body of evidence tying patient satisfaction and provider communication to important health care outcomes. Despite this, few programs have been studied in the emergency department (ED) setting. The authors designed a communication curriculum and conducted trainings for all ED clinical staff. Although only 72% of clinicians believed the course would be a valuable use of their time before taking it, 97% reported that it was a valuable use of their time after ( P < .001). Pre-course self-evaluation of knowledge, skill, and ability were high. Despite this, post-course self-efficacy improved statistically significantly. This study suggests that it is possible, in a brief training session, to deliver communication content that participants felt was relevant to their practice, improved their skills and knowledge, changed their attitude, and was perceived to be a valuable use of their time.
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Affiliation(s)
- Emily L Aaronson
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA.,2 Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA
| | - Benjamin A White
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lauren Black
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David F Brown
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore Benzer
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Allison Castagna
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ali S Raja
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jonathan Sonis
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Elizabeth Mort
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA.,2 Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA
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30
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Abstract
Emergency department (ED) patient experience continues to be a growing area of focus for ED physicians, administrators, and regulatory agencies. Recent literature has suggested a strong correlation between positive ratings of patient experience and important health system goals, including improved clinical outcomes and care quality, increased staff satisfaction, and reduced medicolegal risk. However, given the myriad of factors driving ED patient experience, identifying effective and synergistic interventions can present a challenge, especially in the setting of limited ED resources. Utilizing the themes identified in a recent systematic review of the ED patient experience literature, we developed a conceptual “logic model” of ED patient experience in order to provide a broadly applicable framework for practical intervention and to guide further study of ED patient experience interventions. The logic model was modified in an iterative fashion through review by local patient and staff groups as well as a national interest group until arriving at the current, comprehensive version. Here, we describe the creation of the logic model and, with the aim of providing a framework for readers to develop similar models for their practice settings, provide a case discussion of its use by an ED medical director.
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Affiliation(s)
- Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Allison Castagna
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin White
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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31
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Kim J, Yun BJ, Aaronson EL, Kaafarani HMA, Linov P, Rao SK, Weilburg JB, Lee J. The next step to reducing emergency department (ED) crowding: Engaging specialist physicians. PLoS One 2018; 13:e0201393. [PMID: 30125284 PMCID: PMC6101357 DOI: 10.1371/journal.pone.0201393] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/13/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Much work on reducing ED utilization has focused on primary care practices, but few studies have examined ED visits from patients followed by specialists, especially when the ED visit is related to the specialist's clinical practice. OBJECTIVE To determine the proportion and characteristics of patients that utilized the ED for specialty-related diagnosis. METHODS Retrospective, population-based, cohort study was conducted using information from electronic health records and billing database between January 2016 and December 2016. Patients who had seen a specialist during the last five years from the index ED visit date were included. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. RESULTS Approximately 28% of ED visits analyzed were attributable to specialists. ED visits attributed specialists were represented by older patients and occurred more during working hours and early days of week. The most common diagnoses related to ED visits attributed to specialists were Circulatory, Musculoskeletal, Skin, Breast and Mental. Multiple departments, subdivisions and specialists were involved with each ED visit. The number of specialists following the patients who visited the ED ranged from one to six and the number of departments/subdivisions ranged from one to four. Patients that used the ED often were more likely to belong to departments (OR = 1.53) and specialists (OR = 1.18) associated with high ED utilization patterns. CONCLUSION Patients coming to the ED with specialty-related complaints are unique and require full engagement of the specialist and the specialty group. This study offers a new view of connections patients have with their specialists and engaging specialists both at department level and individual specialist level may be an important factor to reduce ED overcrowding.
