Quality Improvement & Patient Safety Section Newsletter - December 2010 - Vol 12, #1
The Chair’s Letter
Drew Fuller, MD, MPH, FACEP
Strategic Coordinator for Patient Safety
Emergency Medicine Associates, PA, PC
As we embark upon a new year for the section, it is helpful to look at what the QIPS section strives to achieve for its members and the college. Our goal as an interest section is to engage our membership and to help advance issues related to quality improvement and patient safety on both a local and national level.
Helping our members become proactive is an important function of the section. As the field of patient safety and quality assurance grows and evolves, QIPS participation offers members numerous benefits including:
- Networking & Collaboration – Participation in QIPS projects, papers, leadership calls, and the scientific assembly meetings, provides opportunities for like-minded individuals to meet and learn from others from around the country;
- Career Development - Interested in developing a career path that involves quality improvement and patient safety? Participation in section can help foster ideas, encourage position development, and further professional growth;
- Mentoring - Learn from members who are regional and national leaders. Past leaders of the section traditionally remain active and often assist and encourage new member development
- Research & Knowledge Advancement – QIPS projects address issues of importance to the practice of emergency medicine. The recent development and publication of a curriculum for quality and safety as well as the white paper on ED handoffs are important contributions to the field;
- Advocacy – The section works to promote clinical, administrative and policy issues that willadvance safety and quality in our field; and
- Opportunity to contribute – Seeking to make a difference? Involvement in the section can provide a pathway.
Moving forward this year, we will seek new and innovative ways to reach and serve our members as well as to further advance quality improvement and patient safety in the specialty and practice of emergency medicine.
We will need your help. A request will be sent to all our members asking for input on how we can best accomplish our mission. Please let us know what we can do. Your feedback will help guide our future operations and activities. In the meantime, if you have any questions or suggestions please feel free to contact me .
How can we serve you?
Back to Top
Richard T. Griffey MD, MPH, FACEP
Division of Emergency Medicine Washington University School of Medicine
St. Louis, MO
On the heels of recent QIPS successes in ACEP Section Grants to explore best practices in ED Handoffs, a curriculum on quality improvement in emergency medicine (published in the CORD supplement of Academic Emergency Medicine) and efforts underway to survey patient safety and quality officers in emergency medicine.
We are currently soliciting ideas for new patient safety and quality related projects for which the section might to submit grant proposals (details below). In addition, with the successful launch of the first annual QIPS resident quality awards, we would like to advertise this award more widely and encourage more residents to become involved in quality and safety projects in EM. Look for further news on this and please share with interested residents and educators.
Back to Top
QIPS Receives 3 ACEP Awards
2010 Scientific Assembly - Las Vegas
Outstanding Section Newsletter Award of Distinction. This award recognizes the exemplary newsletters published by the section from October 2008 through October 2009. (Drs. Robert Broida and Drew Fuller)
Service to Section Award. This award recognizes the section's exemplary work in developing and completing the Section Grant, Improving Emergency Department Change of Shift "Hand Offs," and in providing an outstanding educational offering at the section's 2009 annual meeting. (Drs. Robert Broida and Dickson Cheung)
Service to College Award in recognition of the section's contribution to meeting the College's strategic objectives from October 2008 through October 2009. QIPS Section members contributed effectively as members of the Quality and Performance Committee to help the committee meet its objectives. (Dr. Robert Broida)
This ACEP awards program is designed to recognize extraordinary work of Sections and their leaders in building strong and active sections that contribute significantly to the College, its members, and the patients we serve.
Back to Top
QIPS Resident Award 2010-11
The QIPS Resident Award for 2010-11 is a new annual recognition for graduating resident emergency physicians who demonstrate excellence in, and a passion for quality improvement. Awardees are Nicole Riordan, MD, of the Indiana University School of Medicine Emergency Medicine Residency.
Back to Top
QIPS Education Programs at Scientific Assembly 2010
Program, (Left Dr. Elaine Thallner, Dr. Nicole Riordan, Award Recipient ) and Kara S. Kim, MD, of the Regions Hospital Emergency Medicine Residency Program.
Brent Asplin, MD, FACEP, Chair of the Quality & Performance Committee (QPC), contributed to the educational portion of the meeting with his presentation: Emergency Care, Quality and Health Care Reform: May You Live in Interesting Times”.
His thoughts for the day were: “Why did “care reform happen?”, the paradox of healthcare reform, and emergency medicine’s opportunities and threats in a value-based reimbursement system.
Dr. Asplin also discussed key questions as health care reform as Implemented, including “Are we moving toward a high value Healthcare system or not? And “What does ‘not not’ look like? (across the board cuts in provider payments). Access Dr. Brent Asplin’s presentation on our QIPS site: Emergency Care, Quality & Healthcare Reform "May You Live in Interesting Times".
David P. John, MD, FACEP, Chief of Emergency Medicine at Caritas Carney Hospital discussed “Errors in the First Two Years Out of Training”.
The objectives of his talks were to: identify typical errors for new grads, identify risk factors for a quality case, present these potential problem cases to a second provider, distinguish between training and experience, and to keep them from making the same mistakes that others have made before them. Dr. John also reviewed “The Ten Commandments of Quality,” which he discusses in his article below, Real-Time Case Reviews
Access Dr. David John’s presentation on our QIPS site: Errors in the First Two Years Out of Training.
Back to Top
2011 Section Grant Project Solicitation
QIPS is seeking ideas from our members for projects suitable for an ACEP Section Grant for 2011. QIPS has an excellent track record in successfully applying for Section Grants and is now in search of that next "great idea." The section grant program was established to assist sections in meeting member's needs, educating the public, and furthering the advancement of emergency medicine.
The Board of Directors awards up to $25,000 total annually under the program.
Additional details regarding ACEP's section grant project may be found at this link: https://www.acep.org/sectiongrantmanual. Please forward your ideas to Angela Franklin by December 31.
