ED Hospital Medicine Observation Project: A Quality ...
Transcript of ED Hospital Medicine Observation Project: A Quality ...
Lehigh Valley Health NetworkLVHN Scholarly Works
USF-LVHN SELECT
ED Hospital Medicine Observation Project: AQuality Improvement InitiativeRachel Appelbaum BSUSF MCOM-LVHN Campus, [email protected]
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Published In/Presented AtAppelbaum, R. (2015, March). ED Hospital Medicine Observation Project: A Quality Improvement Initiative. Poster presented at: TheSELECT Capstone Project in the Kasych Conference Room, Lehigh Valley Health Network, Allentown, PA.
© 2015 Lehigh Valley Health Network
• Problem:Inefficiencyintriage,labelingasobservationvs.inpatientadmission,andtimelycommunicationbetweenproviders
• Equatingtocountlessworkhoursspentandincreasedcostforthenetwork
• Opportunitytobettermanageobservationpatientsanddecreasetheiroveralllengthofstay
• ThenewCMS“2midnightrule”hasincreasedtheneedforobservationpatientstobecloselymonitoredtoensurecasesthatexceed48hoursareduetomedicalnecessity
• TheObservationProjectisaqualityimprovementinitiativeandcollaborationoftheDepartmentofEmergencyMedicine,theDepartmentofHospitalMedicineandancillaryservices
• Thefocusofthisinitiativeisonexpansionoftheobservationcohorting,establishmentofunifiedobservationprotocols,providereducationandlengthofstaymanagement
• TheObservationprojecthasbeenadoptedbyLVHNasoneofthenetwork’smainobjectivesoffiscalyear2015.
Background
Methods
Conclusions
FormationofEBMguidelinescanbeaccomplishedrelativelyexpediently;however,changingthedailypracticeofwell-seasonedclinicianscanbedifficultandtakestime.
1. Knowyouraudienceandhowtheyneedtoreceivenewinformation
2. Gainbuy-infromkeystakeholders(bestwayofcreatinginfluence)
3. Improvementisacontinualprocessthatisneverendingandtakestime
Future Applications• Enhancestandardizationamongproviders• Providesafer,mostcurrent,evidencebasedcare• Limitunnecessaryadmissionsanddiagnosticstudies
tosaveonthebottomline• Createdialogueamongproviderswhosharedifferent
approachestosyncopeandchestpainworkup
Results Discussion
• Determineifyourpatientisathighriskbycompletingathoroughhistoryandphysicalexamaswellas3preliminarytests
Project Goals• Definesyncopeandchestpainobservationand
inpatientadmissioninclusion/exclusioncriteria
• Reviseuniversaltestingtoofferimmediateidentificationofriskfactorsandcriticalclinicalvariables
• Developeducationalmessagingonobservationalpatientwork-ups
• Reducedelaysfortestinganddischarge
Metrics for Success• Increasethepercentageofcohortingtodedicated
observationunits
• Reducelengthofstay
• Reducethenumberofunnecessarytests
• Reduceconversionrates,inpatienttoobservationorviceversa
• Reducereadmissionrates
• EvidenceBasedMedicine(EBM)researchandnationaldatabasereviewfornationalclinicalpracticeguidelinesandexclusioncriteria
• DevelopmentofclinicalpracticeguidelinesforLVHNwhichEMphysiciansandHMhospitalistsagreeuponforatleasttwooutofsixpresentingpatientsymptoms:chestpainandsyncope
• Futureeducationsessionswithphysicians,residentsandancillaryservicestopresentthenewstandardizedclinicalpracticeguidelines.
• Futureimplementationandfeedbacksessions
Definition Pain in the thorax region.
Differential Diagnosis
Cardiac Causes (15-18%) Unstable angina, MI, pericarditis and myopericarditis, aortic dissection
Pulmonary Causes (5-10%) Pneumonia, pleuritis, tension pneumothorax, PE, PHT
GI Causes(8-19%) Esophageal reflux, esophageal spasm, Mallory-Weiss, Boerhaave, peptic ulcer disease, biliary disease, pancreatitis
Musculoskeletal and Miscellaneous Causes
(36-49%) Chostocondritis, muscular strain, herpes zoster
Psychiatric (8-11%) Anxiety
REFERENCES1. (2010).“NationalClinicalGuidelineCentreforAcuteandChronicConditions.Chestpainofrecentonset:assessmentanddiagnosisof
recentonsetchestpainordiscomfortofsuspectedcardiacorigin.”London (UK): National Institute for Health and Clinical Excellence (NICE).Retrievedfromhttp://www.guideline.gov/content.aspx?id=16392.
2. Qassem,A.etal.(2012).“DiagnosisofStableIschemicHeartDisease:SummaryofaClinicalPracticeGuidelinefromtheAmericanCollegeofPhysicians/AmericanCollegeofCardiologyFoundation/AmericanHeartAssociation/AmericanAssociationforThoracicSurgery/PreventiveCardiovascularNursesAssociation/SocietyofThoracicSurgery.”Ann Intern Med.Retrievedfromhttp://www.guideline.gov/content.aspx?id=39253.
3. Gibbons,R.etal.(1999).“ACC/AHA/ACP–ASIMGuidelinesfortheManagementofPatientsWithChronicStableAngina:ExecutiveSummaryandRecommendations:AReportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(CommitteeonManagementofPatientsWithChronicStableAngina).”Journal of the American Heart Association.Retrievedfromhttp://circ.ahajournals.org/content/99/21/2829.full.
