The Development Of Emergency Department Patient Quality/Safety Indicators
The Development ofEmergency DepartmentPatient Quality/Safety IndicatorsPatrick S. Romano, MD MPHUC Davis Center for Healthcare Policy and ResearchAHRQ Annual ConferenceSeptember 27, 2010
Overview HCUP and the AHRQ Quality Indicators Goals and scope of current project Literature review Conceptual frameworks Matrix of potential indicators Specification and testing Future steps
The HCUP Partnership: A VoluntaryFederal-State-Private CollaborationWY40 states90% of alldischarges24 statessubmit EDencounters
The Making of HCUP DataBillingrecordcreatedPatient entersED/hospitalAHRQstandardizes datato create uniformHCUP databases4States store datain varying formatsHospital sendsbilling data and anyadditional dataelements toData Organizations
Types of HCUP ntSample(NEDS)
AHRQ Quality Indicators (QIs) Developed through contract with UCSF-Stanford Evidence-based Practice Center & UC Davis, maintainedand extended through contract with BattelleUse existing HCUP (hospital discharge) data, based onreadily available data elementsIncorporate a range of severity adjustment methods,including APR-DRGs* and comorbidity groupingsDisseminate software and support materials free viawww.qualityindicators.ahrq.govProvide technical support to usersContinuous improvement through user feedback, annualcoding updates, validation projects* All Patient Refined - Diagnosis Related Groups6
Evidence-based indicator developmentINITIALEMPRICAL ANALYSESAND DEFINITIONLITERATURE REVIEWUSER SUGGESTIONSPANEL EVALUATION(MODIFIED DELPHIPROCESS)FURTHEREMPIRICAL ANALYSESFURTHER REVIEW?REFINED DEFINITIONFINAL DEFINITION7
Key considerations in the evaluation ofeach prospective indicatorApplication/experience:Is there reason to believethe indicator will be feasible and useful?Fosters real quality improvement:Is theindicator unlikely to be gamed or cause perverse incentives?Construct validity:Does the indicator identify quality ofcare problems that are suspected using other methods?Minimum bias:Is it possible to account for differences inseverity of illness & other factors that confound comparisons?Precision:Is there substantial “true” variation at the levelof provider measurement?Face validity/consensual validity:Does theindicator capture an important and modifiable aspect of care?
AHRQ Quality Indicator modulesInpatient QIsMortality,Utilization,VolumePrevention QIs(Area Level)AvoidableHospitalizations /Other AvoidableConditionsPediatric QIsPatient SafetyQIsNeonatalQIsComplications,Unexpected Death9
Goals and Scope Goals– Develop two sets of quality indicators that areapplicable to the emergency department setting Patient Safety Indicators (PSI) Prevention Quality Indicators (PQI)– Set the stage for future incorporation into publiclyavailable AHRQ QI software Scope– Implement the established AHRQ QI measurementdevelopment process– Adapt existing AHRQ QI to ED setting when possible– Identify and evaluate new candidate indicators basedon established measurement concepts
Literature review: strategySearch goal: To find studies that introduced or used quality of care measures to assesspatient safety in hospital emergency departments.Search strategy using MESH headings in PubMed: ("Quality Assurance, Health Care"[Mesh] OR "Quality Indicators, HealthCare"[Mesh] OR "Quality of Health Care"[Mesh] OR "Health Care Quality,Access, and Evaluation"[Mesh] OR "United States Agency for HealthcareResearch and Quality"[Mesh] OR "Outcome Assessment (HealthCare)"[Mesh])AND "Emergency Service, Hospital"[Mesh]AND ("Medical Errors"[Mesh] OR "Malpractice"[Mesh] OR "Safety"[Mesh] OR"Equipment Safety"[Mesh] OR "Safety Management"[Mesh])Validation using title and/or abstract keywords: “patient safety” OR “adverse event” OR “avoidable condition”AND “quality”AND (“emergency room” OR “emergency department” For the most important papers, we searched for „all related articles‟.
