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Quality Improvement & Patient Safety Section Newsletter - March 2008, Vol 9, #2

Quality Improvement & Patient Safety Section

circle_arrow The Chair's Letter
circle_arrow ACEP Section Grant Letter of Intent Submission Form
circle_arrow Editor's Note
circle_arrow Historical Figure in Quality: Avedis Donabedian
circle_arrow Six Sigma Primer
circle_arrow How close are we to "Diagnosis Decision Support" in the ED?
circle_arrow Emergency Medicine Quality Course at ICEM
circle_arrow Patient Safety Act of 2005 Finally Poised for Implementation
circle_arrow Report of Patient Safety Conference in Emergency Medicine
circle_arrow QIPS Members Sought for Aging Emergency Physician Task Force
circle_arrow ICEM 2008
circle_arrow CMS Clarifies Reporting of PN-5c Measure
circle_arrow Washington Update: NQF Emergency Care Project, 2007 PQRI Results
circle_arrow Quality and Safety Articles

Newsletter Index

Quality Improvement & Patient Safety Section




The Chair's LetterDickson Cheung, MD, MBA, MPH

Dickson Cheung, MD, MBA, MPH

It is hard to believe that we are almost half way through the year already. And much is happening…the first phase of the Curriculum Project led by Jack Kelly is nearing its completion and the second run of our Quality Course led by David John is set for April 2nd at the International Conference on Emergency Medicine (ICEM) in San Francisco.

Spurred on by a great proposal by Jack Kelly and subsequent spirited discussion on a QIPS leaders calls, we decided last month that QIPS' next ambitious project will focus on standardizing the "hand-off" process between emergency physicians during shift change. Some would argue that the "hand-off" is the most dangerous procedure we as emergency personnel perform each and every day. Yet very little is known about how to do it right. No one teaches it in residency. No one monitors it. No one knows what really works. Some providers round at the bedside, others go over patients at the whiteboard or its equivalent; some hand-offs are verbal, others written. Some departments have sophisticated computerized tracking systems; others have no written census at all.

I think I have worked in departments where all these practices have been used at one time or another. And there are pros and cons of each practice. Some sign outs are too brief, others too verbose but wouldn't it be nice to know what was "just right?" The amount of information that needs to be communicated about each patient probably depends on the complexity of the case and how clear the disposition is. But don't you hate that sign-out with "nothing to do" where all of sudden you are fielding 20 questions from the family or consultants or that won't leave the ED? Or worse yet, the patient who is admitted to the floor (and increasingly, there is no bed available) that develops a complication and you end up having to figure out who this patient with "nothing to do" is. This is just one example of a problematic "hand-off." Yes, the errant sign out process can be a potential mine field.

Transitions in care (hand-offs) across settings, services, providers and levels of care are highlighted in the most recent 2007 National Patient Safety Goals. Our next QIPS project for this year will focus on transition of care in the ED between shifts. We will do this by applying for a Section grant (see the letter of intent in the newsletter), rallying the troops again and figuring this thing out in a series of conference calls and writing assignments which will include surveying current practices, researching risk management databases of "high risk" patients and performing failure modes analysis on various methods of signing out.

For those who have been involved in past grant projects, we again are asking you to roll up your sleeves and join us in the discussion. For those new to the section, this is a great way to get involved in a meaningful way with the rest of your section members. Our hope is to clarify the issues surrounding "hand-offs", identify the patient that is at high risk of falling through the cracks in a sign out and formulating a standardized template that is both efficient for our practice and safe for our patients. This work should dovetail nicely without Curriculum Project and our Quality Course as we build quality and safety "brick by brick" into our practice.




