The Development of Emergency Department Patient Quality/Safety Indicators

Slide Presentation from the AHRQ 2011 Annual Conference

On September 21, 2011, Patrick S. Romano made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (3 MB). Plugin Software Help.


Slide 1

The Development of Emergency Department Patient Quality/Safety Indicators

The Development of Emergency Department Patient Quality/Safety Indicators

Patrick S. Romano, MD MPH
UC Davis Center for Healthcare Policy and Research
AHRQ Annual Conference
September 21, 2011

Slide 2

Overview

Overview

  • Goals and scope of current project.
  • Conceptual frameworks.
  • Literature review.
  • Matrix of potential indicators.
  • Specification.
  • Preliminary results.
  • Recommendations and next steps.

Slide 3

AHRQ Quality Indicators (QIs)

AHRQ Quality Indicators (QIs)

  • Developed through contract with UCSF-Stanford Evidence-based Practice Center & UC Davis, maintained and extended through contract with Battelle.
  • Use existing HCUP (hospital discharge) data, based on readily available data elements.
  • Incorporate a range of severity adjustment methods, including APR-DRGs* and comorbidity groupings.
  • Disseminate software and support materials free via http://www.qualityindicators.ahrq.gov.
  • Provide technical support to users.
  • Continuous improvement through user feedback, annual coding updates, validation projects.

* All Patient Refined—Diagnosis Related Groups

Slide 4

Evidence-based indicator development

Evidence-based Indicator Development

  1. Literature review user suggestions.
  2. Initial empirical analyses and definition.
  3. Panel evaluation (modified Delphi Process).
  4. Further empirical analyses refined definition.
  5. Further review? Final definition.

Slide 5

The HCUP Partnership: A Voluntary Federal-State-Private Collaboration

The HCUP Partnership: A Voluntary Federal-State-Private Collaboration

40+ states.
90% of all discharges.
24+ states submit ED encounters.

Image: A map of the United States showing participating states is shown.

Slide 6

Types of HCUP Databases

Types of HCUP Databases

State Inpatient Databases (SID).

  • Nationwide Inpatient Sample (NIS).
  • Kids' Inpatient Database (KID).
  • Nationwide Emergency Department Sample (NEDS).

State Ambulatory Surgery Databases (SASD).

State Emergency Department Databases (SEDD).

Slide 7

Goals and Scope

Goals and Scope

  • Goals:
    • Develop quality/safety indicators, using HCUP data, that are applicable to the emergency department setting of care.
    • Set the stage for future incorporation into publicly available AHRQ QI software.
  • Scope:
    • Implement the established AHRQ QI measure development process.
    • Adapt existing AHRQ QI to ED setting when possible.
    • Identify and evaluate new candidate indicators based on established measurement concepts.

Slide 8

IOM Committee on the Future of Emergency Care in the United States Health System (2007)

IOM Committee on the Future of Emergency Care in the United States Health System (2007)

  • Called for "a standard national approach to the development of performance indicators."
  • "The measures developed should include structure and process measures, but evolve toward outcome measures over time... (and) should be nationally standardized so that comparisons can be made across regions and states."
  • "Measures should evaluate the performance of individual providers within the system, as well as that of the system as a whole... (and) be sensitive to the interdependence among the components of the system."
  • "Performance data should be collected on a regular basis from all of the emergency care providers in a community" and then publicly disseminated..."

Slide 9

Conceptual framework for prioritization: Institute of Medicine, 2007

Conceptual framework for prioritization: Institute of Medicine, 2007

DomainApplication to the ED
SafeHigh-risk, high-stress environment "fraught with opportunities for error"... frequent interruptions and distractions, crowding, need for rapid decision-making with incomplete information, barriers to effective communication and teamwork, difficulty obtaining timely diagnostic tests
EffectiveLimited by deficiencies in pre-hospital care, unavailability of trained specialists, lack of access to patients' prior medical records, poor primary care follow-up, inability to coordinate care across settings
Patient-centeredCrowding, long wait times, boarding of admitted patients in hallways, design emphasis on visibility and monitoring rather than privacy
TimelyDesigned to provide timely care for emergent medical problems, but often overwhelmed by the demand for their services...
EfficientFrequently asked to provide care for which it is not the most efficient setting... primary care, urgent care for minor complaints, and inpatient care to admitted patients compromises efficiency
EquitableEMTALA requires EDs to treat all patients equitably... (but) variation in resources and personnel across communities may create inequities in how patients in different EDs are treated

Slide 10

Conceptual framework for prioritization: Institute of Medicine, 2010

Conceptual Framework for Prioritization: Institute of Medicine, 2010

Image: The Conceptual framework for prioritization: Institute of Medicine, 2010 is shown.

