Teaching and clinical efficiency: competing demands.

INTRODUCTION: Teaching ability and efficiency of clinical operations are important aspects of physician performance. In order to promote excellence in education and clinical efficiency, it would be important to determine physician qualities that contribute to both. We sought to evaluate the relationship between teaching performance and patient throughput times. METHODS: The setting is an urban, academic emergency department with an annual census of 65,000 patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institution identified 5 prevailing domains of faculty instructional performance. The 5 statistically significant domains identified were: Competency and Professionalism, Commitment to Knowledge and Instruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit a multivariate, random effects model using each of the 5 instructional domains for emergency medicine faculty as independent predictors and throughput time (in minutes) as the continuous outcome. Faculty that were absent for any portion of the research period were excluded as were patient encounters without direct resident involvement. RESULTS: Two of the 5 instructional domains were found to significantly correlate with a change in patient treatment times within both datasets. The greater a physician's Commitment to Knowledge and Instruction, the longer their throughput time, with each interval increase on the domain scale associated with a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes). Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease in throughput (90% CI: -8.83 to -0.07 minutes). CONCLUSION: Some aspects of teaching aptitude are associated with increased throughput times (Openness and Enthusiasm), while others are associated with decreased throughput times (Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist between operational and instructional performance.

The chest pain choice decision aid: a randomized trial.

BACKGROUND: Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. METHODS AND RESULTS: The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24-72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (n=103), decision aid patients (n=101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34-1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6-21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group. CONCLUSIONS: Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.

Episodes of care: is emergency medicine ready?

Optimizing resource use, eliminating waste, aligning provider incentives, reducing overall costs, and coordinating the delivery of quality care while improving outcomes have been major themes of health care reform initiatives. Recent legislation contains several provisions designed to move away from the current fee-for-service payment mechanism toward a model that reimburses providers for caring for a population of patients over time while shifting more financial risk to providers. In this article, we review current approaches to episode of care development and reimbursement. We describe the challenges of incorporating emergency medicine into the episode of care approach and the uncertain influence this delivery model will have on emergency medicine care, including quality outcomes. We discuss the limitations of the episode of care payment model for emergency services and advocate retention of the current fee-for-service payment model, as well as identify research gaps that, if addressed, could be used to inform future policy decisions of emergency medicine health policy leaders. We then describe a meaningful role for emergency medicine in an episode of care setting.

Interventions to safeguard system effectiveness during periods of emergency department crowding.

This article summarizes the proceedings of a breakout session, "Interventions to Safeguard System Effectiveness," at the 2011 Academic Emergency Medicine consensus conference, "Interventions to Assure Quality in the Crowded Emergency Department." Key definitions fundamental to understanding the effectiveness of emergency care during periods of emergency department (ED) crowding are outlined. Next, a proposed research agenda to evaluate interventions directed at improving emergency care effectiveness is outlined, and the paper concludes with a prioritization of those interventions based on breakout session participant discussion and evaluation.

Enhancing systems to improve the management of acute, unscheduled care.

For acutely ill patients, health care services are available in many different settings, including hospital-based emergency departments (EDs), retail clinics, federally qualified health centers, and outpatient clinics. Certain conditions are the sole domain of particular settings: stabilization of critically ill patients can typically only be provided in EDs. By contrast, many conditions that do not require hospital resources, such as advanced radiography, admission, and same-day consultation can often be managed in clinic settings. Because clinics are generally not open nights, and often not on weekends or holidays, the ED remains the only option for face-to-face medical care during these times. For patients who can be managed in either setting, there are many open research questions about which is the best setting, because these venues differ in terms of access, costs of care, and potentially, quality. Consideration of these patients must be risk-adjusted, as patients may self-select a venue for care based upon perceived acuity. We present a research agenda for acute, unscheduled care in the United States developed in conjunction with an Agency for Healthcare Research and Quality-funded conference hosted by the American College of Emergency Physicians in October 2009, titled "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach." Given the possible increase in ED utilization over the next several years as more people become insured, understanding differences in cost, quality, and access for conditions that may be treated in EDs or clinic settings will be vital in guiding national health policy.

Frequent users of emergency department services: gaps in knowledge and a proposed research agenda.