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ACEP Section Grant Letter of Intent Submission Form

Name of section: 

Quality Improvement and Patient Safety (QIPS)

Name/address/phone/e-mail address of section chair:

Dickson Cheung, MD MBA MPH

Name/address/phone/e-mail address of project coordinator:

John J. "Jack" Kelly, DO, FACEP


Dickson Cheung, MD MBA MPH

Title of project:
Improving Emergency Department Change of Shift "Hand Offs"

_Jack Kelly & Dickson Cheung__
Signature of Project Coordinator
(electronic signatures accepted)
____Dickson Cheung_____
Signature of Section Chair

This letter of intent has been written jointly by Drs Jack Kelly and Dickson Cheung and reviewed by the QIPS Section Leaders on a conference call on February 13, 2008 from 1:00-1:30 pm EST.

Brief description of project:

Transitions in care (hand-offs) across settings, services, providers and levels of care are highlighted in the most recent 2007 National Patient Safety Goals. Hand-offs between emergency medicine providers at the change of shift is probably the most dangerous procedure we perform on a daily basis because of the potential of communication failure and its consequences. Surprisingly, this critical portion of our practice has thus far received little attention.

As a specialty, we need to be able to identify the structural and process components that lead to a safer hand-off. Topics related to this issue include but are not limited to:

  • Scheduling of shifts e.g. overlapping shifts to minimize the number of patients that need to be signed out.
  • The necessity of a standardized approach to what specific information needs to be passed along e.g. name, room number, chief complaint, past medical history, workup, diagnosis, communication with other providers, disposition, pending tests, etc.
  • Information systems that allow subsequent providers to easily access key portions of the patient's visit.
  • A summary and evaluation of hand-off practices including face-to-face introductions, rounding on the entire ED census, board sign outs, etc.
  • Identification of "high risk" sign outs including patients with abnormal lab values, unstable vital signs, uncertain diagnosis, and patients who are discharged or dispositioned with "nothing to do" but are still in the department.

The deliverables of this project will include:

  • A review that addresses the issues above that may be published in a journal and/or disseminated via web-based publishing, lecture, standard slide presentation or monograph.
  • A brief survey of hand-off practices in a sample of representative emergency departments across the country.
  • A standardized template for hand-offs that allows for efficient communication and minimizes the potential pit falls of communication failures.

Explanation of project objectives (What will this project accomplish? How will it benefit the section, help educate the public, and/or further the advancement of emergency medicine?):

Quality and Safety:

  1. Provide a standardized template/process to improve communication.
  2. Improve clinical care by increasing the efficiency of passing along necessary information and decreasing communication failure.

Malpractice Liability:

  1. Decrease avoidable suboptimal patient outcomes during these transitions of care.
  2. Identification of the high risk hand-off.

Estimate of project costs and revenues (please itemize):

  • 1 Face-to-Face meeting at the 2008 Scientific Assembly in Chicago: $500
  • 8 Conference Calls (1 hour each): $800
  • Publication distribution: $1000
  • Independent expert review (3 reviewers @$100 per review): $300

Other funding sources requested (please provide information on any other grant programs or funding sources that will be used to complete this project):

Estimate of funds to be requested from the ACEP Section Grant Program:

Estimate of section support to project (in terms of dollars and member time):
A volunteer task force of 10-20 members participating in 8 one hour conference calls and additional time researching and writing as the project dictates.

Estimate of ACEP staff support to project (include time for setting up and staffing conference calls, preparing and mailing surveys, etc.):

  • 1 Face-to-Face meeting at the 2008 Scientific Assembly in Chicago: 1 ½ hours
  • 8 Conference Calls (1 hour each): 12 hours
  • Publishing: 20 hours





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Editor's Note



I'd like to take a moment to welcome new members to the QIPS section. There are many opportunities to get involved, to network, to learn, and to grow professionally. Hopefully, what we learn together will improve health care for our patients while simultaneously having a positive impact on our working environment. I encourage you to submit an article to the newsletter, to contact us, and to use the list serve to network.