Back to Top
2010 QIPS Annual Meeting Minutes
Section members participating included: Elaine A. Thallner, MD, FACEP, Chair, Drew C. Fuller, MD, FACEP, Chair-Elect, Heather L. Farley, MD, FACEP, Secretary/Newsletter Editor, and Robert I. Broida, MD, FACEP, Immediate Past Chair. Also in attendance were Drs. Eric Anderson, Philip Anderson, Ankel, Asplin, Barringer, Cheung, Christopher, Dalsey, Freeman, Gatton, Greco, Griffen, Griffey, Hall, Hamedani, Harrison, Jacobs, John, Kahn, Kelly, Khare, Kim, Klauer, Zachary Meisel, Helmut Meisl, Meyers, Nugent, Phelan, Pines, Ray, Reiter, Schuur, Simmons, Simons, Somand, Venkatesh, Worthy, Zinkel, *Others participating included: Alexander M. Rosenau, DO, FACEP, Board Liaison; and Angela J. Franklin, JD, Staff Liaison.
Welcome and Introductions
- Emergency Care, Quality and Health Care Reform: May You Live in Interesting Times
- Common Errors in the First Two Years of Residency
- QIPS Resident Award
- ACEP Awards to QIPS: Service to Section, Outstanding Newsletter
- Voting: Election of New Officers, Operational Guidelines Changes
- Plans for 2010-2011
Major Points Discussed Dr. Thallner welcomed the attendees to the meeting and introductions were made. After attendees introduced themselves the educational portion of the meeting was provided by David John, MD, FACEP: “Common Errors in the First Two Years of Residency”.
Dr. Thallner presented two residents with the QIPS Resident Award for 2010-11, a new annual recognition for graduating resident emergency physicians who demonstrate excellence in, and a passion for quality improvement. Awardees:
- Kara S. Kim, MD, of the Regions Hospital Emergency Medicine Residency Program was awarded for her project to improve patient care and safety by decreasing the lapse time for reinstating medications for current and chronic medical conditions in psychiatric patients transferring from the emergency department to the in-patient psychiatry floors.
- Nicole Riordan, MD, of the Indiana University School of Medicine Emergency Medicine Residency Program, was awarded for her development of the “Patient Safety Officer” (PSO) system, where residents volunteer as PSOs and participate in development and implementation of a variety of efforts to improve patient safety.
Dr. Thallner began the business meeting, outlining the Section accomplishment including winning section awards between 2008 and 2010 in the categories of Service to Section, Service to College and Outstanding Newsletter, winning section grants as well as publishing an article relating to handoffs in Annals, developing and publishing a quality improvement curriculum, and starting the new resident recognition program. Section membership grew from 261 to 309 members over the year.
Drs. Kelly and Rosenau discussed with the Section pursuing the inclusion of Quality and Patient Safety as a category for EM researchers for the 2011 Research Forum at Scientific Assembly.
The Section voted for its officers for 2010-11:
• Chair/Alternate Councilor - Drew C. Fuller, MD, FACEP
• Chair-elect - Heather L. Farley, MD, FACEP
• Secretary/Newsletter Editor - Richard T. Griffey, MD, MPH, FACEP
• Immediate Past Chair/Councilor - Elaine A. Thallner, MD, FACEP
The Section also voted to amend the QIPS operational guidelines to change ‘chairman’ to ‘chair’ throughout, and to add a new Section position, beginning 2011-2012: Webpage Editor. Dr. Andy Kahn expressed interest in serving in the position. Dr. Fuller presented Dr. Thallner with the ACEP Service as Chair award for 2009-10.
Dr. Fuller concluded the meeting with his plans for Section work over the next year, including increasing resources for members and their mission to improve patient quality and safety. This will be accomplished through the newsletter, networking, tips for career development for those interested in a career in quality and patient safety, mentoring, brainstorming and through research and publication of papers as a Section. Work done by the Section over the last 10 years will be collected into an even more usable format for members on the QIPS webpage. Dr. Fuller also urged members to participate in these activities and to let him know how the Section could improve.
There being no further business, the meeting adjourned.
Back to Top
Admit Decision! Admit Order!
Dickson Cheung, MD, MBA, MPH
Sky Ridge Medical Center
Lone Tree, CO
Tastes great! Less filling! So goes one of the great debates in modern history. Spurred on by the recent passage of the NQF and CMS quality measure “admit decision time to ED departure time for admitted patients,” an equally passionate debate has sprung up in ED quality circles. It goes like this: Admit Decision! Admit Order! At the last QIPS annual meeting in Las Vegas, we lightly touched upon this issue but in order for it not to dominate the meeting, Brent Asplin wisely tabled the discussion before it got out of hand. The issue recently reared its ugly head again in a QPC email chain as we argued whether or not to suggest amending the CMS definition for its new IPPS guideline. Below is an introduction and then some excerpts from the virtual discussion that may enlighten (or complicate) the issue for you. In any event, I thought it was a good exchange to share. Concluding thoughts are provided at the end.
Does the committee agree that the current CMS definition is inappropriate, and should ACEP formally ask for a change in the definition? (The current CMS definition data element “decision to admit time” is the time the physician/APN/PA communicates the decision to admit the patient from the ED to the hospital as an inpatient. This will not necessarily coincide with the time the patient is officially admitted to inpatient status). This issue tends to get people very heated up, so a detailed framing is provided so we are all on the same page.
This time point is a critical element in the new CMS measure "ED-2: Admit Decision Time to ED Departure Time for Admitted Patients" which was designed to measure boarding. EDs will be required to collect this measure for FY 2014 as part of the CMS inpatient quality program. Currently this is specified as a chart review measure.
The debate is whether the time point should be defined as:
- The time the provider (Doc/APRN/PA) makes the Admit Decision (a cognitive decision and somehow documents this).
- The time of the Admit Order.
Our contention is that the time of the admit order is the best definition because it is the most comparable between institutions, and is likely to be electronically captured. The doc's decision may not occur at the same time as the order in some EDs, due to systems issues, like requirements that the ED doc has to do lots of stuff before requesting a bed. Although this is invariably true, we think it is not worth defining the time as the cognitive decision for 2 reasons:
- It will require manual/paper review! This is a huge burden to many EDs. ED throughput measures are available electronically in most EDs, so to accept a paper chart review measure is incredibly inefficient for the average ED.