Literature review: process PubMed:––1,050 abstracts, decreased to 687 when limited to humansubjects, English language, date within 10 yrs.All abstracts were reviewed for relevance (i.e., describing one ormore measures of ED quality/safety). National Quality Measures Clearinghouse–http://qualitymeasures.ahrq.gov/ Organizations and websites–––––––National Quality ForumFederal: AHRQ and CMS/QualityNetED: ACEP and SAEMAMA: Physician Consortium for Performance ImprovementOther developers: NCQA and The Joint CommissionInstitute of Medicine/National Academy of SciencesCanada: Institute for Clinical Evaluative Sciences, CanadianInstitute for Health Information
Literature review: key themes40 journal papers, 23 documents and reports Some TJC Core Measures address processes of care in EDmanagement of pneumonia or myocardial infarctionCritical trauma or shock care, generally based on detailed "peer" reviewof medical records to assess appropriateness and timeliness ofdiagnostic and therapeutic interventionsTime-based measures, generally focused on waiting time, total LOS inthe ED, ED disposition time for admitted/transferred patientsAppropriate prescribing and avoidance of medication errors for commonconditions such as asthma, bronchiolitis, gastroenteritis, lacerationAppropriate use of imaging studies, laboratory, ECGAppropriate assessment of pain, oxygenation, mental status/cognition“Left without being seen" or "left AMA" (premature discharge from ED)Other adverse consequences of crowding/boarding“Missed diagnosis” identified by return within defined time window for aserious conditionRevisits to ED within defined time window for same or related condition
Conceptual framework for prioritization:American College of Emergency Physicians,2009DomainExamplesAccess to emergencycareQuality and patientsafety environmentMedical liabilityenvironmentPublic health and injurypreventionAccess to providers, access to treatment centers,financial barriers, hospital capacityState-supported systems, institutional barriersDisaster preparednessLegal atmosphere, insurance availability, tort reformTraffic safety and drunk driving, immunization,injury control, state injury prevention efforts, healthrisk factorsFinancial resources, state coordination, hospitalcapacity, personnel
Conceptual framework for prioritization:Institute of Medicine, 2010
Conceptual framework for prioritization:Institute of Medicine, entEquitableApplication to the EDHigh-risk, high-stress environment “fraught with opportunities for error” frequent interruptions and distractions, crowding, need for rapiddecision-making with incomplete information, barriers to effectivecommunication and teamwork, difficulty obtaining timely diagnostic testsLimited by deficiencies in pre-hospital care, unavailability of trainedspecialists, lack of access to patients‟ prior medical records, poorprimary care follow-up, inability to coordinate care across settingsCrowding, long wait times, boarding of admitted patients in hallways,design emphasis on visibility and monitoring rather than privacyDesigned to provide timely care for emergent medical problems, butoften overwhelmed by the demand for their services Frequently asked to provide care for which it is not the most efficientsetting primary care, urgent care for minor complaints, and inpatientcare to admitted patients compromises efficiencyEMTALA requires EDs to treat all patients equitably (but) variation inresources and personnel across communities may create inequities inhow patients in different EDs are treated
Conceptual framework for prioritization:ICES/Alberta Quality Matrix for Health, 2010DomainAcceptabilityExamplesHealth services are respectful and responsive to userneeds, preferences and expectations.AccessibilityHealth services are obtained in the most suitable settingin a reasonable time and distance.AppropriatenessHealth services are relevant to user needs and arebased on accepted or evidence-based practice.EffectivenessHealth services are provided based on scientificknowledge to achieve desired outcomes.EfficiencyResources are optimally used in achieving desiredoutcomes.SafetyMitigate risks to avoid unintended or harmful results.Healthy workplace Provision of health services does not lead to anunhealthy work environment for health care staff.
Application of conceptual frameworkStructureProcessOutcomeEffectiveNurse staffing and skillmix (RN/total) in EDAspirin at arrival for AMI(TJC/CMS)Percentage of asthma encountersfollowed by revisit (or admission tohospital) within 3 daysPatientCenteredUse of survey data inPDSA cycles to improvepatient centered care inEDPercentage of patientsundergoing painful procedureswho have pain scoredocumentationPercentage of patients leavingED without being seen by aphysician (proxy outcome, LSUHealth Services)TimelyED triage policies toensure timely evaluationof high-acuity patientsMedian time from ED arrivalto ED departure for admittedED patients (CMS)Percentage of orthopedic painpatients with 3-point reduction inpain score within 60 minutesSafeComputerized physicianorder entry with decisionsupport tools to detectmedication errorsConfirmation of endotracheal tube placement(Cleveland ClinicFoundation)Death or disability due to airembolism from a medicaldevice (NQF)EfficientAvailability of laboratoryand radiologic support tofacilitate rapid evaluationand disposition in EDPercentage of low back painpatients with appropriatediagnostic test utilizationDollars per episode of low backpain evaluated in the EDEquitableAvailability of adequateinterpreting services in EDPercentage of non-Englishspeaking patients for whominterpreting services are usedDisparity in any other outcomeaccording to primary language