Elaine Thallner, MD, MS




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Historical Figure in Quality: Avedis Donabedian

Elaine Thallner, MD, MS, FACEP

Elaine Thallner, MD, MS, FACEPAvedis Donabedian (1919-2000) wrote eleven books and over 100 articles, has become known as the father of quality assurance in healthcare, and earned world-wide recognition and admiration. He was born in Lebanon after his family fled the Armenian holocaust. He received a BA and MD from American University in Lebanon in 1944, practiced medicine for ten years, and then moved to Boston. In 1955 he graduated from the Harvard School of Public Health with a MPH. Several years later he was recruited to University of Michigan, where he remained for 28 years.

Dr. Donabedian is best known for establishing a conceptual framework of healthcare quality measures in his 1966 article "Evaluating the Quality of Healthcare."1 He divided the measures into structure, process, and outcomes. Studies of process and outcomes are well-represented in quality improvement literature. Studies of structure are more elusive. Donabedian identified ‘structure' as physical structure, provider qualifications, and facilities; recently Glickman et al2 suggest a broader understanding of the term ‘structure' to include organizational characteristics such as executive management/leadership, organizational culture, organizational design, incentive structures, and information technology.

In Donabedian's three volume book set entitled "Explorations in quality assessment and monitoring"3 (1980-1985) he articulated seven pillars of quality: efficacy, efficiency, optimality, acceptability, legitimacy, equity, and cost. This has provided a framework for research addressing access to care, cultural biases, measuring and evaluating healthcare quality, and patient satisfaction.
During a 1993 interview4, Donabedian called for medical education in quality and eloquently expressed his inspirational thoughts on professional responsibility for quality: "Doing one's best and being self critical, self adjusting, constantly seeking improvement is a fundamental trait of professionalisation; without it one wonders whether any person could be called a true professional. So I believe that the foundations for quality are largely moral in nature, that they have to do with the fundamental nature of what a profession is, with acceptance of responsibility for the welfare of others and the determination to serve, rather than simply to succeed financially or in any other way. That's why I believe that concern for quality is central and has been central in the health care professions."


  1. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 1966; 44: 166-206.
  2. Glickman S et al. Promoting quality: the health-care organization from a management perspective. International Journal for Quality in Health Care. 2007;19:6
  3. Donabedian A. Explorations in quality assessment and monitoring. Vol. I. The definition of quality and approaches to its assessment, 1980; Vol. II. The criteria and standards of quality, 1982; Vol. III. The methods and findings of quality assessment and monitoring: an illustrated analysis. Ann Arbor: Health Administration Press, 1985.
  4. Baker R. Avedis Donabedian: an interview. Quality in Health Care. 1993;2:40-46.



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Six Sigma Primer

Dickson Cheung, MD, MBA, MPH

This article is a continuation of a primer on quality tools that have been used in business Past and Present and now making its way into medicine. Isn't it disturbing that medicine always seems 20 years behind the times? We're discovering paisley while everyone else is now wearing stripes. These tools do tend to have a fashion cycle just like clothes. But since these methods still do and probably always will have validity in limited contexts, it is useful for us in quality to learn about some of these tools especially Six Sigma and Lean methodology.

First an editorial word about Six Sigma: Six Sigma has come under recent attack as evidenced by articles in Harvard Business Review, Newsweek, Business Week, etc. mainly for its inclination to flatten innovation. While this may be true, it is somewhat an unfair criticism because Six Sigma was never meant to address innovation nor creativity. In the right/left brain world of business, Six Sigma and other analytic managerial tools utilize the left brain and creativity/innovation can be fostered by using other tools that stimulate the right brain. Six Sigma was never meant to produce the next "big thing" but rather to control existing processes. Trouble begins when management relies on only one tool they believe can meet all their needs. When you have a great hammer, everything starts looking like a nail. Anyway, onto the Six Sigma primer…

High functioning businesses seek to drive out variation. Manufacturers strive for products to come off the assembly line without imperfections. Customers at high end stores expect a consistent level of service. Unfortunately, variation abounds in clinical medicine. Not only does the process vary between hospitals in different cities but also among providers in the same department. One cannot even expect the same service by the same provider on the same day. Variation abounds in quality, utilization, efficiency and service.