- The difference between admit decision (cognitive) and admit order are internal process issues that EDs and hospitals will have great incentives to fix once this data is publicly published... going to great effort to collect an extra data point doesn't seem worthwhile.
I am in the camp that agrees with the CMS definition for the following reasons:
- I work in a facility where I may know/decide the patient needs admitted but I often have to adjudicate between potential admitting services before I can put the admission/bed request order in. Having to sort between the systolic vs. diastolic CHF service (not really) is very different from institutions where admissions are carried out as ordered by the EP with no questions asked. This challenges the proposal that admission order is the definition that is most comparable among institutions. While the hospital may be motivated by a quality measure to improve upon this, the medical school or individual services may have little motivation to change. We can get stuck in the middle. We have actually improved our process quite a bit, but this remains an issue that is likely very different and incomparable to a small non-academic ED.
- In our EMR, we have a separate “admit” button anticipating the patient’s disposition before the bed request is entered that triggers contemporaneous chart review to make sure the patient meets inpatient criteria. This does not set into motion the formal request for a bed and can work as a traceable cognitive decision to admit. When I do put the formal admit order in, it automatically pages the admitting service and triggers a number of events that I would rather not have to undo – so when I put in the admit order I generally need to be ready to do so. In the event that decision to admit is not documented, the admit order would be the default.
- In many institutions with either computerized tracking, OE, or EMR there have been prior efforts to track “decision to admit” where the cognitive decision to admit is entered separately from the admit order, for many of the usual reasons you allude to and in #1 above. In facilities with a computerized element to their patient record, it should not be difficult to include such an option. In those without, you would be performing a paper chart review anyway.
- Why not allow the individual institution to decide (and report) which option they use? Provided there are only a couple of choices as to how you report (decision to admit vs. admit order), I don’t see the real downside. Meanwhile in those facilities where the admission process is not as straightforward, the ED is not held externally accountable for all of the time sorting between services and boarding times reflect the inefficiency. If internal use of “decision to admit” is challenged as padding the numbers, then you can look at time to admit order as well to see what is “owned” by another service or due to the inefficiency and it will still be a lever to introduce improvement.
This [CMS] section was not written well. One of the issues is who puts this order in and when did it occur. In our system I write down an order and our health unit coordinator (secretary) places an order electronically for a bed through our bed request system. The bed request in "adtr" is tracked electronically, the initial order I wrote is not. We should argue that being able to utilize this electronic format maybe a better metric overall than trying to hand abstract with X % of missing data to confound the matter.
1) This is what we want and those with electronic ER records can document both time stamps (when the emergency physician has finished their work up to the point they can call the attending or whoever and ask for the pt to be admitted AND when the admitting process is finished and the bed assigned).
2) Those who don't have an electronic record (which will be in a relatively short time frame be nonexistent) will have to chart abstract but that is not unreasonable since emergency medicine has this as a top priority (having this quality measure so hospitals can address the overcrowding issue) and want to push to have the best measure possible and not have to settle for a measure that does not reflect reality.
I would favor a different approach. I think the time to admit decision is made is when 'boarding' starts and it is helpful to address system issues that impair the patient from moving from ED after admit decision has been made. It better reflects the end of the priority ED activity under our control. It is time-stamped for EMR but will require some burden for others. I think the attempt is to address 'boarding' rather than just internal processes like bed control/system issues which are important but not the major issues causing 'prolonged' stays in ED i.e. boarding.
We as an organization are trying to document the ADT as the time the emergency provider puts a call/page out to the admitting physician to admit the patient. Even though it is very difficult to define on paper when a patient is "ready" to be admitted, we all know in our gut when that time is. As has been mentioned, an EHR is so critical in capturing this critical data point.
We toyed with different time options for ADT such as the moment you know the patient needs to be admitted. For many patients such as the chest painer with a classic story this would mean the moment the patient walked in the door w/o an EKG or first set of enzymes. This is when many of our sites order a bed but we didn't feel this really met the intent of the measure.
The other option was to document it as when the admitting physician had orders on the chart. We felt like this didn't really meet the intent of the measure either.
Therefore we went with the first option because we felt the true intent of the measure was to document ADT as the actual time the patient was ready to be admitted by the admitting service and could leave the ED as an inpatient.
I agree that ACEP should push for electronic ED medical records, which automate the time stamping of critical decisions involved in patient flow through the department, but I'm a bit more cynical than you about how long it will take to get all EDs up to speed with this. At my institution we have several different electronic systems that don't talk to each other, residents and nurses chart on paper and the attending dictate. Talk of an EMR for ED use has been ongoing for many years and the latest is that "something is coming in 5-7 years" - and this is in a relatively resource-rich environment, so I can only assume that other institutions are even farther behind. I suppose if measures get passed that require some critical EMR functionality for the ED, this may help stimulate faster adoption of new systems, but I still see such a disparate mix of home grown and off the shelf systems out there that it will be hard to standardize data collection.
I suppose we could look at all the current chaos as an opportunity - we can define what the essential times should be and how they should be reported, so as systems are developed, they are built with these agreed upon standards in mind. For what it's worth I think the "decision to admit" time should be the time that the attending physician decides to admit the patient, as this will create incentives to streamline the process flow between this decision and when the inpatient bed is actually assigned, which would greatly reduce crowding.
Hello All, I am beginning to appreciate the complexity of this issue. We utilize an EMR and have been able to electronically capture the cognitive process of the admit decision time as our residents flag a chart and timestamp the process. This has allowed us to go to the hospital administration and demonstrate that our ED LOS is doubled due to the factors everyone has already outlined: bed processing, assignment, admit orders, transport, etc… We make the case that all items up until the admit decision (lab testing, study interpretation, consults, etc…) can be impacted by us in some way (okay, not all), but we don’t control anything about the process after the admit decision. I appreciate the argument about having consistency across institutions as a reason to use the inpt order placement – unfortunately, that will artificially inflate many ED’s LOS.