Slide 11

Conceptual framework for prioritization: ICES/Alberta Quality Matrix for Health, 2010

Conceptual Framework for Prioritization: ICES/Alberta Quality Matrix for Health, 2010

DomainExamples
AcceptabilityHealth services are respectful and responsive to user needs, preferences and expectations.
AccessibilityHealth services are obtained in the most suitable setting in a reasonable time and distance.
AppropriatenessHealth services are relevant to user needs and are based on accepted or evidence-based practice.
EffectivenessHealth services are provided based on scientific knowledge to achieve desired outcomes.
EfficiencyResources are optimally used in achieving desired outcomes.
SafetyMitigate risks to avoid unintended or harmful results.
Healthy workplaceProvision of health services does not lead to an unhealthy work environment for health care staff.


Slide 12

Conceptual framework for prioritization: American College of Emergency Physicians, 2009

Conceptual Framework for Prioritization: American College of Emergency Physicians, 2009

DomainExamples
Access to emergency careAccess to providers, access to treatment centers, financial barriers, hospital capacity
Quality and patient safety environmentState-supported systems, institutional barriers
Medical liability environmentLegal atmosphere, insurance availability, tort reform
Public health and injury preventionTraffic safety and drunk driving, immunization, injury control, state injury prevention efforts, health risk factors
Disaster preparednessFinancial resources, state coordination, hospital capacity, personnel


Slide 13

Application of conceptual framework

Application of Conceptual Framework

 StructureProcessOutcome
EffectiveNurse staffing and skill mix (RN/total) in EDAspirin at arrival for AMI (TJC/CMS)Percentage of asthma encounters followed by revisit (or admission to hospital) within 3 days
Patient CenteredUse of survey data in PDSA cycles to improve patient centered care in EDPercentage of patients undergoing painful procedures who have pain score documentationPercentage of patients leaving ED without being seen by a physician (proxy outcome, LSU Health Services)
TimelyED triage policies to ensure timely evaluation of high-acuity patientsMedian time from ED arrival to ED departure for admitted ED patients (CMS)Percentage of orthopedic pain patients with 3-point reduction in pain score within 60 minutes
SafeComputerized physician order entry with decision support tools to detect medication errorsConfirmation of endo-tracheal tube placement (Cleveland Clinic Foundation)Death or disability due to air embolism from a medical device (NQF)
EfficientAvailability of laboratory and radiologic support to facilitate rapid evaluation and disposition in EDPercentage of low back pain patients with appropriate diagnostic test utilizationDollars per episode of low back pain evaluated in the ED
EquitableAvailability of adequate interpreting services in EDPercentage of non-English speaking patients for whom interpreting services are usedDisparity in any other outcome according to primary language


Slide 14

Literature review: strategy

Literature review: strategy

Search goal:

  • To find studies that introduced or used quality of care measures to assess patient safety in hospital emergency departments.

Search strategy using MESH headings in PubMed:

  • ("Quality Assurance, Health Care"[Mesh] OR "Quality Indicators, Health Care"[Mesh] OR "Quality of Health Care"[Mesh] OR "Health Care Quality, Access, and Evaluation"[Mesh] OR "United States Agency for Healthcare Research and Quality"[Mesh] OR "Outcome Assessment (Health Care)"[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.'

Slide 15

Literature review: process

Literature Review: Process

  • PubMed®:
    • 1,050 abstracts, decreased to 687 when limited to human subjects, English language, date within 10 yrs.
    • All abstracts were reviewed for relevance (i.e., describing one or more measures of ED quality/safety).
  • Similar review by Alessandrini et al. for PECARN.
  • Organizations and Web sites:
    • National Quality Measures Clearinghouse™ (AHRQ).
    • National Quality Forum.
    • Federal: AHRQ QIs and CMS/QualityNet.
    • ED: ACEP and SAEM.
    • AMA: Physician Consortium for Performance Improvement.
    • Other developers: NCQA and The Joint Commission.
    • Institute of Medicine/National Academy of Sciences.
    • Canada: Institute for Clinical Evaluative Sciences, Canadian Institute for Health Information.