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Affiliation(s)
- Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Brian J. Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Haytham M. A. Kaafarani
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Pamela Linov
- Massachusetts General Physician Organization, Boston, Massachusetts, United States of America
| | - Sandhya K. Rao
- Department of Primary Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jeffery B. Weilburg
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Ouchi K, Jambaulikar GD, Hohmann S, George NR, Aaronson EL, Sudore R, Schonberg MA, Tulsky JA, Schuur JD, Pallin DJ. Prognosis After Emergency Department Intubation to Inform Shared Decision-Making. J Am Geriatr Soc 2018. [PMID: 29542117 DOI: 10.1111/jgs.15361] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To inform the shared decision-making process between clinicians and older adults and their surrogates regarding emergency intubation. DESIGN Retrospective cohort study. SETTING Multicenter, emergency department (ED)-based cohort. PARTICIPANTS Adults aged 65 and older intubated in the ED from 2008 to 2015 from 262 hospitals across the United States (>95% of U.S. nonprofit academic medical centers). MEASUREMENTS Our primary outcome was age-specific in-hospital mortality. Secondary outcomes were age-specific odds of death after adjusting for race, comorbid conditions, admission diagnosis, hospital disposition, and geographic region. RESULTS We identified 41,463 ED intubation encounters and included 35,036 in the final analysis. Sixty-four percent were in non-Hispanic whites and 54% in women. Overall in-hospital mortality was 33% (95% confidence interval (CI)=34-35%). Twenty-four percent (95% CI=24-25%) of subjects were discharged to home, and 41% (95% CI=40-42%) were discharged to a location other than home. Mortality was 29% (95% CI=28-29%) for individuals aged 65 to 74, 34% (95% CI=33-35%) for those aged 75 to 79, 40% (95% CI=39-41%) for those aged 80 to 84, 43% (95% CI=41-44%) for those aged 85 to 89, and 50% (95% CI=48-51%) for those aged 90 and older. CONCLUSION After emergency intubation, 33% percent of older adults die during the index hospitalization. Only 24% of survivors are discharged to home. Simple, graphic representations of this information, in combination with an experienced clinician's overall clinical assessment, will support shared decision-making regarding unplanned intubation.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | | | - Samuel Hohmann
- Center for Advanced Analytics, Vizient, Irving, Texas.,Department of Health Systems Management, Rush University, Chicago, Illinois
| | - Naomi R George
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rebecca Sudore
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Abstract
Introduction: Patient experience with emergency department (ED) care is an expanding area of focus, and recent literature has demonstrated strong correlation between patient experience and meeting several ED and hospital goals. The objective of this study was to perform a systematic review of existing literature to identify specific factors most commonly identified as influencing ED patient experience. Methods: A literature search was performed, and articles were included if published in peer-reviewed journals, primarily focused on ED patient experience, employed observational or interventional methodology, and were available in English. After a structured screening process, 107 publications were included for data extraction. Result: Of the 107 included publications, 51 were published before 2011, 57% were conducted by American investigators, and 12% were published in nursing journals. The most commonly identified themes included staff-patient communication, ED wait times, and staff empathy and compassion. Conclusion: The most commonly identified drivers of ED patient experience include communication, wait times, and staff empathy; however, existing literature is limited. Additional investigation is necessary to further characterize ED patient experience themes and identify interventions that effectively improve these domains.
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Affiliation(s)
- Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Lawrence Center for Quality and Safety, Boston, MA, USA
| | - Rebecca Y Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Ouchi K, Jambaulikar G, George NR, Xu W, Obermeyer Z, Aaronson EL, Schuur JD, Schonberg MA, Tulsky JA, Block SD. The "Surprise Question" Asked of Emergency Physicians May Predict 12-Month Mortality among Older Emergency Department Patients. J Palliat Med 2017; 21:236-240. [PMID: 28846475 DOI: 10.1089/jpm.2017.0192] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Identification of older adults with serious illness (life expectancy less than one year) who may benefit from serious illness conversations or other palliative care interventions in the emergency department (ED) is difficult. OBJECTIVES To assess the performance of the "surprise question (SQ)" asked of emergency physicians to predict 12-month mortality. DESIGN We asked attending emergency physician "Would you be surprised whether this patient died in the next 12 months?" regarding patients ≥65 years old that they had cared for that shift. We prospectively obtained death records from Massachusetts Department of Health Vital Records. SETTING An urban, university-affiliated ED. MEASUREMENT Twelve-month mortality. RESULTS We approached 38 physicians to answer the SQ, and 86% participated. The mean age of our cohort was 76 years, 51% were male, and 45% had at least one serious illness. Out of 207 patients, the physicians stated that they "would not be surprised" if the patient died in the next 12 months for 102 of the patients (49%); 44 of the 207 patients (21%) died within 12 months. The SQ demonstrated sensitivity of 77%, specificity of 56%, positive predictive value of 32%, and negative predictive value of 90%. When combined with other predictors, the model sorted the patient who lived from the patient who died correctly 72% of the time (c-statistic = 0.72). CONCLUSION Use of the SQ by emergency physicians may predict 12-month mortality in older ED patients and may help emergency physicians identify older adults in need of palliative care interventions.
