Reducing low-value testing in the emergency department through cost-effective physician education and personalised audit and feedback scorecards

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR ( P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

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Leveraging Antimicrobial Stewardship in the Emergency Department to Improve the Quality of Urinary Tract Infection Management and Outcomes

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy101 ◽

2018 ◽

Vol 5 (6) ◽

Cited By ~ 8

Author(s):

Sarah C J Jorgensen ◽

Samantha L Yeung ◽

Mira Zurayk ◽

Jill Terry ◽

Maureen Dunn ◽

...

Keyword(s):

Emergency Department ◽

Urinary Tract Infection ◽

Urinary Tract ◽

Tract Infection ◽

Antimicrobial Stewardship ◽

Treatment Algorithm ◽

Rapid Change ◽

Audit And Feedback ◽

Prescribing Practices ◽

Return Visits

Abstract Background The complex and fast-paced emergency department (ED) practice setting presents unique challenges that demand a tailored approach to antimicrobial stewardship. In this article, we describe the strategies applied by 1 institution’s antimicrobial stewardship program (ASP) that were successful in improving prescribing practices and outcomes for urinary tract infection (UTI) in the ED. Methods Core strategies included pre-implementation research characterizing the patient population, antimicrobial resistance patterns, prescribing behavior, and morbidity related to infection; collaboration across multiple disciplines; development and implementation of a UTI treatment algorithm; education to increase awareness of the algorithm and the background and rationale supporting it; audit and feedback; and early evaluation of post-implementation outcomes. Results We observed a rapid change in prescribing post-implementation with increased empiric nitrofurantoin use and reduced cephalosporin use (P < .05). Our elevation of nitrofurantoin to firstline status was supported by our post-implementation analysis showing that its use was independently associated with reduced 30-day return visits (adjusted odds ratio, 0.547; 95% confidence interval, 0.312–0.960). Furthermore, despite a shift to a higher risk population and a corresponding decrease in antimicrobial susceptibility rates post-implementation, the preferential use of nitrofurantoin did not result in higher bug-drug mismatches while 30-day return visits to the ED remained stable. Conclusions We demonstrate that an outcomes-based ASP can impart meaningful change to knowledge and attitudes affecting prescribing practices in the ED. The success of our program may be used by other institutions as support for ASP expansion to the ED.

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Abstract W P183: Testing the Utility of an Emergency Room-Based Stroke Evaluation Protocol

Stroke ◽

10.1161/str.45.suppl_1.wp183 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Gyeong-Moon Kim ◽

Johanna Helenius ◽

E Murat Arsava ◽

Hakan Ay

Keyword(s):

Emergency Department ◽

Clinical Evaluation ◽

Diagnostic Testing ◽

Cost Effective ◽

Vascular Imaging ◽

Cardiac Monitoring ◽

Evaluation Protocol ◽

Evaluation Strategies ◽

Fundamental Goal ◽

Major Stroke

Background and purpose: A fundamental goal in diagnostic stroke evaluation is to identify the underlying etiology. We sought to determine the yield of an emergency department-based diagnostic evaluation protocol for identifying the etiology of stroke. Methods: We determined etiologic stroke subtypes using the automated Causative Classification System (CCS, available at https://ccs.mgh.harvard.edu) in 2422 consecutive patients with ischemic stroke at admission and discharge. Admission assessment was based on information from clinical evaluation, ECG, brain imaging (CT or MRI), and vascular imaging (CTA/MRA). Discharge CCS was performed blinded to the admission CCS subtype using information from additional tests such as echocardiography, cardiac monitoring, and special blood and CSF tests. Results: Table 1 shows the distribution of CCS subtypes. Overall, admission and discharge CCS subtypes were different in 29% of the patients. The size of “undetermined” category decreased from 37% at admission to 12% at discharge. The shift from “undetermined” to a known etiology was primarily due to detection of cardiac sources with low or uncertain risk of stroke (94%). The yield of investigations performed after admission in identifying a major known subtype was only 4.1% (p=0.008). Conclusions: A careful clinical evaluation and first-line diagnostic testing including brain and vascular imaging in the emergency department identify > 90% of those with a major stroke etiology. The low yield of additional testing suggests a need for developing cost-effective evaluation strategies in suspected patients.