While the enemy in Lean methodology is waste, the focus in Six Sigma is elimination of variation. Six Sigma methodology was developed in the 1980s by Motorola and later famously championed by General Electric. It is a quality improvement tool that relies heavily on statistics in quantifying variation using standard deviation, hence (S). The success of a process is measured in terms of how many standard deviations i.e. sigmas one can go from the mean outcome variable also known as the project Y before a defect can be found. A defect is defined as a product that does not meet specifications. Six Sigma is symbolic of a perfect process. If a process is operating at "six sigma", one can find only 3.4 defects in one million opportunities. For example, if the goal is to have the lab turnaround time of a troponin level within 60 minutes, the process is operating at six sigma if one can go out to six standard deviations from the mean lab turnaround time and still be within 60 minutes. In reality, processes in most clinical situations operate at the 2-3 sigma level e.g. think about beta blocker therapy in acute coronary syndrome.

The Six Sigma process is generally well accepted by academicians because it is akin to the scientific methodology. It begins with identifying a key outcome measure to be impacted. This is usually determined by upper level management. In emergency medicine, examples include length of stay, the number or rate of patients leaving without being seen, door to balloon times, patients with an acute myocardial infarction who did not receive an aspirin or admitted patients with pneumonia who did not receive timely antibiotics. This outcome measure serves as the dependent variable and may be continuous or discrete. Next, a group of front line staff determines all the possible inputs that may have an effect on the outcome measure. For example, if the outcome measure is time from door to balloon in primary coronary angioplasty then input variables such as time of day, individual providers, age of patient may all have an influence on the time. A series of "funneling" techniques such as using a cause and effect matrix and failure modes and effects analysis help identify which input variables are of greatest importance and limit the number of variables to measure to a manageable few. The data is then analyzed by multiple logistic regression if the outcome variable is dichotomous or by multiple linear regression if the outcome variable is continuous. The variables that are statistically significant are those that command the process. The frontline staff then reconvenes and develops plans to control those inputs.

And this is where Six Sigma's weakness is exposed. It remains relatively silent on how to fix and control those drivers once identified. Another common problem with implementing Six Sigma is that it requires substantial expertise and heavy resources on a number of levels. Organizations that have used Six Sigma successful have invested a great deal of human resources to pull it off. It is hard to do half-heartedly akin to conducting a randomized control trial in your spare time. It requires project coordinators that are well versed in the technique (training courses run in the tens of thousands of dollars), leadership buy-in and a front-line crew that is able to dedicate several months to the project. In my experience, an additional stumbling block in completing a successful project is collecting the necessary data to analyze. Medical systems in general and perhaps most emergency departments in particular are not presently equipped to collect useful data autonomously. Most data is recorded manually and extracted from chart review. Prospective collection of data is slow and expensive often requiring hiring dedicated data collectors to observe a process.

In summary, Lean and Six Sigma are two hot "new" tools that may be making its way into your emergency department. Lean methodology is suited for projects where the primary aim is to reduce lead time i.e. the time it takes to complete a process. It is generally quicker and easier to complete than Six Sigma because its tools are better defined and do not involve statistics to the degree that Six Sigma does. But a strong sense of what the key inputs are i.e. the potential problems is required. Six Sigma is useful for projects where reducing defects and/or variation is the goal. It is more scientifically rigorous and free form but requires considerable dedication on behalf of the organization to make the project successful.




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How close are we to "Diagnosis Decision Support" in the ED?Jack Kelly, DO, FACEP

Jack Kelly, DO, FACEP

Diagnosis error in Emergency Medicine is not uncommon, and so far there has been a void of technology to help us with "diagnosis support". We have read the book on "How Doctors Think"...and let's face it, our differential diagnosis continues to be pretty short for most cases. Just how short is the differential diagnosis for really complex cases?... probably worse.