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Affiliation(s)
- Kei Ouchi
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program , Ariadne Labs, Boston, Massachusetts
| | - Guru Jambaulikar
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Naomi R George
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Wanlu Xu
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Ziad Obermeyer
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program , Ariadne Labs, Boston, Massachusetts
| | - Emily L Aaronson
- 2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,4 Department of Emergency Medicine, Massachusetts General Hospital , Boston, Massachusetts
| | - Jeremiah D Schuur
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Mara A Schonberg
- 5 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - James A Tulsky
- 6 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,7 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Susan D Block
- 3 Serious Illness Care Program , Ariadne Labs, Boston, Massachusetts.,6 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,7 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,8 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts
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35
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Aaronson EL, Yun BJ, Mort E, Brown D, Raja AS, Kaafarani HMA, Chang Y, Lee J. Association of magnetic resonance imaging for back pain on seven-day return visit to the Emergency Department. Emerg Med J 2017; 34:677-679. [DOI: 10.1136/emermed-2016-206250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 03/24/2017] [Accepted: 04/01/2017] [Indexed: 11/04/2022]
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Ouchi K, Hohmann S, Goto T, Ueda P, Aaronson EL, Pallin DJ, Testa MA, Tulsky JA, Schuur JD, Schonberg MA. Index to Predict In-hospital Mortality in Older Adults after Non-traumatic Emergency Department Intubations. West J Emerg Med 2017; 18:690-697. [PMID: 28611890 PMCID: PMC5468075 DOI: 10.5811/westjem.2017.2.33325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/10/2017] [Accepted: 02/15/2017] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Our goal was to develop and validate an index to predict in-hospital mortality in older adults after non-traumatic emergency department (ED) intubations. METHODS We used Vizient administrative data from hospitalizations of 22,374 adults ≥75 years who underwent non-traumatic ED intubation from 2008-2015 at nearly 300 U.S. hospitals to develop and validate an index to predict in-hospital mortality. We randomly selected one half of participants for the development cohort and one half for the validation cohort. Considering 25 potential predictors, we developed a multivariable logistic regression model using least absolute shrinkage and selection operator method to determine factors associated with in-hospital mortality. We calculated risk scores using points derived from the final model's beta coefficients. To evaluate calibration and discrimination of the final model, we used Hosmer-Lemeshow chi-square test and receiver-operating characteristic analysis and compared mortality by risk groups in the development and validation cohorts. RESULTS Death during the index hospitalization occurred in 40% of cases. The final model included six variables: history of myocardial infarction, history of cerebrovascular disease, history of metastatic cancer, age, admission diagnosis of sepsis, and admission diagnosis of stroke/ intracranial hemorrhage. Those with low-risk scores (<6) had 31% risk of in-hospital mortality while those with high-risk scores (>10) had 58% risk of in-hospital mortality. The Hosmer-Lemeshow chi-square of the model was 6.47 (p=0.09), and the c-statistic was 0.62 in the validation cohort. CONCLUSION The model may be useful in identifying older adults at high risk of death after ED intubation.