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Is Whole Body CT Safe and Cost Effective in Managing MT (Major Trauma) Patients in the Emergency Department (ED)?

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2012.09.119 ◽

2012 ◽

Vol 43 (5) ◽

pp. 939

Author(s):

M. Majeed ◽

D. Yeo ◽

J. Kayani

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Cost Effective ◽

Whole Body ◽

Trauma Patients ◽

Whole Body Ct ◽

Body Ct

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Emergency Department Thoracotomy: A Cost-Effective Model for Simulation Training

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2019.06.022 ◽

2019 ◽

Vol 57 (3) ◽

pp. 375-379 ◽

Cited By ~ 1

Author(s):

Deena I. Bengiamin ◽

Cory Toomasian ◽

Dustin D. Smith ◽

Timothy P. Young

Keyword(s):

Emergency Department ◽

Simulation Training ◽

Cost Effective ◽

Effective Model ◽

Emergency Department Thoracotomy

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Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

CJEM ◽

10.1017/cem.2020.374 ◽

2020 ◽

Vol 22 (5) ◽

pp. 678-686

Author(s):

Shawn K. Dowling ◽

Inelda Gjata ◽

Nathan M. Solbak ◽

Colin G.W. Weaver ◽

Katharine Smart ◽

...

Keyword(s):

Emergency Department ◽

Control Charts ◽

Patient Characteristics ◽

Pediatric Emergency ◽

Therapeutic Interventions ◽

Audit And Feedback ◽

Absolute Difference ◽

Emergency Physicians ◽

Feedback Session ◽

Statistical Process

ABSTRACTObjectiveDespite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.MethodsOur cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.ResultsSeventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.ConclusionThe combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

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Interventions to reduce emergency department consultation time: A systematic review of the literature

CJEM ◽

10.1017/cem.2019.435 ◽

2019 ◽

Vol 22 (1) ◽

pp. 56-64

Author(s):

Weiwei Beckerleg ◽

Krista Wooller ◽

Delvina Hasimjia

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Length Of Stay ◽

Decision Time ◽

Primary Objective ◽

Audit And Feedback ◽

Post Intervention ◽

Consultation Process ◽

Admission Process ◽

The Impact

ABSTRACTObjectivesOvercrowding in the emergency department (ED) is associated with increased morbidity and mortality. Studies have shown that consultation to decision time, defined as the time when a consultation has been accepted by a specialty service to the time when disposition decision is made, is one important contributor to the overall length of stay in the ED.The primary objective of this review is to evaluate the impact of workflow interventions on consultation to decision time and ED length of stay in patients referred to consultant services in teaching centres, and to identify barriers to reducing consultation to decision time.MethodsThis systematic review was performed in accordance with the PRISMA guidelines. An electronic search was conducted to identify relevant studies from MEDLINE, EMBASE, Cochrane Central, and CINAHL databases. Study screening, data extraction, and quality assessment were carried out by two independent reviewers.ResultsA total of nine full text articles were included in the review. All studies reported a decrease in consultation to decision time post intervention, and two studies reported cost savings. Interventions studied included short messaging service (SMS) messaging, education with audit and feedback, standardization of the admission process, implementation of institutional guideline, modification of the consultation process, and staffing schedules. Overall study quality was fair to poor.ConclusionsThe limited evidence suggests that audit and feedback in the form of SMS messaging, direct consultation to senior physicians, and standardization of the admission process may be the most effective and feasible interventions. Additional high-quality studies are required to explore sustainable interventions aimed at reducing consultation to decision time.