Slide 16

Literature review: key themes

Literature Review: Key Themes
40 Journal Papers, 23 Documents and Reports

  • Some TJC Core Measures address processes of care in ED management of pneumonia or myocardial infarction.
  • Critical trauma or shock care, generally based on detailed "peer" review of medical records to assess appropriateness and timeliness of diagnostic and therapeutic interventions.
  • Time-based measures of waiting time, total LOS in the ED, ED disposition time for admitted/transferred patients.
  • Appropriate prescribing and avoidance of medication errors for common conditions: asthma, bronchiolitis, acute GE, laceration.
  • Appropriate use of imaging studies, laboratory, ECG.
  • Appropriate assessment of pain, oxygenation, cognition.
  • "Left without being seen" or "left AMA" (premature ED discharge).
  • "Missed diagnosis" identified by return within defined time window for a serious condition.
  • Revisits to ED within time window for same or related condition.

Slide 17

Matrix of potential indicators: Inclusion/exclusion criteria

Matrix of Potential Indicators: Inclusion/exclusion Criteria

  • Identified from published source:
    • Literature review (40 journal articles).
    • Organizations and Web sites (if a consensus-based approach and/or modified Delphi approach was used).
  • Address the domains of effectiveness and/or safety:
    • A few measures of timeliness were included because the measure developer characterized them as having implications for safety in the ED.
  • Focus on care provided in the ED (not pre-hospital care).
  • Clinical guidelines, standards of care, and ED decision rules were not included unless operationalized as indicators.
  • Can be implemented in at least one HCUP partner state using available HCUP data.
  • When ≥2 indicators addressed the same outcome, only the more recent and/or more clearly specified indicator was retained.
  • Excluded measures that were evaluated and discarded or rejected through a consensus-based expert panel process.

Slide 18

Matrix of potential indicators: Application of existing inpatient PSIs

Matrix of potential indicators
Application of existing inpatient PSIs

  • Foreign body left in.
  • Iatrogenic pneumothorax.
  • "Postoperative" hip fracture.
  • "Postoperative" hemorrhage or hematoma.
  • Accidental puncture or laceration.
  • Transfusion reaction.

Slide 19

Matrix of potential indicators: 35 new candidate indicators

Matrix of potential indicators
35 new candidate indicators

  • Age range:
    • 12 for children only.
    • 10 for adults only.
    • 13 for both children and adults.
  • Donabedian'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 researchers.
  • Endorsement—6 endorsed by NQF.

Slide 20

Matrix of potential indicators: 35 new candidate indicators

Matrix of potential indicators
35 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 care.
    • 6 admission for missed diagnosis (AMI/ACS, SAH, ectopic pregnancy, traumatic injury, appendicitis).
  • Appropriate use of diagnostic test or imaging—5.
  • Acute complications of ED procedures—3.
  • Time within ED awaiting definitive care—3.
  • Appropriate admission for inpatient care—2.
  • Appropriate use of treatment or intervention—1.
  • Left "against medical advice"—1.

Slide 21

Challenges in specification and testing

Challenges in specification and testing with HCUP data

  • Identification of patients "at risk":
    • What procedures place patients at risk for hemorrhage, pneumothorax, or accidental puncture/laceration?
  • Timing:
    • Only 5 states (GA, MA, MN, NJ, TN) have POA in SEDD; only MA and TN also have PNUM.
    • In SID, POA means "present at the time the order for inpatient admission occurs" and ED dx may be lost.
  • Low frequency with "true" frequency unknown:
    • Unable to choose "best" specification.
  • Uncertain validity of utilization flag variables to identify patients who had specific procedures (US, ECG, CT).
  • Unable to operationalize all specifications:
    • Exclusion of "planned" (or "invited") return visits to ED.
    • All presenting symptoms for "missed diagnoses."