I agree with the original suggestion to recommend CMS change the definition to coincide with the NQF definition. Whether measured electronically or by chart abstraction, an order to admit would likely be a more accurate and reliable measure across varied institutions (and therefore makes the measure more valid). The decision to admit is important but I don’t think it can be accurately measured and recorded; the order to admit is actionable and measurable and correlates with the operations of the department.
Agree with [LG]. EMRs time stamp everything- no longer a matter of a time easily collected. The decision to admit- order placed by the ED doc would be the basis for everyone. Time in the department after the order is placed is important to capture as well but doesn't necessarily reflect "boarding" time.
I agree with making the definitions standard, and I agree that EMRs do provide a fairly easy mechanism for time stamping this event. I think some of the issues that tend to be debated or discussed on this topic are ones of syntax or semantics. For instance, I am hearing that the decision to disposition is difficult to measure. However, if this is defined as synonymous with putting the order in for the admission, then the issue is moot. Just like with any measure, all providers need to adapt to the terminology and mechanism for compliance.
I think the key in measurement of such a metric is when an item becomes actionable. So, when the hospital has to act on the doctor’s decision to admit, the time clock for decision to disposition begins to run.
For the past seven years that I have been a part of this debate, I have always landed on the side of "admit order" as the more elegant metric because it is "actionable", "observable", "consistent", "and legal." Although I see more of its imperfections, I believe it is still the stronger timestamp. I have worked in both situations where the "admission decision" could be quickly transitioned into an "admit order" and in other institutions, where there were many hoops to jump through before you could write an "admit order" (after various services passed the patient around like a hot potato). In the end, I stand on the side of "admit order" because for all its faults, "admit decision" is even more variable and game able.
Part of the resistance I am hearing from the "admit decision" folks is that the ED doesn't want to be held responsible for more than their fair share of the "arrival to departure" pie. But from the hospital viewpoint (and it is the hospitals who are ultimately held accountable for improving the metric), it is a zero sum game. The "median time from ED arrival to ED departure for admitted patients" will be a constant. Therefore, I think we shouldn't place undue emphasis on what is the "EDs" vs. "the hospitals" because in the end, we have to fix it all anyways including all the problems with bed control, competing services, housecleaning, handoffs, transport, etc. So if we had to pick an intermediary metric, "admit order" makes more sense in terms of being electronically captured, consistent with workflow, etc. as previously mentioned.
If we recommend admit order time, then we need to define what constitutes an "admit order". For example, would time stamping "Admit Inpatient" in an EHR that doesn't trigger any further chain of events constitute an "admit order"? Verbal to ED clerk?; or placement on bed tracking software requesting a bed?
As demonstrated, this is a topic never to bring up casually at a cocktail party or meeting unless you want it to fill the rest of the time. If I could distill the sentiments of the debate, I would group them into the following issues:
- Where to draw the line. To begin with, few would argue that the most important metric to the admitted patient is the “arrival to departure time” (i.e. the whole enchilada). After all, the patient wants to know when they are going to leave the uncomfortable gurney and noisy confines of the ED for their private room and pressure sore-reducing bed. The intermediate metric of “admit decision to departure” is an artificial one. But one that hotly is debated. If constructively used, it may expose the inefficiencies of the system and decrease the overall “arrival to departure time.” If it becomes a source of contention between parties, it may just produce “blame shifting.”
- Better vs. ideal. Admit order proponents will argue that their metric is more actionable, measurable and consistent with the workflow. Admit decision proponents will argue that the admit order time and process is variable from institution to institution and does not perfectly capture the intent of measuring “boarding.” Both are true. It does come down to picking the least of two evils. I guess the debate could aptly be framed as: Tastes awful! More filling!
- The now and the not yet. Everyone agrees that chart abstraction is cumbersome. Electronic capture of quality metrics is clearly the future. But we are not there yet. Will EHRs catch up in time for the implementation of the CMS measure? Are you an idealist or a cynic?
- Can’t we all just get along? An unspoken but strong underlying current in the debate is the fear that the ED will be held responsible for events beyond its control in the “arrival to departure” scenario. This blame avoidance is a real phenomenon (on both sides of the “ED” and “hospital” aisle) but if progress is to be made, meaningful collaboration between laboratories, imaging, administrative and clinical services will need to occur. The hope of the measure is that all parties will put aside their own self interests and be open to looking at their own operational deficiencies.
Back to Top
Real-Time Case Reviews
David P. John, MD, FACEP
Chief of Emergency Medicine
Caritas Carney Hospital
In the first year that I got out of my residency I was asked to be the CQI guy. That stands for continuous quality improvement for those of you under the age of 30. The original quality section a.k.a. the continuous quality improvement section was founded by Jim Espinoza in the early 90s. He actually had a grant to write a book Continuous Quality Improvement in the Emergency Department. I met with the guy who was doing quality at my hospital for about half an hour and he gave me a bunch of floppy disks with quality reviews that he had done in the past five years. My boss gave me Jim’s book and I was off and running.
In my first couple of years, I realized that I was reviewing the same quality issues over and over again. Every once in a while we would have a C-spine fracture that was missed, or a missed pulmonary embolus, or a missed subarachnoid hemorrhage. It seemed like every year I was reviewing subarachnoid hemorrhages. So I started to collect these cases and put together some algorithms for how to manage people with presentations that could result in missed diagnoses. I brought in articles, experts in the field etc. eventually I think I hit on something. After I dedicated one meeting to a certain clinical condition that condition would go away for a while. Every once in a while I would start seeing misses again. I realized that our new hires whether they were fresh out of residency or not had not had the benefit of these lectures. This was really driven home when I finally fixed the pneumonia core measures. Our scores were in the 99th percentile and I was asked to give lectures at other hospitals on how to fix the core measures. We hired four new docs in a six-month period and all of a sudden our scores started dropping. You guessed it, the new hires and not had the benefit of my droning on and on for the previous two years. I met with them individually and we were back up to speed within a short period of time.
