Description and Yield of Current Quality and Safety Review in Selected US Academic Emergency Departments.

OBJECTIVES: Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement. We hypothesized that decades-old approaches used in many academic EDs are inefficient and low yield for identifying patient harm. METHODS: We conducted a prospective observational study to evaluate the efficiency and yield of current quality review processes at five academic EDs for a 12-month period. Sites provided descriptions of their current practice and collected summary data on the number and severity of events identified in their reviews and the referral sources that led to their capture. Categories of common referral sources were established at the beginning of the study. Sites used the Institute for Healthcare Improvement's definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for grading severity of events. RESULTS: Participating sites had similar processes for quality review, including a two-level review process, monthly reviews and conferences, similar screening criteria, and a grading system for evaluating cases. In 60 months of data collection, we reviewed a total of 4735 cases and identified 381 events. This included 287 near-misses, errors/events (MERP A-I) and 94 adverse events (AEs) (MERP E-I). The overall AE rate (event rate with harm) was 1.99 (95% confidence interval = 1.62%-2.43%), ranging from 1.24% to 3.47% across sites. The overall rate of quality concerns (events without harm) was 6.06% (5.42%-6.78%), ranging from 2.96% to 10.95% across sites. Seventy-two-hour returns were the most frequent referral source used, accounting for 47% of the cases reviewed but with a yield of only 0.81% in identifying harm. Other referral sources similarly had very low yields. External referrals were the highest yield referral source, with 14.34% (10.64%-19.03%) identifying AEs. As a percentage of the 94 AEs identified, external referrals also accounted for 41.49% of cases. CONCLUSIONS: With an overall adverse event rate of 1.99%, commonly used referral sources seem to be low yield and inefficient for detecting patient harm. Approximately 6% of the cases identified by these criteria yielded a near miss or quality concern. New approaches to quality and safety review in the ED are needed to optimize their yield and efficiency for identifying harm and areas for improvement.

We all make choices: A decision analysis framework for disposition decision in the ED.

BACKGROUND: Emergency Department (ED) providers' disposition decision impacts patient care and safety. The objective of this brief report is to gain a better understanding of ED providers' disposition decision and risk tolerance of associated outcomes. METHODS: We synthesized qualitative and quantitative methods including decision mapping, survey research, statistical analysis, and word clouds. Between July 2017 and August 2017, a 10-item survey was developed and conducted at the study hospital. Descriptive and statistical analyses were used to assess the relationship between the participant characteristics (age, gender, years of experience in the ED, and level of expertise) and risk tolerance of outcomes (72-h return and negative outcome) associated with disposition decision. Word clouds facilitated prioritization of qualitative responses regarding information impacting and supporting the disposition decision. RESULTS: Total of 46 participants completed the survey. The mean age was 39.5 (standard deviation (SD) 10years), and mean years of experience was 9.6years (SD 8.7years). Decision map highlighted the connections between patient-, provider-, and system-related factors. Survey results showed that negative outcome resulted in less risk tolerance compared to 72-h return. Chi-square tests did not provide sufficient evidence to indicate that the responses are independent of participants characteristics - except age and the risk of 72-h return (p=0.046). CONCLUSION: Discharge decision making in the ED is complex as it involves interconnected patient, provider, and system factors. Synthesizing qualitative and quantitative methods promise enhanced understanding of how providers arrive to disposition decision, as well as safety and quality of care in the ED.

Observational Study on Safety of Prehospital BLS CPAP in Dyspnea.

Introduction Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware's (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS). Hypothesis This study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival. METHODS: This was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar's and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was "improved," "unchanged," or "worsened." RESULTS: Seventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO224, and cyanosis (P<.01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD=1.9) to 14.1 (SD=1.9) after CPAP (mean difference [MD]=0.17; 95% CI, -0.49 to 0.83; P=.59). The HR decreased from 115.7 (SD=53) to 105.1 (SD=37) after CPAP (MD=-10.9; 95% CI, -3.2 to -18.6; P<.01). The SpO2 increased from 80.8% (SD=11.4) to 96.9% (SD=4.2) after CPAP (MD=17.8; 95% CI, 14.2-21.5; P<.01). CONCLUSION: The BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training. Sahu N , Matthews P , Groner K , Papas MA , Megargel R . Observational study on safety of prehospital BLS CPAP in dyspnea. Prehosp Disaster Med. 2017;32(6):610-614.