Improving Emergency Department Throughput Using Audit-and-Feedback With Peer Comparison Among Emergency Department Physicians

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Jean Scofi ◽  
Vivek Parwani ◽  
Craig Rothenberg ◽  
Amitkumar Patel ◽  
Shashank Ravi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Audit And Feedback

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

2018 ◽  
Vol 5 (6) ◽  
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.

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

CJEM ◽  
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.

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

CJEM ◽  
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.

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

Blood ◽  
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.

A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

2017 ◽  
Vol 51 (9) ◽  
pp. 774-790 ◽  
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.

scholarly journals P126: Are we transfusing wisely? An analysis of transfusion practices among hemodynamically stable patients with anemia in four hospitals

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S120-S121
Author(s):  
A.A. Wang ◽  
K. Lonergan ◽  
D. Wang ◽  
E. Lang
Keyword(s):  
Emergency Department ◽  
Retrospective Analysis ◽  
Single Unit ◽  
Patient Discharge ◽  
Audit And Feedback ◽  
Iron Therapy ◽  
Left Without Being Seen ◽  
Red Blood Cell Transfusions ◽  
Iv Iron ◽  
L 14

Introduction: To help mitigated risks associated with red blood cell transfusions, CWC guidelines recommend practicing restrictively. Transfusion Medicine recommends using a Hgb threshold of 70 g/L, and ordering a single unit at a time (with reassessment after). The purpose of this study is to investigate Emergency Department (ED) compliance with these more restrictive thresholds among hemodynamically stable patients. Methods: A retrospective analysis was performed on data from all emergency visits to 4 adult urban ED sites from July 1 2014 to July 1 2016. We excluded unstable patients (CTAS1, temperature &gt;38°C, HR &gt;100 bpm, RR &gt;20 rpm, systolic BP &lt;90 mmHg, and O2 sat &lt;85%) and certain others (patients without a Hgb level, patients who left without being seen, and orders cancelled via patient discharge). After applying exclusion factors, we examined transfusions ordered. Appropriateness was assessed using the stratified Choosing Wisely Canada Guidelines for Transfusion. As an adjunct, IV iron therapy data was also analyzed for the same period between July 1 2014 and July 1 2016, excluding patients who did not have a Hgb level. Results: We identified 1329 eligible patients (54% female), with a mean age of 68 and average first hemoglobin of 72 g/L. Across all groups, 16% of patients received only 1 unit of blood. 19% of transfused patients had a hemoglobin less than 60 g/L, 45% had a Hgb &lt;70 g/L, 32% had a Hgb 70-80 g/L, 14% had a Hgb 81-90 g/L, and 8% had a Hgb &gt;90 g/L. Over the same two-year period, 178 patients received IV iron. The average Hgb for those patients was 82 g/L. Conclusion: A retrospective analysis documents a significant likelihood of pRBC over-transfusion among Emergency Department physicians and an underutilization of IV iron therapy for certain hemodynamically stable and anemic patients. The development of audit and feedback methods, and creation of a clinical pathway may help address the rate of over-transfusion.

scholarly journals A step toward understanding the mechanism of action of audit and feedback: a qualitative study of implementation strategies

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Mellanie V. Springer ◽  
Anne E. Sales ◽  
Nishat Islam ◽  
A. Camille McBride ◽  
Zach Landis-Lewis ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Mechanism Of Action ◽  
Implementation Strategies ◽  
Mechanisms Of Action ◽  
Audit And Feedback ◽  
Stroke Treatment ◽  
Treatment Practices ◽  
Causal Pathway ◽  
Acute Stroke Treatment

Abstract Background Audit and feedback (A&F) is a widely used implementation strategy. Understanding mechanisms of action of A&F increases the likelihood that the strategy will lead to implementation of an evidence-based practice. We therefore sought to understand one hospital’s experience selecting and implementing an A&F intervention, to determine the implementation strategies that were used by staff and to specify the mechanism of action of those implementation strategies using causal pathway models, with the ultimate goal of improving acute stroke treatment practices. Methods We selected an A&F strategy in a hospital, initially based on implementation determinants and staff consideration of their performance on acute stroke treatment measures. After 7 months of A&F, we conducted semi-structured interviews of hospital providers and administrative staff to understand how it contributed to implementing guideline-concordant acute stroke treatment (medication named tissue plasminogen activator). We coded the interviews to identify the implementation strategies that staff used following A&F and to assess their mechanisms of action. Results We identified five implementation strategies that staff used following the feedback intervention. These included (1) creating folders containing the acute stroke treatment protocol for the emergency department, (2) educating providers about the protocol for acute stroke, (3) obtaining computed tomography imaging of stroke patients immediately upon emergency department arrival, (4) increasing access to acute stroke medical treatment in the emergency department, and (5) providing additional staff support for implementation of the protocol in the emergency department. We identified enablement, training, and environmental restructuring as mechanisms of action through which the implementation strategies acted to improve guideline-concordant and timely acute stroke treatment. Conclusions A&F of a hospital’s acute stroke treatment practices generated additional implementation strategies that acted through various mechanisms of action. Future studies should focus on how initial implementation strategies can be amplified through internal mechanisms.

scholarly journals Information technology tools can automate imaging measures for Emergency Department patients with suspected pulmonary embolism

2019 ◽  
Author(s):  
Vlad I Valtchinov ◽  
Ivan Ip ◽  
Ramin Khorasani ◽  
Laila Cochon ◽  
Ronilda Lacson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Chest Pain ◽  
Language Processing ◽  
Signs And Symptoms ◽  
Pulmonary Angiography ◽  
Audit And Feedback ◽  
Pleuritic Chest Pain ◽  
Suspected Pulmonary Embolism ◽  
Ed Visits

Abstract CT pulmonary angiography (CTPA) utilization rates for patients with suspected pulmonary embolism (PE) in the Emergency Department (ED) have increased steadily with associated radiation exposure, costs and overdiagnosis. A new measure is needed to more precisely assess efficiency of CTPA utilization normalized to numbers of patients presenting with suspected PE, based on patient signs and symptoms. This study used natural language processing (NLP) to develop, automate, and validate SPE (“Suspected Pulmonary Embolism [PE]”), a measure determining CTPA utilization in ED patients with suspected PE. This retrospective study was conducted 4/1/2013-3/31/2014 in a Level-1 ED. A NLP engine processed “Chief Complaint” sections of ED documentation, identifying patients with PE-suggestive symptoms based on four Concept Unique Identifiers (CUIs: shortness of breath, chest pain, pleuritic chest pain, anterior pleuritic chest pain). SPE was defined as proportion of ED visits for patients with potential PE undergoing CTPA. Manual reviews determined specificity, sensitivity and negative predictive value (NPV). Among 5,768 ED visits with 1+SPE CUI, and 795 CTPAs performed, SPE=13.8% (795/5,768). NLP identified patients with relevant CUIs with specificity=0.94 [95%CI (0.89-0.96)]; sensitivity=0.73 [95%CI (0.45-0.92)]; NPV=0.98. Using NLP on ED documentation can identify patients with suspected PE to computate a more clinically-relevant CTPA measure. This measure might then be used in an audit-and-feedback process to increase the appropriateness of imaging of patients with suspected PE in the ED.

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