I used to sit with each new graduate for an hour or two when they first began working for us to talk about quality and common mistakes that they made in their first few years. I also met with them individually on each of their first few quality cases. I encourage them to run difficult cases by other more experienced physicians and even call me at home. I would rather have them wake me than find out that a patient had been harmed the next day. I had already begun to realize the importance of verbal communication and processing of information so that another could understand the case. Sometimes we are tired especially the middle of the night. Sometimes we are overwhelmed at the end of a busy shift. And sometimes we just need a fresh set of eyes to look at a case that we are involved with. I found that by going over quality cases one-on-one with my new graduates I was able to convey information about how I review a case. I began to show that there were common risk factors in most quality cases. They became quite comfortable running difficult cases by a second person and by virtue of that; they had very few quality cases compared to the new graduates that had gone before them.
I started to use this tool of real-time case reviews with any of our new hires. I found it was easier to teach them to do their own quality reviews real-time than it was for me to have to go over every case with them and the group. It was also difficult to re-create all of my previous lectures for each individual that we hired. I am not lazy by nature; I came upon the idea that it is the job of the person who reviews quality and risk management. We need to impart what we know to the rest of the group.
Everybody in your group cannot review every quality case, but they can be apprised of common themes and risk factors.
For the sake of brevity, I am not going to go into all of the individual cases that led me to my conclusions. I will give a few specific examples of what can go wrong and I will hope that you trust me that these risk factors are pretty obvious to anybody that works in quality.
A 32-year-old woman was brought into the ED on a busy evening shift by her husband and two small children. She was not acting right. Her vital signs were stable, her labs and toxicology screen were signed out as normal, and she was held in the ED to see the psychiatrist in the morning. She had a history of alcohol abuse and depression, but her toxicology screen was negative. During the overnight shift the nurses found that she went from somnolent to unexcitable. They asked the physician to reevaluate her. When he looked at her labs from earlier he noted that her bicarb was 10. He intubated her, got a CAT scan of her head, and called the husband at two o'clock in the morning to ask him about anti-freeze. Like every good New Englander he had a half-full bottle in his garage. Her repeat bicarb was eight and she was developing renal failure. Her toxicology screen came back positive for ethylene glycol.
| Risk Factors for a Quality Review
- The extremes of age
- Off hours
- Sign out/change of shift
- Negative tests
- Unanticipated return visits
- Inexperienced Provider
- Appropriate tests not available
- Disagreement about discharge
- Overcrowded conditions
- Communication issues (language, cognitive, etc.): 3 or more? Present the case to another provider.
As smart and experienced as we all like to think we are we occasionally run into those cases where we are not really sure what is going on or we can't decide whether to admit or discharge. One other caveat, this usually occurs at the end of your shift. These are the cases that usually end up in the quality bin. Most of us don't feel really good about these cases and if you really tune in to your clinical instincts, you know there is something wrong. These are the gray zone cases, the ones where something is just not right. These are also the cases that you should score real-time.
It is a simple process. The rule used to be that if anybody in the department was uncomfortable with the disposition of the patient, the physician would score the case. Most of us are type A personalities and when I showed a dramatic improvement in quality reviews for new graduates, all of my experienced docs begin to jump on board. This initiative is now physician driven. I knew that I had achieved success when my old boss started presenting a case to me on a shift we were working together. I stopped him in mid-presentation and said Mike are you doing a real time quality review? He told me to shut up and listen. He literally did not make it through more than a couple of sentences before he stopped and said “what was I thinking.” Sometimes I don't even score cases anymore. If I feel uncomfortable in any way about a case I go straight to the presentation. When I look back on these cases, they usually have 4 to 5 risk factors for quality review.
I just want to throw in one last case. I was finishing up a shift at about midnight I had a meeting at the hospital at 7 AM. I was taking care of a 12-year-old girl who had severe left lower quadrant pain. I was actually giving her some pretty heavy doses of Dilaudid to keep her on the stretcher. This was in the dark days before ED ultrasound and at the time, we could not get ultrasounds in the middle of the night. I ordered a CAT scan on a young woman against my better judgment. I also called the OB/GYN on-call and presented the case to her. She told me to call her back if there was anything suspicious on CAT scan and she would admit her. I signed the case out to one of my mentors and essentially said if there was anything on CAT scan go ahead and admit to OB/GYN. I told him I was concerned about ovarian torsion. We were using teleradiology at night and the report would not be back for several hours. They read the film as negative.
The next morning the radiologist with his fresh cup of Starbucks called over to the ED stating that he thought there was an adnexal mass and more than physiologic free fluid in the peritoneum. We attempted to call her back, but the mother chose to bring her to another hospital. Why should she bring her back to the hospital that missed the diagnosis in the first place? She had ovarian torsion and had her ovary was removed that day.
This article has a somewhat targeted audience. Most of you reading this probably work in quality. You probably know most of the stuff I'm talking about. We have been remiss as quality wonks for not sharing what we know with the rank-and-file in emergency medicine. Nobody likes to make mistakes and nobody likes to harm patients. Most doctors would like to improve their clinical skills. If you attend a Scientific Assembly look at the number of people in the rooms for the medical error reduction lecture and the malpractice lectures. We have a captive audience out there and we just need to share what we know. Go back to your home institution and try a Real-Time Quality Review with your next difficult case. It makes a lot of sense once you have done it a few times.
|The 10 Commandments of Quality
- Do not force a diagnosis on a patient. Tell them you don’t know and give them permission to come back.
- Do the same thing when it is crowded as when it is not.
- If anybody disagrees with discharging the patient, rethink your plan.
- Don’t rely on tests unless they are positive. Trust your instincts.
- Sign out and change of shift need formal guidelines and standards.
- Either look up or discuss with pharmacy any medications with which you are unfamiliar.
- Make error reporting simple to complete and non-punitive.* These will identify your system failures and create a culture of safety.
- Quality reviews should be educational and accurate. Leave out the names and meet individually with all new grads.
- Beware of off hours.
- It is all about the discharged patients. Make sure the follow up plan makes sense and that the patient/family can accomplish it.
Back to Top
QIPS TIPS “Data Talk
Shari Welch, MD, FACEP
Data talk and the data in the National Hospital Ambulatory Care Survey: 2006 Emergency Department Summary tells some interesting stories about the work we do in emergency medicine. First, the number of ED visits per thousand populations keeps going up and our aging demographic sees utilization by seniors increasing at the fastest rate.