4. Huff,S.etal.(2007)“ClinicalPolicy:ManagementofSyncope.”Clinical & Practice Management: ACEP News.Retrievedfromhttp://www.acep.org/Clinical---Practice-Management/Clinical-Policy--Management-of-Syncope/.
5. Reed,M.etal.(2007).“TheRiskstratificationOfSyncopeintheEmergencydepartment(ROSE)pilotstudy:acomparisonofexistingsyncopeguidelines.”Emergency Medicine Journal.Retrievedfromhttp://www.acep.org/content.aspx?id=48303.
6. Reed,M.etal.(2010)“TheROSE(RiskStratificationofSyncopeintheEmergencyDepartment)Study.”Journal of the American College of Cardiology.Retrievedfromhttp://www.ncbi.nlm.nih.gov/pubmed/20170806.
7. Huff,S.etal.(2007)“ClinicalPolicy:CriticalIssuesintheEvaluationandManagementofAdultPatientsPresentingtotheEmergencyDepartmentwithSyncope.”American College of Emergency Physicians.Retrievedfromhttp://www.mayo.edu/research/documents/clin-pol-crit-issuespdf/DOC-10026672.
8. Arrigo,T.(2013)“Syncopeunits:Onesolutiontoanexpensiveproblem:Approachmayhelpavoidunnecessarytesting,enhancediagnosis.” ACP Hospitalist.Retrievedfromhttp://www.acphospitalist.org/archives/2013/11/yp.htm.
9. Strickberger,S.A.etal.(2006).“AHA/ACCFScientificStatementontheEvaluationofSyncope:FromtheAmericanHeartAssociationCouncilsonClinicalCardiology,CardiovascularNursing,CardiovascularDiseaseintheYoung,andStroke,andtheQualityofCareandOutcomesResearchInterdisciplinaryWorkingGroup;andtheAmericanCollegeofCardiologyFoundation:InCollaborationWiththeHeartRhythmSociety;EndorsedbytheAmericanAutonomicSociety.”Circulation:Journal of the American Heart Association. Retrievedfromhttp://circ.ahajournals.org/content/113/2/316.full.
10. Sabatine,M.(2011).“SyncopeandChestPain.”Pocket Medicine: Fourth Edition.Retrievedfrombook.Worcester,S.(2010).“RoseRuleCouldSimplifySyncopeRiskAssessment.”ACEPNews:ElsevierGlobalMedicalNews.Retrievedfromhttp://www.acep.org/content.aspx?id=48303.
11. (2011).“Qualityimprovement.”US Department of Health and Human Services: Health Resources and Services Administration.Retrievedfromhttp://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/.
12. (1994).“ChestPainUnitsinEmergencyDepartments.”Retrievedfromhttp://www.acep.org/Clinical---Practice-Management/Chest-Pain-Units-in-Emergency-Departments/.
13. (2014).“QualityInitiatives–GeneralInformation.”Center for Medicare and Medicaid Services.Retrievedfromhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/.
14. (2010).HEART.Retrievedfromhttp://heartscore.nl/score/.
Example Clinical PracticeGuidelines for Chest Pain
• Stratifiedyourpatient’sriskandmanageaccordingly.HighRiskpatientsshouldbeadmitted.IntermediateRiskpatientsshouldbeobserved.LowRiskpatientsshouldbedischargedwithoutpatientfollow-up.Seebelow.
HistoryObtainfrompatientandwitnessifavailable
Include:HPI–Quality,severity,location,radiation,provokingandpalliatingfactors,duration,frequency,andpatter,settinginwhichitoccurred,associatedsymptomsPMH–PriorepisodesofchestpainMedications–ListofalltakenincludingrecentchangesFamilyHistory–Specificallycardiac(MIetc)
Physical ExamVitalsigns(BPinbotharms)Inspection,palpation(seeifreproducespain),auscultation,percussionFullycardiacevaluation(auscultateformurmurs,rubs,gallops)Signsofvasculardisease(bruits)Signsofheartfailure(peripheral/pulmedema,JVDetc)
Other Initial Studies12LeadEKG,Cardiactroponins,CXR
Is your patient at high risk?
HistoryandPhysicalExamFindings
12LeadEKG,Cardiactroponins,CXR
High Risk =Admit
Intermediate Risk =Observe
Low Risk =Discharge
Atleastoneofthefollowingfeaturesmustbepresent:Prolonged,ongoing
(>20min)painatrest,Pulmonaryedema,mostlikelyrelatedtoischemia;AnginaatrestwithdynamicSTsegmentchanges>1mm;Anginawithneworworsening
mitralregurgitationmurmur;AnginawithS3ornew/worseningrales;Anginawith
hypotension
Nohighriskfeaturesbutmusthaveanyofthefollowing:Prolonged(>20min)restangina,nowresolved,withmoderatetohighlikelihoodofCAD;Restangina(>20minorresolvedwith
sublingualnitro);Nocturnalangina;AnginawithdynamicTwavechanges;NewonsetCCSC3or4anginainthepast2wkswithmoderateorhighlikelihoodofCAD;PathologicQwavesorrestingSTsegdepression<1minormultiple
leadgroups;Age>65yrs
Nohighorintermediateriskfeaturesbutmay
haveanyofthefollowing:Increasedangina
frequency,severity,orduration;Anginaprovokedatalowerthreshold;Newonsetanginawithonset2wkto2monthbefore
presentation;NormalorunchangedECG
Lehigh Valley Health Network, Allentown, PA
Emergency and Hospital Medicine Observation Project: A Quality Improvement Initiative
Rachel Applebaum, MS4Mentor - Ada Rivera, Department of Medicine