I went to a meeting where a company called "Isabel" presented their solution. Isabel is a web-based, "pattern recognition software" ...almost like the Google search engine that we use every day. Type in your positive clinical findings, and up comes a robust codified differential diagnosis list based on those positive clinical findings. Add into the search engine the patient's age, gender, and problem list, and your Isabel Search just got even more specific. It provides us those "failure-to-diagnose" alternatives...that most of us just never think of. It reduces "failure to diagnose" and "delay to diagnose" cases. It helps us not to create a premature closure. Isabel also has a Bioterror link, a causative drug link, and a "lessons learned" related content.

This diagnosis-reminder system helps us mobilize knowledge, and works at the point of care...the patient. It is linked to Up-to-Date, and other sources.

What does it not do? Well, first of all, the Doc has to use Isabel. Once the Doc is sure of the diagnosis (anchoring bias!), it is unlikely the Doc would enter the positive findings into Isabel. It would be amazing if this was automatically linked directly to every EMR in Emergency Medicine... but we are not there yet. Also, Isabel does not link digital Radiology Readings or Labs values to help in this IS based "cognitive decision".

In summary, I will enthusiastically support Isabel being brought into my Medical Center (and I have no conflict of interest here). If it helps us nail one case, or save one life, or stop one ER Doc from litigation... it has paid itself with dividends. MDConsult or Up to Date are excellent, and we all refer to these web based technologies, but they are only helpful if you nailed the diagnosis! Isabel puts the Differential List in front of you, and I can't wait until it is spliced into every EDIS EMR that is being offered!

Check it out at Let me know what you think!




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Emergency Medicine Quality Course at ICEM

David P. John MD, FACEPDavid P. John MD, FACEP
Course Director, Emergency Medicine Quality Course

We hope you are planning to attend the 12th International Conference on Emergency Medicine. ACEP is very pleased to be hosting this extraordinary conference in San Francisco, April 3-6, 2008 (pre-conference events on April 2).

The QIPS Section is also pleased to be able to offer you a free 4-hour course, the Emergency Medicine Quality Course, on Wednesday, April 2nd from 1:00-5:00 pm.

This is a stand alone course which starts a day before the official conference. The course was designed by experts in emergency medicine quality. It was originally written as a grant through the American College of Emergency Physicians and the ACEP Quality Improvement and Patient Safety (QIPS) Section (over 200 members). The course was designed as a collaborative, "state of the art" look at Emergency Medicine Quality. The intended audience includes both novices and seasoned veterans in quality, as well as emergency department (ED) directors and nursing staff.

The course design is as follows:

Introduction: (15 minutes). A brief history of EM quality including references to successful industry initiatives and highly reliable organizations.

The Case Review: (45 minutes). Quality cases come to us whether we are looking for them or not. How you deal with them, present them to your group, design education, and collect data determine whether your quality program is successful or not.

Data Collection: (45 minutes). Data drives change. What data do you have and what do you need? Here you learned what to collect and how to collect it and how to use your data to improve outcomes and processes?

System Fixes: (45 minutes). Now that you have reviewed the cases and collected and studied the data, what next? We use examples of proven successful strategies for systems improvements along with practical methodologies.

Expert Panel: (45 minutes). Luminaries from the world of quality tackle the hard questions regarding outside agencies and how to guide organizational success. At the end, the experts will address questions from the audience.

This course was given in San Diego last year at ACEP's Spring Congress to overwhelmingly positive reviews. Participants are invited to an informal gathering after the course to meet and socialize with the faculty.

Please plan to join us on Wednesday, April 2, 2008 in San Francisco, California, USA. All are welcome, but please send a response to the ACEP Meeting Registrar at if you are planning to attend.