In terms of what happens during an ED encounter, we are using more diagnostics than ever before. This is likely because as the population ages the complexity of the acute care rendered increases linearly and diagnostics are required to sort these patients with their many co-morbidities. Planning our physical space and our operations for this changing demographic is critical to safe and efficient health care delivery.
There have been some stable trends in the ED. Minor orthopedic cases and lacerations have remained stable for a decade whereas self-inflicted wounds have almost trebled, reflecting the collapse of the mental health system in this country. Preparing for the scores of patients that will come to our emergency departments with acute psychosis, addiction problems, and acute behavioral problems is critical to the safety of emergency departments. Designing mental health suites with ample security will be part of the new design.
Finally, the ED is rendering less CPR and more IV therapy. We are treating acute exacerbations of chronic disease. Follow-up visits are increasing as we move care to an outpatient model even as there is no place for the patient to follow-up. Some ED’s are planning for this with special processes for follow-up IV treatment and even using recliners in a cluster in the ED as an treatment space for these patients instead of tying up rooms.
The point is this: The NHAMC report is a worthwhile read for emergency physicians. It is a treasure trove of data about our practice and the data outline trends and transformations in the practice of emergency medicine. Have a look!
Back to Top
The Healthy Emergency Department
Mark T. Fleming and Pat Croskerry
Continuing our series, a portion of Chapter 7 – “The Healthy Emergency Department” by Laura Pimentel is excerpted with permission from Croskerry, P., Cosby, K.S., Schenkel, S.M., and Wears, R.L, Patient Safety in Emergency Medicine. Philadelphia: Lippincott Williams and Wilkins, 2009.
The adjective healthy suggests specific characteristics; an absence of disease or infirmary is fundamental to health. Beyond this negative association are the positive attributes of strength and vigor. A robust constitution and wholesome outlook suggest soundness and balance. When applied to an emergency department (ED), a vision emerges of the way emergency medicine was designed to be practiced. The maladies of adverse patient events, inefficiency, and overcrowding are gone. Emergency departments assume their rightful places as the sites of choice for ht care of acutely ill or injured patients. High-quality evidence-based medicine is practiced by well-trained, compassionate emergency physicians and nurses. Thoughtfully designed operations allow rapid initial patient assessments and initiation of care. A culture of safety is manifested by teamwork, effective communication, and fail-safe technology. The goals of this chapter are to outline the components of the healthy ED and offer a strategy to transition EDs from the maladies of health care today to the ideal envisioned by the pioneers of emergency medicine.
Outstanding leadership is the most important component of a healthy ED. Internal and external levels of leadership affect the structure and function of the department. At the executive level of hospital leadership, the chief executive officer and senior team set the tone and the mission; they shape the culture of the organization. A culture of safety begins at this level. Support for the clinical operations of the ED includes capital resources, infrastructure, human resources and ancillary services.
Internally, the physician chief of service and nursing director provide vision and operational direction. Bennis (1) describers seven attributes essential to effective leadership: technical competence, facility for abstract or strategic thinking, track record of achieving results, people skills, and the ability to cultivate talent, judgment, and character. He notes unequivocally that character is the most important and that it is responsible for 85% of a leader’s success. The short definition of character is moral excellence. Drucker (2) agrees, noting that effective leaders all submit themselves to the mirror test. “They made sure that the person they saw in the mirror in the morning was the kind of person they wanted to be, respect and believe in.” The respect and working relationship between the physician and nursing leaders establish the dynamic for teamwork within the department.
Given a strong working relationship among the leaders, a culture of safety is fundamental to a healthy ED. Larson (3) contrasts the styles of two departmental leaders under whom he worked that resulted in drastically different error rates. When describing the successful service chief he notes that, “Every morning the chief of medicine reviewed admissions and problems at a meeting with all senior residents. He created an open, sensitive, Hippocratic atmosphere and promoted intense communication with radiology and nuclear medicine. We learned from all mistakes as a team, became therapeutic conservatives, supported each other, and made constant use of the library and medical reviews. “One of the most important components of a safety culture is a blameless approach to adverse patient events and near misses. Individual clinicians must feel safe reporting these occurrences. Effective leaders understand that most adverse events are the result of a faulty system rather than a negligent practitioner. They subscribe to normal accident theory, the paradigm suggesting that errors are the consequence rather than the cause of adverse events (4).
Another patient safety cultural component generated by a strong leadership teams is development of a high reliability organization. This theory acknowledges that individuals working in complex systems such as the ED are not sufficiently complex to foresee adverse events created by the system. A strong interdependent team, however can successfully navigate this environment. Team characteristics include mutual support, trust, and friendly and open relationships. The work environment will reinforce these characteristics and high achievement (5).
A healthy ED is one that is consistently staffed at safe levels with well-trained professionals. The Emergency Nurses Association (ENA) advocates best practice staffing; the ENA (6) defines this as “that which provides timely and efficient patient care and a safe environment for both patients and staff, while promoting an atmosphere of professional nursing satisfaction.” There is debate at both the policy and practice levels about how to determine safe and efficient staffing. The question is not trivial Aiken et al. (7) demonstrated a direct correlation between nursing staffing and patient mortality in a large study of surgical inpatients admitted to Pennsylvania hospitals. The same study demonstrated a correlation between high nurse-patient ratios and burnout and job dissatisfaction.
Some groups, including nursing organizations, unions, and state legislatures, have called for mandatory nurse-to patient ratios set to reflect the clinical setting. The California legislature enacted a law establishing minimum safe ratios in 1999 (8). The law has had mixed consequences, with reports of more nursing care on medical and surgical floors, but closure of some unites where the ratios could not be met. From the ED perspective, there are reports of prolonged stays for admitted patients waiting to go to floors until the ratio is met (9).
