Discharging PE Patients from the ED
Evidence indicates that EDs are overcrowded, that length of stay is of major concern, and that decreasing hospital admissions is good for patients. For a study, researchers in Boston compared outcomes among patients with pulmonary embolism (PE) before and after implementation of an outpatient treatment protocol that combined risk stratification, treatment with rivaroxaban, and rapid follow-up. Overall, ED discharge rates increased from 10.5% to 14.8% after implementation. The rates of patients with PE or deep vein thrombosis who were discharge with rivaroxaban increased from 24.2% to 58.9%. Major bleeding, 7-day mortality, and hospital readmission rates were not significantly different before and after implementation of the protocol. The study authors stress the importance of follow-up in their protocol, note that it is not difficult and should not be a deterrent, and add that reducing PE-related hospitalizations saves healthcare costs without sacrificing patient safety.
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Survival After Naloxone Rescue
Data on the success rates of naloxone use in the resuscitation of opioid overdose patients have been lacking. An analysis of Massachusetts state-level data on more than 12,000 administrations of naloxone by emergency medical services was conducted for a study. While 85% of patients administered naloxone lived for at least 1 year, a 15% 1-year mortality rate is less than optimal. Of those who died within 1 year, about 40% of fatalities occurred the same day as resuscitation; among the other 60%, about 38% died outside the hospital, and about half within 1 month of initial rescue. Opioid overdose was the cause of death of nearly half who died the same day and approximately 35% who died within 1 year.
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Pediatric Concussion Underdiagnosed in the ED
Few studies have assessed ED physician understanding and diagnosis of pediatric concussion. For a study, study investigators conducted a retrospective chart review of children presenting to a dedicated pediatric ED at a level 1 trauma center and applied a consensus statement to establish whether patients manifested signs of concussion. Two-thirds of participants were boys, with an average age of 11. Of children with features compatible with the diagnosis of concussion, 62.7% were not diagnosed. Under-diagnosis was predicted by suffering an injury while participating in sports and undergoing a CT scan. Conversely, patients involved in auto accidents were more likely to receive a concussion diagnosis. The study authors speculate that lack of provider recognition of the constellation of signs and symptoms that satisfy diagnostic criteria may have contribute to such a large under-diagnosis rate.
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Improving ED Admit Times
“Dr. Admit” is a pilot ED program meant to speed triage. Under the program, providers handling ED triage answer whether the patient looks sick and will likely be admitted. If the answer to both is a “clear yes,” the program is activated. When answers are unclear, patients are immediately referred to an available emergency provider for potential admission. The process was designed to have providers identify candidate patients early upon presentation and reduce the time they spend in the emergency department by rallying nursing, clinician, laboratory, imaging and consulting service resources in a coordinated fashion to prioritize patient’s care needs and hopefully facilitate admission to an inpatient service within 1 hour. When comparing the 12 months prior to implementation of Dr. Admit at a ED with the 12 months following, researchers found that average admission time decreased from 329 to 192 minutes. Median admission time was reduced from 271 to 165 minutes.
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Global Budgets & ED Admissions
Studies have shown that hospital admissions account for the majority of national health expenditures, with the ED as the greatest source of admissions in the United States. The global budget revenue program (GBR) is a payment model that prospectively determines the annual budget for participating hospitals, incentivizing each to minimize expenditures and prevent avoidable admissions, with the overall goals of reducing per capita costs, enhancing quality of care, and improving population health. A study seeking to examine the impact of the GBR model on ED hospitalizations assessed nearly 1.5 million ED encounters in Maryland (MD) and Washington, DC (DC). ED hospitalization rates decreased 3.03% in MD and 1.98% in DC hospitals following use of the GBR model. In MD, post-GBR declines were observed in the proportion of hospitalized ED encounters with milder severity of illness (SOI) and risk of morality (ROM), reflecting encounters that may be amenable to outpatient management, as well as in extreme SOI and ROM, which may reflect advancement with GBR’s population health goals.
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Optimizing MRI Use in the ED
According to the Emergency Department Benchmarking Alliance 2013 data, the expected rate of MRI use was 1.9 MRIs ordered for every 100 patients. However, few studies have evaluated the appropriateness of MRIs ordered with the goal of improving MRI order optimization in the ED. For a study, researcher formed a Lean Six Sigma Green Belt project and incorporated the Define-Measure-Analyze-Improve-Control process to investigate MRI use in the ED. At baseline, the MRI use rate based on initial chart reviews was 4.1 MRIS ordered per 100 patients seen. After implementation of the education and process improvement, the rate fell to 3.45 MRIs ordered per 100 patients seen. Appropriateness of MRIs ordered, as determined by American College of Radiology Select Criteria, improved from 90.8% to 97.9%.