Frequent use of emergency department (ED) services is often perceived to be a potentially preventable misuse of resources. The underlying assumption is that similar and more appropriate care can be delivered outside of EDs at a lower cost. To reduce costs and incentivize more appropriate use of services, there have been efforts to design interventions to transition health care utilization of frequent users from EDs to other settings such as outpatient clinics. Many of these efforts have succeeded in smaller trials, but wider use remains elusive for varying reasons. There are also some fundamental problems with the assumption that all or even the majority of frequent ED use is misuse and invoking reasons for that excessive use. These tenuous assumptions become evident when frequent users as a group are compared to less frequent users. Specifically, frequent users tend to have high levels of frequent ED use, have a higher severity of illness, be older, have fewer personal resources, be chronically ill, present for pain-related complaints, and have government insurance (Medicare or Medicaid). Because of the unique characteristics of the population of frequent users, we propose a research agenda that aims to increase the understanding of frequent ED use, by: 1) creating an accepted categorization system for frequent users, 2) predicting which patients are at risk for becoming or remaining frequent users, 3) implementing both ED- and non-ED-based interventions, and 4) conducting qualitative studies of frequent ED users to explore reasons and identify factors that are subject to intervention and explore specific differences among populations by condition, such as mental illness and heart failure.

Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care.

The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.

Research priorities for palliative and end-of-life care in the emergency setting.

Palliative care focuses on the physical, spiritual, psychological, and social care from diagnosis to cure or death of a potentially life-threatening illness. When cure is not attainable and end of life approaches, the intensity of palliative care is enhanced to deliver the highest quality care experience. The emergency department (ED) frequently cares for patients and families during the end-of-life phase of the palliative care continuum. The intersection between palliative care and emergency care continues to be more clearly defined. Currently, there is a mounting body of evidence to guide the most effective strategies for improving palliative and end-of-life care in the ED. In a workgroup session at the 2009 Agency for Healthcare Research and Quality (AHRQ)/American College of Emergency Physicians (ACEP) conference "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach," four key research questions arose: 1) which patients are in greatest need of palliative care services in the ED, 2) what is the optimal role of emergency clinicians in caring for patients along a chronic trajectory of illness, 3) how does the integration and initiation of palliative care training and services in the ED setting affect health care utilization, and 4) what are the educational priorities for emergency clinical providers in the domain of palliative care? Workgroup leaders suggest that these four key questions may be answered by strengthening the evidence using six categories of inquiry: descriptive, attitudinal, screening, outcomes, resource allocation, and education of clinicians.

Conference proceedings-improving the quality and efficiency of emergency care across the continuum: a systems approach.

In October 2009, the American College of Emergency Physicians (ACEP) convened a conference held in Boston, Massachusetts, to outline critical issues in emergency care quality and efficiency and to develop a series of research agendas and projects aimed at addressing important questions about how to improve acute, episodic care. The aim of the conference was to describe how hospital-based emergency department (ED) systems could provide solutions for broader delivery problems in the U.S. health care system. The conference featured keynote speakers Drs. Carolyn Clancy (Director, Agency for Healthcare Research and Quality) and Elliott Fisher (Director, Center for Health Policy Research at Dartmouth Medical School). Panels focused on: 1) systems and workflow redesign to improve health care and 2) improving coordination of care for high-cost patients. Additional sessions were conducted to develop five research agendas on the following topics: 1) health information technology; 2) demand for acute care services; 3) frequent, high-cost users of emergency care; 4) critical pathways for post-emergency care diagnosis and treatment; and 5) end-of-life and palliative care in the ED.

Emergency department operational metrics, measures and definitions: results of the Second Performance Measures and Benchmarking Summit.

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

Regionalization and emergency care: the institute of medicine reports and a federal government update.

The 2010 Academic Emergency Medicine consensus conference on regionalization in emergency care began with an update on the Institute of Medicine (IOM) reports on the Future of Emergency Care. This was followed by two presentations from federal officials, focusing on regionalization from the perspective of the White House National Security Staff and the Emergency Care Coordination Center. This article summarizes the content of these presentations. It should be noted that this summary is the perspective of the authors and does not represent the official policy of the U.S. government.

The Chest Pain Choice trial: a pilot randomized trial of a decision aid for patients with chest pain in the emergency department.