Matrix of potential indicatorsInclusion/exclusion criteria Identified from published source––– Address the domains of effectiveness and/or safety– Literature review (40 journal articles)Organizations and websites (if a consensus-based approach and/ormodified Delphi approach was used)Similar review by Alessandrini et al. for PECARNA few measures of timeliness were included because the measuredeveloper characterized them as having implications for safety in the EDFocus on care provided within the ED (not pre-hospital care)Clinical guidelines, standards of care, and ED decision rules were notincluded unless operationalized as indicatorsCan be implemented in at least one HCUP partner state usingavailable HCUP dataWhen 2 indicators appeared to address the same outcome, only themore recent and/or more clearly specified indicator was retainedMeasures that were evaluated and discarded or rejected through aconsensus-based expert panel process were not included
Matrix of potential indicatorsApplication of existing inpatient PSIs Foreign body left inIatrogenic pneumothorax“Postoperative” hip fracture“Postoperative” hemorrhage or hematomaAccidental puncture or lacerationTransfusion reaction BUT critical problem is timing–––Only 5 states (GA, MA, MN, NJ, TN) have POA in SEDD; only MAand TN also have PNUMIn SID, POA means “present at the time the order for inpatientadmission occurs” (i.e., after some period of ED treatment)ED diagnoses are “lost” in SID when patient admitted to samehospital
Matrix of potential indicators35 new candidate indicators Age range– 12 for children only– 10 for adults only– 13 for both children and adultsDonabedian‟s typology– 11 process– 17 outcome (or proxy outcome such as revisit)– 6 hybrid (“missed serious diagnosis”)– 1 patient experience or health risk behavior (“left AMA”)Developer(s)– 20 Institute for Clinical Evaluative Sciences, specified in ICD-10-CA– 3 ACEP and/or PCPI– 3 CMS– 4 other organizations– 5 researchersEndorsement - 6 endorsed by NQF
Matrix of potential indicators35 new candidate indicators Revisits - 13–––4 within 24 hours (1 specified as 24 hrs or 72 hrs)3 within 48 hours (2 specified as 48 hrs or 72 hrs)6 within 72 hours (1 specified as 72 hrs or 1 week) Missed serious diagnoses - 7–– 1 unanticipated death within 7 days following ED care6 admission for missed diagnosis (AMI/ACS, SAH, ectopicpregnancy, traumatic injury, appendicitis)Appropriate use of diagnostic test or imaging – 5Acute complications of ED procedures – 3Time within ED awaiting definitive care – 3Appropriate admission for inpatient care – 2Appropriate use of treatment or intervention – 1Left “against medical advice” – 1
Challenges in specification andtesting Identification of patients “at risk”– What procedures place patients at risk for hemorrhageor accidental puncture/laceration? Timing– Did the fall occur prior to ED arrival, in ED, or later? Low frequency with “true” frequency unknown– Unable to choose “best” specification Use of utilization flag variables to identify patientswho had specific procedures– ultrasound, ECG, CT scan, transfusion Unable to operationalize all specifications– Exclusion of “planned” (or “invited”) return visits to ED– All presenting symptoms for “missed diagnoses”
Future steps Complete testing of adapted inpatient PSIs Prioritize 23 candidate indicators applicable to adults toselect 7-12 for full specification and testing––Denominator inclusion/exclusion rulesNumerator definition Assess face validity based on empirical analyses of HCUPdata from 9 states Recommend 5-7 indicators for review and feedback by anexternal “work group” with a diverse set of stakeholders Formal evaluation by expert panels through a modifiedDelphi panel process? Release of new module of ED PSIs?
Acknowledgments UC Davis team–––Banafsheh Sadeghi (epidemiologist)David Barnes and Aaron Bair (emergency physicians)Yun Jiang and Daniel Tancredi (programming and analysis) External advisors–Jesse Pines (GWU), Michael Phelan (Cleveland Clinic), EmilyCarrier (HSC), Evaline Alessandrini (CCHMC), Astrid Guttmann(ICES), Jeremiah Schuur (Brigham & Women‟s) AHRQ CDOM staff–––Pamela Owens and Ryan Mutter (ED task)Mamatha Pancholi and John Bott (QI program)Jenny Schnaier and Carol Stocks (HCUP) HCUP partners–Arizona, California, Florida, Hawaii, Indiana, Nebraska, SouthCarolina, Tennessee, Utah
Goals and Scope Goals - Develop two sets of quality indicators that are applicable to the emergency department setting Patient Safety Indicators (PSI) Prevention Quality Indicators (PQI) - Set the stage for future incorporation into publicly available AHRQ QI software Scope - Implement the established AHRQ QI measurement development process
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