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Patient Safety Act of 2005 Finally Poised for Implementation

Barbara K. Tomar, Federal Affairs Director

Proposed regulations implementing certain parts of the Patient Safety and Quality Improvement Act of 2005 have finally been released by DHHS' Agency for Healthcare Research and Quality (AHRQ). The proposed regulations establish a framework for doctors, hospitals, and other health care providers to voluntarily report information to PSOs. Not to be confused with Provider Sponsored Organizations of the 1990s, these Patient Safety Organizations will be new and separate entities from any currently existing entities that address health care quality.

The creation of PSOs has been called for by the Institute of Medicine and are envisioned to improve the quality and safety by allowing for the voluntary reporting of patient safety events without fear of new tort liability. In addition, they would encourage clinicians and health care organizations to voluntarily share data on patient safety events more freely and consistently. Under the proposal, PSOs can collect, aggregate and analyze data and provide feedback to help clinicians and health care organizations improve health care quality.

AHRQ will publish non-identifiable data on national and regional statistics, including trends and patterns of patient safety events. This information will be published in AHRQ's annual National Healthcare Quality Report.

After a more thorough read of the proposed regulation, ACEP will consider submitting formal comments before the April 14th deadline.

For additional background, see also Dr. Meyer's January 2006 article on PSO's: Additional information on PSOs may be found at:




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Report of Patient Safety Conference in Emergency Medicine

Christopher B. Beach, MD, FACEP

Christopher B. Beach MD FACEPOn September 19, 2007, Northwestern University Feinberg School of Medicine's Department of Emergency Medicine, in partnership with Northwestern Center for Patient Safety, Northwestern Memorial Hospital, and Northwestern University Feinberg School of Medicine hosted the first Chicago wide Patient Safety in Emergency Medicine Conference. Resident and Attending physicians from across the Chicago area came together to discuss the challenges and successes in the patient safety movement as it pertains to emergency healthcare. Most teaching programs and numerous safety experts from across the region attended providing ample evidence of the important nature of this agenda.

Highly regarded national experts in this field presented both basic and advanced topics in patient safety. Dr. James Adams, Chairman of the Department of Emergency Medicine at Northwestern University began the discussion by addressing the challenges of patient safety and the importance of leadership in advancing safe practice. Dr. Karen Cosby, Assistant Professor of Emergency Medicine at Rush Medical College introduced the audience to important educational concepts. Dr. Christopher Carpenter, Assistant Professor at Washington University's Department of Emergency Medicine followed with a detailed discussion of cognitive decision-making. Dr. Robert Wears, Professor of Emergency Medicine at the University of Florida, Shands Hospital completed the formal didactics with a theoretical treatise on the Illusion of Explanation. All four speakers engaged the audience in thought provoking and applicable safety concepts.

The morning's agenda was completed with a panel discussion that included all four speakers and notable safety experts from Northwestern Memorial Hospital, Dr. Charles Watts, Professor, Chief Medical Officer and Associate Dean for Hospital Affairs, and Dr. Gary Noskin, Associate Professor, Associate Chief Medical Officer, Director of the Northwestern Center for Patient Safety. Dr. Christopher Beach, Vice Chairman of the Department of Emergency Medicine at Northwestern University, moderated the panel. The discussion covered both specific clinical care safety practices and broad national safety movements. This conference uniquely satisfied all levels of learning.

Physicians are key stakeholders in this process. Ensuring the safety of our patients begins with engaging clinicians in this duty and sharing effective concepts and skills. Executive Director, Sarah Donlan, MD, and Planning Committee Chair Peter Pang, MD challenged attendees to champion ideas and initiate projects at their own institutions that put patients first. This first conference, supported by Northwestern Center for Patient Safety, the Augusta Webster Grants for Innovation in Medical Education and the Chester B. Tripp Endowment, Office of the Dean, Northwestern University Feinberg School of Medicine was an overwhelming success. Although tremendous progress has occurred since the Institute of Medicine report in 1999, there is much work left. For EM residents, attendings and researchers throughout the Chicago area this conference may serve as a start to improving safety practice, education, and research ideas.