Emergency Nurses Association has rejected ratios as the preferred tool for determining ideal nursing staffing. The organization observes that tools such as ratios or a gross calculation of nursing hours per patient visit are insufficiently sensitive to the variables that drive nursing resources (8). Emergency Nurses Association has designed a complex formula that incorporates variables such as patient census, acuity, and average length of stay to determine best practice staffing for individual EDs. The formula for deriving the correct number of nursing full time equivalents (FTEs) includes consideration of the nonpatient care activities such as meetings and in-services necessary for quality nursing care (10).
With respect to physician staffing of EDs, little research has been done to define optimal staffing. It is an important question, however. Inadequate staffing leads to excessive waits for initial patient evaluations; this situation carries inherent danger and increases the number of patients who leave without treatment. Chisholm et al. (11) measured the number of interruptions experienced by emergency physicians during clinical shifts. The documented a positive correlation between number of interruptions and the average number of patients simultaneously managed by an emergency physician. Interruptions and distractions are known causes of error in medical and nonmedical work settings.
Physician-to-patient ratios are frequently used to decide ED physician coverage. Zun (12) notes that ratios as varied as 1.8 to 5 patients per hour are advocated as guidelines. The author has noted a steady decrease in the ratios listed as safe and appropriate for ED coverage over the past 20 years. This has occurred as the intensity of patient evaluation has increased with the diagnostic technology available to emergency physicians. Overcrowding and patient boarding are reasons to increase physician staffing relative to patient volume. The American Academy of Emergency Medicine (AAEM) released a position in 2001 calling for ratios of physician staffing to patient influx not to exceed 2.2.5 patients per physician per hours (13). This is a reasonable guideline for most community EDs. In 2007 the author suggests that physician staffing range from 2 to 2.25 patients per physician per hour on average such that the actual ratio rarely exceeds the AAEM ceiling. There is little published on the effect of mid-level providers on physician staffing. In healthy EDs, it is important to understand that emergency care is provided by emergency physicians. Physician assistants and nurse practitioners can assist with care and efficiency but should never be substituted for the expertise of an emergency physician.
When considering optimal ED staffing, quality is as important as quantity. A healthy ED should be managed by a Certified Emergency Nurse (CEN). Certified Emergency Nurse certification is a benchmark for mastering the core competencies of emergency nursing. A four year designation, certification ensured current skills and fund of knowledge. Maintaining certification requires regular continuing education. The manager should preferentially hire CENs and encourage all staff nurses to obtain the designation.
Healthy EDs are led and staffed by board-certified and board-eligible emergency physicians. Many hospitals now require board certification within a few years of residency completion to grant or maintain clinical privileges. Emergency medicine residency training and board certification ensure that physicians master the core content of emergency medicine and maintain a current fund of knowledge. There are undoubtedly healthy EDs, particularly in rural areas, that are staffed by physicians without these credentials; nevertheless, the standard of care at the time of this writing, nearly 20 years after closure of the practice track for board certification, calls for emergency medicine residency training for those seeking a career in emergency medicine.
Back to Top
Quality & Safety Articles
Helmut Meisl, MD, FACEP
Quality Improvement Director
Good Samaritan Hospital
San Jose, California
Here is a list of recent articles for your interest. These are compiled by AHRQ PSNet at (http://psnet.ahrq.gov/).
Medication safety initiative in reducing medication errors. Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.
Errors of diagnosis in pediatric practice: a multisite survey. Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.
Eight recommendations for policies for communicating abnormal test results.
Singh H; Vij MS. Jt Comm J Qual Patient Saf. 2010;36:226-232.
Patient record review of the incidence, consequences, and causes of diagnostic adverse events.
Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-1021.
The impact of interruptions on clinical task completion.
Westbrook JI, Coiera E, Dunsmuir WTM, et al. Qual Saf Health Care. 2010 May 12.
Health literacy and the quality of physician–patient communication during hospitalization.
Kripalani S, Jacobson TA, Mugalla IC, Cawthon CR, Niesner KJ, Vaccarino V. J Hosp Med. 2010;5:269-275.
Influence of language barriers on outcomes of hospital care for general medicine inpatients.
Karliner LS, Kim SE, Meltzer DO, Auerbach AD. J Hosp Med. 2010;5:276-282.
Effect of hospital follow-up appointment on clinical event outcomes and mortality.
Grafft CA, McDonald FS, Ruud KL, Liesinger JT, Johnson MG, Naessens JM. Arch Intern Med. 2010;170:955-960.
Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being.
Sirriyeh R, Lawton R, Gardner P, Armitage G. Qual Saf Health Care. 2010 May 31.
Medication errors recovered by emergency department pharmacists.
Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.
Safety of using a computerized rounding and sign-out system to reduce resident duty hours.
Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.
Patient safety: latent risk factors.
van Beuzekom M, Boer F, Akerboom S, Hudson P. Brit J Anaesth. 2010;105:52-59.
Learning accountability for patient outcomes.
Pronovost PJ. JAMA. 2010;304:204-205.
Comparison of methods for identifying patients at risk of medication-related harm.
van Doormaal JE, Rommers MK, Kosterink JGW, Teepe-Twiss IM, Haaijer-Ruskamp FM, Mol PGM. Qual Saf Health Care. 2010 Jun 27.
Medication errors with electronic prescribing (eP): two views of the same picture.
Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.
An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.
Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-476.
Checklists and guidelines: imaging techniques for visualizing what to do.
Davidoff F. JAMA. 2010;304:206-207.
Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3?
Meeks DW, Lally KP, Carrick MM, et al. Am J Surg. 2010 Jun 21.
Characteristics of quality and patient safety curricula in major teaching hospitals.
Pingleton SK, Davis DA, Dickler RM. Am J Med Qual. 2010;25:305-311.
Computerized order entry systems may miss medication errors.
Dolan PL. American Medical News. July 19, 2010.
A systems approach to morbidity and mortality conference.
Szostek JH, Wieland ML, Loertscher LL, et al. Am J Med. 2010;123:663-668.
Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.
Eva KW, Link CL, Lutfey KE, McKinlay JB. Acad Med. 2010;85:1112-1117.
Patient handovers within the hospital: translating knowledge from motor racing to healthcare.
Catchpole K, Sellers R, Goldman A, McCulloch P, Hignett S. Qual Saf Health Care. 2010 Jun 17.