Slide 22

Iatrogenic Pneumothorax 8 States, 2005-2008

Iatrogenic Pneumothorax 8 States, 2005-2008

StateCalendar yearDenominatorNumerator with POA MissingNumerator with POA=N
A2005-20086660*0
B2005-200822518140
C2005-2008148700
D2005-200813120360
E2005-200823500
F2005-200835816*0
G2005-200810172*0
H2005-2008241400

Eligible patients—central venous catheterization (including transvenous pacemaker); thoracentesis; pericardiocentesis; paracentesis; insertion of ETT with or without mechanical ventilation.

Slide 23

Postoperative Hemorrhage or Hematoma 8 States, 2005-2008

Postoperative Hemorrhage or Hematoma 8 States, 2005-2008

StateCalendar yearDenominatorNumerator with POA MissingNumerator with POA=N
A2005-20087762200
B2005-2008314272160
C2005-20081548100
D2005-2008141246180
E2005-2008198000
F2005-2008150588*0
G2005-20089778100
H2005-20082542700

Eligible patients—central venous or arterial catheterization; aspiration or I&D; thoracentesis or thoracostomy; pericardiocentesis; paracentesis; insertion of ETT or rectal tube; LP; nerve block, fecal disimpaction.

Slide 24

Potentially Missed Acute Myocardial Infarction (AMI)

EDPSI #4: Potentially Missed Acute Myocardial Infarction (AMI) 

Numerator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, ages 18 to 95 years, meeting the inclusion and exclusion rules for the denominator and dated no more than 7 days previous to the linked SID record, with an eligible diagnosis code for a chest pain-related condition in ICD-9 CM diagnosis field.

Denominator

State Inpatient Databases: All hospital discharges, ages 18 to 95 years, with an eligible diagnosis code of acute myocardial infarction (AMI) in the ICD-9 principal diagnosis field and HCUP_ED>0.

Excludes all records with:

  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any AMI diagnosis (ICD-9-CM 410.00-410.92) on any linked SID record in the 12 months before this admission (if linked data are available).

Slide 25

Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 1 Percentage of eligible patients with Unanticipated Worsening of Acute Coronary Syndrome (ED-PSI #4) is shown:

Blue = 2007.
Red = 2008.
CV = 0.38-0.49.
Year-year corr = 0.94.

Slide 26

Electrocardiogram for Non-Traumatic Chest Pain

EDPSI #5 Electrocardiogram for Non-Traumatic Chest Pain 

Numerator

Emergency department discharges meeting the inclusion and exclusion rules for the denominator with a utilization flag (U_EKG>0) indicating than an electrocardiogram (ECG) was performed and billed (based on an NUBC revenue code of 730 (EKG/ECG), 731 (Holter monitor), or 739 (Other EKG/ECG); or an ICD-9-CM procedure code of 89.51 [rhythm electrocardiogram] or 89.52 [electrocardiogram]).

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 40 years or older, with an eligible diagnosis code of nontraumatic chest pain in any ICD-9-CM diagnosis field and HCUP_ED>0.

Exclude all records with:

  • A principal or secondary diagnosis of ventricular fibrillation (427.41), ventricular flutter (427.42), or cardiac arrest (427.5).
  • Any procedure of cardiopulmonary resusicitation, not otherwise specified (99.60), or closed chest cardiac massage (99.63).
  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any documentation indicating death in the ED (DISPUNIFORM=20).
  • Any documentation indicating patient left the ED against medical advice (DISPUNIFORM=7).

Slide 27

Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 2. Percentage of eligible patients Electrocardiogram for Non-Traumatic Check Pain (ED-PSI #5) is shown:

Blue = 2007.
Red = 2008.
CV = 0.01-0.03.
Year-year corr = 0.79.

Slide 28

Electrocardiogram for Stroke

EDPSI #5 Electrocardiogram for Stroke 

Numerator

Emergency department discharges meeting the inclusion and exclusion rules for the denominator with a utilization flag (U_EKG>0) indicating than an electrocardiogram (ECG) was performed and billed (based on an NUBC revenue code of 730 (EKG/ECG), 731 (Holter monitor), or 739 (Other EKG/ECG); or an ICD-9-CM procedure code for electrocardiogram 89.52 [electrocardiogram]. Exclude numerator records with an ICD-9-CM procedure code for electrocardiogram (89.52) dated after the date of admission to the hospital.

