ED Management- Interesting recent article...

I am always searching for recent information on patient claims, statistics, etc. and stumbled upon this article. The numbers were a bit surprising- 22,000 preventable deaths directly related to pneumonia and heart attacks??? As it turns out, seems that documentation may be the real issue. I understand RVU and I understand the need to move patients through the ED as quickly as possible, but isn't there a better way? The numbers are frightening- screaming patient claims!! Who is managing your documentation? With the shortage of emergency physicians, the pressure to move patients up or out (see Movin' Meat) combined with paperwork, documentation WHY do so many people who are clearly NOT ill visit the ED?! Don't they know?? They are putting themselves at greater risk visiting the ED vs. ignoring their ear aches, stuffy noses and headaches!! Maybe we should send out e-mail blasts to everyone with some statistics, urging them to eat chicken soup and visit their family doc.

Study Claims EDs Fall Short on Pneumonia and Heart Care
ED Management
January 18, 2008
According to a new study by Johns Hopkins researchers, Emergency Department (ED) managers and their staffs are doing a poor job of treating pneumonia and heart attack patients.
In fact, the authors of the Academic Emergency Medicine article say that as many as 22,000 preventable deaths occur each year in the United States because EDs across the country aren’t meeting national goals.The researchers looked at the records of 1,492 heart attack and 3,955 pneumonia patients treated at 544 EDs between 1998 and 2004.
They found that only 40% of eligible heart attack patients received recommended aspirin therapy, and only 17% received recommended beta-blocker treatment; and among pneumonia patients, only 69% received recommended antibiotics, and 46% had blood oxygen levels assessed, as recommended by the American Thoracic Society.
However, ED observers assert that these numbers paint an inaccurate picture of care given in EDs, and that by and large it is poor documentation—not poor care—that caused the statistics to appear so disappointing.
“Once core measures started to be introduced, CMS (Centers for Medicare & Medicaid Services) would come to us an ask why we were not giving aspirin (to heart attack victims),” said Kevin Klauer, DO, FACEP, director of quality and clinical education and the Center for Emergency Medical Education with Emergency Medicine Physicians (EMP), a Canton, OH-based provider of emergency medical services.
“We discovered that in every hospital, there was some component of sampling that was to blame,” he added. “For example, EMS might have already given the patient aspirin, or they had taken it before arrival and the chart abstractor either didn’t know to check that or just didn’t do it.”
Certainly, some areas are documented better than others, says the study’s principal investigator, Julius Cuong Pham, MD, an assistant professor in the Department of Emergency Medicine at Johns Hopkins University School of Medicine, Baltimore, and a practicing emergency physician.
“But if a patient gets an aspirin, the medical record is a legal document,” Pham said, “so if you give someone aspirin you had better be sure you document it—the same thing with beta-blockers.”
For other variables, such as pulse oximetry, Pham concedes that the physician could just measure it, determine it is normal and not write that down. “What percentage (of reported errors) is due to documentation? We don’t know,” he said.
Klauer’s own documentation, he said, shows good compliance when it comes to aspirin. “Two years ago, we went to physicians checking charts and came up with different numbers than the hospital (was reporting),” he said. “We have physician reviewers review their peers’ charts. They know to look in a specific part of the chart.”
The numbers for all of his practice have been about 99%, with beta-blockers at 96% to 97%, Klauer said. “We have a quality director at every site. These statistics are measured quarterly and annually and compared to the other facilities, and the doctors are partially compensated on that basis,” he said.
This incentive-based compensation plan puts a certain portion of the physician pay at risk, and of that portion, 5% to10% is assigned to quality, Klauer said. Pham and Klauer agree the most controversial measure involves antibiotics. Pham said, “There’s a lot of controversy in the ED as the whether four hours (from admission) is appropriate, versus six or eight hours.”
There isn’t a single piece of controlled literature that assigns a specific time, Klauer said. “So, we may appear to not be in compliance because of flawed parameters, but we certainly won’t let our doctors practice bad medicine.”
Pham and his colleagues recommend the creation of systems in the ED to minimize whatever lapses in care are occurring. “Standardized protocols are shown in the literature to be effective,” he said. “For example, every patient with acute MI or chest pain gets aspirin and beta-blockers as part of their care unless it is contraindicated.” The nurse should serve as a check and balance by ensuring the doctors are following the protocol.
There may even be a role for IT, Pham said. “If you have a diagnosis of heart attack and you are about to log off without giving aspirin, a red flag may pop up. This takes the individual caregiver out of the equation,” he said. “The ED is very hectic, and it is not unreasonable to forget something. We need some warning feedback.”
Any performance feedback should be easily visualized, Pham added. “It could be a blinking light on the computer screen, a red flag on a chart. The bottom line is, these errors are likely lead to patient harm and death, and whatever we can do to improve on that will affect the health of patients.”
Klauer said, “If patients are getting aspirin 44% of the time, we are doing them a huge disservice, but I don’t believe that is happening.”