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P5.023 Novel Emergency Department Registration Kiosk For HIV Screening Increases Engagement of High Risk Patients and is Cost-Effective

Sexually Transmitted Infections ◽

10.1136/sextrans-2013-051184.1068 ◽

2013 ◽

Vol 89 (Suppl 1) ◽

pp. A341.3-A341

Author(s):

Y Hsieh ◽

S Peterson ◽

M Gauvey-Kern ◽

C A Gaydos ◽

D Holtgrave ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Cost Effective ◽

Hiv Screening ◽

High Risk Patients ◽

Risk Patients

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Use Of Prothrombin Complex Concentrates In Warfarin Anticoagulation Reversal In The Emergency Department: A Quality Improvement Study Of Administration Delays

Blood ◽

10.1182/blood.v122.21.4824.4824 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4824-4824

Author(s):

Simon Bordeleau ◽

Daniele Marceau ◽

Julien Poitras ◽

Patrick Archambeault ◽

Carolle Breton

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Action Plan ◽

Blood Bank ◽

Audit And Feedback ◽

Chart Audit ◽

Improvement Project ◽

Administration Time ◽

The Mean ◽

Timely Administration

Introduction In some bleeding situations, quick reversal of warfarin anticoagulation is important. In the event of a major life-threatening bleeding event, the anticoagulation reversal delay can have an impact on mortality. This study aimed to improve the administration delay when using Prothrombin Complex Concentrate (PCC) for the emergent reversal of warfarin anticoagulation in the emergency department. Methods An audit and feedback quality improvement project was conducted in three phases: a retrospective audit phase, an analysis and feedback phase and prospective evaluation phase. The charts of all eligible patients in a single Emergency Department (ED) in Québec, Canada, who received 4-factor PCC since the introduction of this product in 2009 until October 31, 2011 were retrospectively audited with pre-planned evaluation criteria. The administration delay of PCC was calculated from the time of prescription to the time of administration. After this retrospective chart audit, we determined where improvements could be attained, gave feedback to the ED and the blood bank, and we created an action plan to ensure the timely administration of PCC. The action plan was then implemented in practice to reduce the administration delay. Finally, a six-month prospective evaluation study was conducted to determine if our action plan was followed and improved the administration delays. Results Seventy-seven charts were reviewed in the retrospective chart audit. The mean administration delay was 73.6 minutes (STD [34.1]) with a median of 70.0 minutes (25-75% IQR [45.0-95.0]). We found that this delay was principally due to the following barriers that prevented timely administration of PCCs: communication problems between the ED and the blood bank and reconstitution and delivery inefficiencies. In order to address these barriers, we developed an action plan that involved the following elements: a flowchart to remind all clinicians how to order PCCs and a new delivery method from the blood bank to the ED. During the 6 months following the implementation of our action plan, 39 patients received PCCs and the mean administration time decreased to 33.2 minutes (STD [14.2]) (p<.0001) with a median of 30.0 minutes (25-75% IQR [24.3-38.8]). Conclusion This audit and feedback quality improvement project involving the development and the implementation of an action plan comprising of a flowchart and a new delivery process reduced the administration time of PCC by more than half. Future studies to measure the impact of implementing a similar audit and feedback process involving an action plan in other centers should be conducted before this type of improvement process is implemented on wider scale. Disclosures: No relevant conflicts of interest to declare.

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A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

Annals of Pharmacotherapy ◽

10.1177/1060028017709820 ◽

2017 ◽

Vol 51 (9) ◽

pp. 774-790 ◽

Cited By ~ 16

Author(s):

Mia Losier ◽

Tasha D. Ramsey ◽

Kyle John Wilby ◽

Emily K. Black

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Antimicrobial Stewardship ◽

Repeated Measures ◽

Audit And Feedback ◽

Controlled Trials ◽

Process Of Care ◽

Provider Education ◽

Antimicrobial Utilization ◽

Improve Patient

Background/Objective: To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use. Methods: This study was completed as a systematic review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other than English were excluded. Results: A total of 43 studies meeting inclusion criteria were identified from our search. Patient or provider education and guideline or clinical pathway implementation were the most commonly reported interventions. Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias. Conclusion: AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear. Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit and feedback are needed.

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