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Affiliation(s)
- Kei Ouchi
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts.,Ariadne Labs, Serious Illness Care Program, Boston, Massachusetts
| | - Samuel Hohmann
- Vizient, Center for Advanced Analytics, Irving, Texas.,Rush University, Department of Health Systems Management, Chicago, Illinois
| | - Tadahiro Goto
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Peter Ueda
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, Massachusetts
| | - Emily L Aaronson
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Daniel J Pallin
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Marcia A Testa
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Department of Biostatistics, Boston, Massachusetts
| | - James A Tulsky
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Medicine, Division of Palliative Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts
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37
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Ouchi K, Block SD, Schonberg MA, Jamieson ES, Aaronson EL, Pallin DJ, Tulsky JA, Schuur JD. Feasibility Testing of an Emergency Department Screening Tool To Identify Older Adults Appropriate for Palliative Care Consultation. J Palliat Med 2017; 20:69-73. [DOI: 10.1089/jpm.2016.0213] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | - Susan D. Block
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emily S. Jamieson
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Aaronson EL, Filbin MR, Brown DFM, Tobin K, Mort EA. New Mandated Centers for Medicare and Medicaid Services Requirements for Sepsis Reporting: Caution from the Field. J Emerg Med 2016; 52:109-116. [PMID: 27720289 DOI: 10.1016/j.jemermed.2016.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/05/2016] [Accepted: 08/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The release of the Center for Medicare and Medicaid Service's (CMS) latest quality measure, Severe Sepsis/Septic Shock Early Management Bundle (SEP-1), has intensified the long-standing debate over optimal care for severe sepsis and septic shock. Although the last decade of research has demonstrated the importance of comprehensive bundled care in conjunction with compliance mechanisms to reduce patient mortality, it is not clear that SEP-1 achieves this aim. The heterogeneous and often cryptic presentation of severe sepsis and septic shock, along with the multifaceted criteria for the definition of this clinical syndrome, pose a particular challenge for fitting requirements to this disease, and implementation could have unintended consequences. OBJECTIVE Following a simulated reporting exercise, in which 50 charts underwent expert review, we aimed to detail the challenges of, and offer suggestions on how to rethink, measuring performance in severe sepsis and septic shock care. DISCUSSION There were several challenges associated with the design and implementation of this measure. The ambiguous definition of severe sepsis and septic shock, prescriptive fluid volume requirements, rigid reassessment, and complex abstraction logic all raise significant concern. CONCLUSIONS Although SEP-1 represents an important first step in requiring hospitals to improve outcomes for patients with severe sepsis and septic shock, the current approach must be revisited. The volume and complexity of the currently required SEP-1 reporting elements deserve serious consideration and revision before they are used as measures of accountability and tied to reimbursement.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathy Tobin
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Elizabeth A Mort
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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39
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Aaronson EL, Chang Y, Borczuk P. A prediction model to identify patients without a concerning intraabdominal diagnosis. Am J Emerg Med 2016; 34:1354-8. [PMID: 27113130 DOI: 10.1016/j.ajem.2016.03.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Patients with abdominal diagnoses constitute 5% to 10% of all emergency department (ED) presentations. The goal of this study is to identify which of these patients will have a nonconcerning diagnosis based on demographic, physical examination, and basic laboratory testing. METHODS Consecutive patients from July 2013 to March 2014 discharged with a gastrointestinal (GI) diagnosis who presented to an urban, university-affiliated ED were identified. The cohort was split into a derivation set and a validation set. Using univariate and multivariable logistic regression analysis, a risk score was created based on the deviation data and then tested on the validation data. RESULTS There were 8852 patients with a GI diagnosis during the study period. A total of 7747 (87.5%) of them had a nonconcerning diagnosis. The logistic regression model identified 13 variables that predict a concerning GI diagnosis and created a scoring system ranging from 0 to 20. The area under the receiver operating characteristic was 0.81. When dichotomized at greater than or equal to 7 vs less than 7, the risk score has a sensitivity of 91% (95% confidence interval [CI], 88-94), specificity of 46% (95% CI, 44-48), positive predictive value of 17% (95% CI, 15-19) and negative predictive value of 98% (95% CI, 97-99). CONCLUSION One can determine with a high degree of certainty, based only on an initial evaluation and screening laboratory work (excluding radiology) whether a patient who presents with a GI-related complaint has a nonconcerning diagnosis. This model could be used as a tool to aid in quality assurance when reviewing patients discharged with GI complaints and with future study, as a secondary triage instrument in a crowded ED environment, and aid in resource allocation.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