BACKGROUND: Chest pain is a common presenting complaint in the emergency department (ED). Despite the frequency with which clinicians evaluate patients with chest pain, accurately determining the risk of acute coronary syndrome (ACS) and sharing risk information with patients is challenging. The aims of this study are (1) to develop a decision aid (CHEST PAIN CHOICE) that communicates the short-term risk of ACS and (2) to evaluate the impact of the decision aid on patient participation in decision-making and resource use. METHODS/DESIGN: This is a protocol for a parallel, 2-arm randomized trial to compare an intervention group receiving CHEST PAIN CHOICE to a control group receiving usual ED care. Adults presenting to the Saint Mary's Hospital ED in Rochester, MN USA with a primary complaint of chest pain who are being considered for admission for prolonged ED observation in a specialized unit and urgent cardiac stress testing will be eligible for enrollment. We will measure the effect of CHEST PAIN CHOICE on six outcomes: (1) patient knowledge regarding their short-term risk for ACS and the risks of radiation exposure; (2) quality of the decision making process; (3) patient and clinician acceptability and satisfaction with the decision aid; (4) the proportion of patients who decided to undergo observation unit admission and urgent cardiac stress testing; (5) economic costs and healthcare utilization; and (6) the rate of delayed or missed ACS. To capture these outcomes, we will administer patient and clinician surveys after each visit, obtain video recordings of the clinical encounters, and conduct 30-day phone follow-up. DISCUSSION: This pilot randomized trial will develop and evaluate a decision aid for use in ED chest pain patients at low risk for ACS and provide a preliminary estimate of its effect on patient participation in decision-making and resource use. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT01077037.

Developing a standardized faculty evaluation in an emergency medicine residency.

BACKGROUND: Quality educators are a core component of successful residency training. A structured, consistent, validated evaluation of clinical educators is important to improve teaching aptitude, further faculty development, and improve patient care. STUDY OBJECTIVES: The authors sought to identify specific domains of instructional quality and to develop a composite instrument for assessing instructional quality. METHODS: The study setting is a 3-year residency program. Residents rated the quality of faculty member instruction using an 18-item survey twice over a 2-year period (2004-2005). Each survey item used a 9-point scale. Factor analysis employing a Varimax rotation identified domains of instructional performance. Cronbach's alpha was used to assess the internal consistency of the identified domains. RESULTS: There were 29 faculty members evaluated. Using 2004 data, five domains of instructional quality were identified that explained 92.5% of the variation in survey responses (χ(2) = 2.33, P = 0.11). These were: Competency and Professionalism (30% of variation), Commitment to Knowledge and Instruction (23%), Inclusion and Interaction (17%), Patient Focus (13%), and Openness to Ideas (9%). Competency and Professionalism included appropriate care, effective patient communication, use of new techniques, and ethical principles. Commitment to Knowledge and Instruction included research, mentoring, feedback, and availability. Inclusion and Interaction included procedural participation and bedside teaching. Patient Focus included compassion, effective care, and sensitivity to diverse populations. Openness to Ideas included enthusiasm and receptivity of new ideas. These five domains were consistent in the 2005 data (Cronbach's alpha 0.68-0.75). CONCLUSIONS: A five-domain instrument consistently accounted for variations in faculty teaching performance as rated by resident physicians. This instrument may be useful for standardized assessment of instructional quality.

Modafinil and zolpidem use by emergency medicine residents.

OBJECTIVES: The objective was to assess the prevalence and patterns of modafinil and zolpidem use among emergency medicine (EM) residents and describe side effects resulting from use. METHODS: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national American Board of Emergency Medicine in-training examination. Data regarding frequency and timing of modafinil and zolpidem use were collected, as well as demographic information, reasons for use, side effects, and perceived dependence. RESULTS: A total of 133 of 134 residency programs distributed the surveys (99%). The response rate was 56% of the total number of EM residents who took the in-training examination (2,397/4,281). Past modafinil use was reported by 2.4% (57/2,372) of EM residents, with 66.7% (38/57) of those using modafinil having initiated their use during residency. Past zolpidem use was reported by 21.8% (516/2,367) of EM residents, with 15.3% (362/2,367) reporting use in the past year and 9.3% (221/2,367) in the past month. A total of 324 of 516 (62.8%) of zolpidem users initiated use during residency. Side effects were commonly reported by modafinil users (31.0%)-most frequent were palpitations, insomnia, agitation, and restlessness. Zolpidem users reported side effects (22.6%) including drowsiness, dizziness, headache, hallucinations, depression/mood lability, and amnesia. CONCLUSIONS: Zolpidem use is common among EM residents, with most users initiating use during residency. Modafinil use is relatively uncommon, although most residents using have also initiated use during residency. Side effects are commonly reported for both of these agents, and long-term safety remains unclear.