To think is good: querying an initial hypothesis reduces diagnostic error in medical students.
Coderre S, Wright B, McLaughlin K. Acad Med. 2010;85:1125-1129.
Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.
Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.
Contextual errors and failures in individualizing patient care: a multicenter study.
Weiner SJ, Schwartz A, Weaver F, et al. Ann Intern Med. 2010;153:69-75.
Nursing care quality and adverse events in US hospitals.
Lucero RJ, Lake ET, Aiken LH. J Clin Nurs. 2010;19:2185-2195.
Information transfer and communication in surgery: a systematic review.
Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-239.
Reducing diagnostic error through medical home-based primary care reform.
Singh H, Graber M. JAMA. 2010;304:463-464.
Medication reconciliation in a community pharmacy setting.
Johnson CM, Marcy TR, Harrison DL, Young RE, Stevens EL, Shadid J. J Am Pharm Assoc. 2010;50:523-526.
Ashamed to admit it: owning up to medical error.
Ofri D. Health Aff (Millwood). 2010;29:1549-1551.
Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.
Davies EC, Green CF, Mottram DR, Pirmohamed M. Br J Clin Pharmacol. 2010;70:102-108.
Ambulance personnel perceptions of near misses and adverse events in pediatric patients.
Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010 Jul 21.
Paediatric dosing errors before and after electronic prescribing.
Jani YH, Barber N, Wong ICK. Qual Saf Health Care. 2010;19:337-340.
Comparison of potential risk factors for medication errors with and without patient harm.
Zaal RJ, van Doormaal JE, Lenderink AW, et al. Pharmacoepidemiol Drug Saf. 2010;19:825-833.
Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.
Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.
Communication discrepancies between physicians and hospitalized patients.
Olson DP, Windish DM. Arch Intern Med. 2010;170:1302-1307.
Bearing witness to the ethics of practice: storying physicians' medical mistake narratives.
Carmack HJ. Health Commun. 2010;25:449-458.
Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.
Levtzion-Korach O, Frankel A, Alcalai H, et al. Jt Comm J Qual Patient Saf. 2010;36:402-410.
Liability claims and costs before and after implementation of a medical error disclosure program. Kachalia A, Kaufman SR, Boothman R, et al. Ann Intern Med. 2010;153:213-221.
The elephant of patient safety: what you see depends on how you look.
Shojania KG. Jt Comm J Qual Patient Saf. 2010;36:399-401, AP1-AP3.
Ethics, oversight and quality improvement initiatives.
Taylor HA, Pronovost PJ, Sugarman J. Qual Saf Health Care. 2010;19:271-274.
Developing a common language for evaluation questions in quality and safety improvement.
Lambert MF, Shearer H. Qual Saf Health Care. 2010;19:266-270.
“Water cooler” learning: knowledge sharing at the clinical “backstage” and its contribution to patient safety.
Waring JJ, Bishop S. J Health Organ Manag. 2010;24:325-342.
Disclosure of patient safety incidents: a comprehensive review.
O'connor E, Coates HM, Yardley IE, Wu AW. Int J Qual Health Care. 2010 Aug 13.
(Mis)understanding safety culture and its relationship to safety management.
Guldenmund FW. Risk Anal. 2010 Jul 8.
New legal protections for reporting patient errors under the Patient Safety and Quality Improvement Act: a review of the medical literature and analysis.
Howard J, Levy F, Mareiniss DP, et al. J Patient Saf. 2010 Jul 15.
Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.
Gosbee J. Clin Obstet Gynecol. 2010;53:545-558.
Economic evaluation of healthcare safety: which attributes of safety do healthcare professionals consider most important in resource allocation decisions?
Steuten L, Buxton M. Qual Saf Health Care. 2010 Aug 10.
The disclosure dilemma—large-scale adverse events.
Dudzinski DM, Hébert PC, Foglia MB, Gallagher TH. N Engl J Med. 2010;363:978-986.
Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients.
Sharek PJ, Parry G, Goldmann D, et al. Health Serv Res. 2010 Aug 16.
Reviewing methodologically disparate data: a practical guide for the patient safety research field.
Brown KF, Long SJ, Athanasiou T, Vincent CA, Kroll JS, Sevdalis N. J Eval Clin Pract. 2010 Aug 4.
When do supervising physicians decide to entrust residents with unsupervised tasks?
Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. Acad Med. 2010;85:1408-1417.
Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.
White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Qual Saf Health Care. 2010 Aug 19.
Diagnostic error in a national incident reporting system in the UK.
Sevdalis N, Jacklin R, Arora S, Vincent CA, Thomson RG. J Eval Clin Pract. 2010 Aug 19.
Diagnostic error in acute care.
PA-PSRS Patient Saf Advis. 2010;7:76-86.
National costs of the medical liability system.
Mello MM, Chandra A, Gawande AA, Studdert DM. Health Aff (Millwood). 2010;29:1569-1577.
Why diagnostic errors don't get any respect—and what can be done about them.
Wachter RM. Health Aff (Millwood). 2010;29:1605-1610.
The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative.
Parand A, Burnett S, Benn J, Pinto A, Iskander S, Vincent C. J Eval Clin Pract. 2010 Aug 24.
Patient safety beyond the hospital.
Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.
Safety through redundancy: a case study of in-hospital patient transfers.
Ong MS, Coiera E. Qual Saf Health Care. 2010 Jul 29.
Incidence of medication errors and adverse drug events in the ICU: a systematic review.
Wilmer A, Louie K, Dodek P, Wong H, Ayas N. Qual Saf Health Care. 2010 Jul 29.
Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.
Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.
Patient perceptions of mistakes in ambulatory care.
Kistler CE, Walter LC, Mitchell CM, Sloane PD. Arch Intern Med. 2010;170:1480-1487.
Errors and electronic prescribing: a controlled laboratory study to examine task complexity and interruption effects.
Magrabi F, Li SY, Day RO, Coiera E. J Am Med Inform Assoc. 2010;17:575-583.
Improving the quality of drug error reporting.
Armitage G, Newell R, Wright J. J Eval Clin Pract. 2010 Aug 27.
Back to Top
This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.