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 18 years or older, with an eligible diagnosis code of stroke in any ICD-9-CM diagnosis field and HCUP_ED>0.

Exclude all SED records with:

  • A principal or secondary diagnosis of ventricular fibrillation (427.41), ventricular flutter (427.42), or cardiac arrest (427.5).
  • Any procedure of cardiopulmonary resusicitation, not otherwise specified (99.60), or closed chest cardiac massage (99.63).
  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any documentation indicating death in the ED (DISPUNIFORM=20).
  • Any documentation indicating patient left the ED against medical advice (DISPUNIFORM=7).

Exclude all SID records with:

  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.

Slide 29

Variation Across States and Years

Image: A bar graph labeled: Figure 3. Percentage of eligible patients (treat and release visits only) Electrocardiogram for Stroke (ED-PSI #6) is shown:

Blue = 2007.
Red = 2008.
CV = 0.12-0.14.
Year-year corr = 0.99.

Slide 30

Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 4. Percentage of eligible patients (treat and admit visits only) Electrocardiogram for Stroke (ED-PSI #6) is shown:

Blue = 2005.
Red = 2006.
Gold = 2007.
Cyan = 2008.
CV = 0.02-0.03.
Year-year corr = 0.77-0.98.

Slide 31

Electrocardiogram for Syncope

EDPSI #7 Electrocardiogram for Syncope

Numerator

Emergency department discharges meeting the inclusion and exclusion rules for the denominator with a utilization flag (U_EKG>0) indicating than an electrocardiogram [ECG] was performed and billed (based on an NUBC revenue code of 730 (EKG/ECG), 731 (Holter monitor), or 739 (Other EKG/ECG); or an ICD-9-CM procedure code for electrocardiogram 89.52 [electrocardiogram]. 

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 60 years or older, with an eligible diagnosis code of syncope in any ICD-9-CM diagnosis field and HCUP_ED>0.

State Inpatient Databases: All hospital discharges, age 60 years or older, with an eligible diagnosis code in the ICD-9-CM principal diagnosis field and HCUP_ED>0.

Exclude all SED records with:

  • A principal or secondary diagnosis of ventricular fibrillation (427.41), ventricular flutter (427.42), or cardiac arrest (427.5).
  • Any procedure of cardiopulmonary resusicitation, not otherwise specified (99.60), or closed chest cardiac massage (99.63).
  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any documentation indicating death in the ED (DISPUNIFORM=20).
  • Any documentation indicating patient left the ED against medical advice (DISPUNIFORM=7).

Exclude all SID records with:

  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.

Slide 32

 Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 5. Percentage of eligible patients (treat and release visits only) Electrocardiogram for Syncope (ED-PSI #7) is shown:

Blue = 2007.
Red = 2008.
CV = 0.03-0.04.
Year-year corr = 0.76.

Slide 33

 Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 6. Percentage of eligible patients (treat and admit visits only) Electrocardiogram for Syncope (ED-PSI #7) is shown:

Blue = 2005.
Red = 2006.
Gold = 2007.
Cyan = 2008.
CV = 0.02.
Year-year corr = 0.51-0.999.

Slide 34

 Electrocardiogram for Asthma Revisit

EDPSI #8 Asthma Revisit 

Numerator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 18 years or older, meeting the inclusion and exclusion rules for the denominator and dated no more than 1 day after the previous linked SEDD record, with an eligible diagnosis code of asthma or related symptoms in any ICD-9-CM diagnosis field and HCUP_ED>0.

State Inpatient Databases: All hospital discharges, age 18 years or older, with an eligible diagnosis code of asthma (493.00-493.12, 493.90-493.92) in the ICD-9-CM principal diagnosis field or in a secondary field with another qualifying diagnosis as the principal diagnosis, with an admission date no more than 1 day after the previous linked SEDD record, and HCUP_ED>0.

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 18 years or older, with an eligible diagnosis code of asthma or related symptoms in any ICD-9-CM diagnosis field and HCUP_ED>0.

Exclude all records with:

  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any documentation indicating death in the ED (DISPUNIFORM=20).

Slide 35

 Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 7. Percentage of eligible patients Asthma Revisit (ED-PSI #8) is shown:

Blue = 2007.
Red = 2008.
CV = 1.44-1.66.
Year-year corr = 0.999.