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40
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Aaronson EL, Marsh RH, Guha M, Schuur JD, Rouhani SA. Emergency department quality and safety indicators in resource-limited settings: an environmental survey. Int J Emerg Med 2015; 8:39. [PMID: 26520848 PMCID: PMC4628609 DOI: 10.1186/s12245-015-0088-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 10/16/2015] [Indexed: 11/16/2022] Open
Abstract
Background As global emergency care grows, practical and effective performance measures are needed to ensure high quality care. Our objective was to systematically catalog and classify metrics that have been used to measure the quality of emergency care in resource-limited settings. Methods We searched MEDLINE, Embase, CINAHL, and the gray literature using standardized terms. The references of included articles were also reviewed. Two researchers screened titles and abstracts for relevance; full text was then reviewed by three researchers. A structured data extraction tool was used to identify and classify metrics into one of six Institute of Medicine (IOM) quality domains (safe, timely, efficient, effective, equitable, patient-centered) and one of three of Donabedian’s structure/process/outcome categories. A fourth expert reviewer blinded to the initial classifications re-classified all indicators, with a weighted kappa of 0.89. Results A total of 1705 articles were screened, 95 received full text review, and 34 met inclusion criteria. One hundred eighty unique metrics were identified, predominantly process (57 %) and structure measures (27 %); 16 % of metrics were related to outcomes. Most metrics evaluated the effectiveness (52 %) and timeliness (28 %) of care, with few addressing the patient centeredness (11 %), safety (4 %), resource-efficiency (3 %), or equitability (1 %) of care. Conclusions The published quality metrics in emergency care in resource-limited settings primarily focus on the effectiveness and timeliness of care. As global emergency care is built and strengthened, outcome-based measures and those focused on the safety, efficiency, and equitability of care need to be developed and studied to improve quality of care and resource utilization. Electronic supplementary material The online version of this article (doi:10.1186/s12245-015-0088-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
| | - Moytrayee Guha
- Center for Clinical Excellence, Brigham and Women's Hospital, Boston, MA, USA.
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
| | - Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
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Aaronson EL, Wittels KA, Nadel ES, Schuur JD. Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety. West J Emerg Med 2015; 16:810-7. [PMID: 26594271 PMCID: PMC4651575 DOI: 10.5811/westjem.2015.8.26559] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/25/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction Morbidity and mortality conferences (M+M) are a traditional part of residency training and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective was to determine the goals, structure, and the prevalence of practices that foster strong safety cultures in the M+Ms of U.S. emergency medicine (EM) residency programs. Methods The authors conducted a national survey of U.S. EM residency program directors. The survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding; Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare Research & Quality Safety Culture survey. Results There was an 80% (151/188) response rate. The primary objectives of M+M were discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous case submission, with 10% (15/151) maintaining complete anonymity during the presentation and 21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of programs report regular debriefing with residents who have had their cases presented. Conclusion The structure and goals of M+Ms in EM residencies vary widely. Many programs lack features of M+M that promote a non-punitive response to error, such as anonymity. Other programs lack features that support strong safety cultures, such as following up on systems issues or reporting back to residents on improvements. Further research is warranted to determine if M+M structure is related to patient safety culture in residency programs.
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Affiliation(s)
- Emily L Aaronson
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts ; Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Kathleen A Wittels
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts ; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Eric S Nadel
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts ; Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts ; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts ; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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