Slide 36

 Missed Subarachnoid Hemorrhage

EDPSI #9 Missed Subarachnoid Hemorrhage (SAH)

Numerator
State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 18 years or older, with an eligible diagnosis code for a headache-related condition in any ICD-9-CM diagnosis field and HCUP_ED>0.

Denominator

State Inpatient Databases: All hospital discharges, age 18 years or older, with an eligible diagnosis code of nontraumatic subarachnoid hemorrhage in the ICD-9-CM principal diagnosis field, and HCUP_ED>0.

Exclude all records with:

  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any subarachnoid hemorrhage or intracranial aneurysm (ICD-9-CM 430, 437.7, 747.81) on any linked SID record in the 12 months before this admission (if linked data are available).

Slide 37

 Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 8. Percentage of eligible patients with Possibly Mixed Subarachnoid Hemorrhage (ED-PSI #9) is shown:

Blue = 2007.
Red = 2008.
CV = 0.37-0.41.
Year-year corr = 0.54.

Slide 38

 Electrocardiogram for Chest Pain Revisit

EDPSI #11 Chest Pain Revisit

Numerator

State Inpatient Databases: All hospital discharges, age 18 years or older, with a qualifying diagnosis of acute coronary syndrome in the ICD-9-CM principal diagnosis field, with an admission date no more than 7 days after the index visit, and HCUP_ED>0.

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 18 years or older, with an eligible diagnosis code related to chest pain in any ICD-9-CM diagnosis field and HCUP_ED>0.

Exclude all records with:

  • Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
  • Any documentation indicating death in the ED (DISPUNIFORM=20).

Slide 39

Variation Across States and Years

Variation Across States and Years

Image: A bar graph labeled: Figure 9 Percentage of eligible patients with Chest Pain Revisit (ED-PSI #11) is shown:

Blue = 2007.
Red = 2008.
CV = 0.29-0.43.
Year-year corr = 0.89.

Slide 40

Expert Work Group

Expert Work Group

  • General interest in quality and safety-related concepts that can theoretically be captured using HCUP data:
    • Utilization of indicated services to optimize patient safety.
    • Revisits for related conditions after a high-risk index ED visit.
    • Prior ED visits for symptoms or signs of a potentially missed dx.
  • Limited ongoing quality improvement efforts in EDs, typically based on EMR or manual record review .
  • Some skepticism about whether gaps in care actually exist for ECG utilization.
  • Questions re face validity of observed variation in the rates of some proposed ED-PSIs across states.
  • Great interest in preliminary results.
  • Strong support for further testing and refinement, with a focus on bringing states up to a common standard.

Slide 41

Recommendations and Next Steps
Recommendations and Next Steps

  • More states should be included in the next round of empirical analyses, to better understand patterns of variation and the potential scope of use of ED-PSIs.
  • Timeliness indicators are not promising, due to the easier availability of "time stamp" data from other sources.
  • Utilization-related and revisit-related indicators appear to be most promising for further development and testing.
  • Validation work should be undertaken to confirm that administrative data sets consistently capture:
    • Relevant service utilization, such as electro-cardiography.
    • Relevant revisits.
  • Complications based on current PSIs represent important concepts, but there are severe limitations due to confusion and inconsistency in reporting of POA status:
    • Collaboration with HCUP partners needed.

Slide 42

Acknowledgments

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), Emily Carrier (HSC), Evaline Alessandrini (CCHMC), Astrid Guttmann and Michael Schull (ICES), Jeremiah Schuur (Brigham & Women's), Drew Dawson, MD (Federal Inter-agency Committee on Emergency Medical Services), Rollin Fairbanks (National Center for Human Factors Engineering in Healthcare, MedStar), Andrew Garrett (ASPR), Charlotte Yeh (AARP).
  • AHRQ CDOM staff:
    • Pamela Owens and Ryan Mutter (ED task).
    • Jenny Schnaier and Carol Stocks (HCUP).
  • HCUP partners:
    • AZ, CA, FL, HI, IN, NE, SC, TN, UT.
Current as of March 2012
Internet Citation: The Development of Emergency Department Patient Quality/Safety Indicators. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/romano/index.html