2008 PQRI Measures Specified for Emergency Medicine 


#28. Aspirin at Arrival for Acute Myocardial Infarction (AMI)
#31. Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage
#34. Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered
#54. Electrocardiogram Performed for Non-Traumatic Chest Pain
#55. Electrocardiogram Performed for Syncope
#56. Vital Signs for Community-Acquired Bacterial Pneumonia
#57. Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia
#58. Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
#59. Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
#76. Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol




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QIPS Members Sought for Aging Emergency Physician Task Force

As a result of an ACEP Board of Directors directive, the Wellness Section has been asked to assemble a task force to explore issues related to the aging emergency physician.

An hour-long conference call has been scheduled for March 25th at 2 p.m. CT to clarify goals and objectives, assign section-specific tasks and establish a time-line for the initial report to the BOD in June of this year.

Please contact Marilyn Bromley, Director Emergency Medicine Practice Department ( ), to indicate your interest in this Task Force.



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ICEM 2008

The American College of Emergency Physicians (ACEP) is proud to present the 12th International Conference on Emergency Medicine (ICEM 2008), April 3-6, in San Francisco, CA. This conference welcomes emergency physicians and other emergency medicine staff from around the world to the United States to share their knowledge, skills, and distinctive practice environments.

ICEM is held every other year and is hosted by member organizations of the International Federation for Emergency Medicine (IFEM). Due to the rapid growth in the number of IFEM member societies in recent years, this will be the last opportunity ACEP will have to host this extraordinary conference for more than a decade. Therefore, ICEM 2008 in San Francisco will be a rare opportunity for all who participate to be part of a world-class, global educational and social experience hosted by ACEP in the U.S.!

2008 ICEM




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CMS Clarifies Reporting of PN-5c Measure

Reproduced from (October 22, 2007)

The Centers for Medicare & Medicaid Services (CMS) has clarified upcoming public reporting procedures for two pneumonia measures. CMS has decided to suppress "Initial Antibiotic Received within Four Hours of Hospital Arrival" (PN-5b) and to report "Initial Antibiotic Received within Six Hours of Hospital Arrival" (PN-5c) on Hospital Compare beginning in March 2008.

After a year of deliberations, the National Quality Forum (NQF) Pulmonary Consensus Standards Maintenance Committee on April 20, 2007, endorsed the pneumonia measure "Initial Antibiotic Received within Six Hours of Hospital Arrival" (PN-5c). However, the Final Fiscal Year (FY) 2008 IPPS Rule specifies the pneumonia measure "Initial Antibiotic Received within Four Hours of Hospital Arrival" (PN-5b) as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program measure for both FY 2008 and FY 2009.

In terms of public reporting, CMS has decided to suppress "Initial Antibiotic Received within Four Hours of Hospital Arrival" (PN-5b) and report Initial "Antibiotic Received within Six Hours of Hospital Arrival" (PN-5c) on Hospital Compare beginning in March 2008 when only 2Q07 data will be reported.

Hospitals will continue to submit data for "Initial Antibiotic Received within Four Hours of Hospital Arrival" (PN-5b) until the IPPS rule can be altered through the rulemaking process. Since the data elements for both pneumonia antibiotic timing measures are exactly the same, calculation of the six-hour measure will be based upon data submitted for the four-hour measure.

CMS has decided that "Initial Antibiotic Received within Six Hours of Hospital Arrival" (PN-5c) data to be previewed and subsequently reported on Hospital Compare can be suppressed by hospitals upon request until such time that the IPPS rule can be changed through the rulemaking process to correctly name the NQF-endorsed variant of the antibiotic timing measure for pneumonia inpatients.

References: www.QualityNet.orgThe Joint Commission; "Joint Commission to Extend Time to Antibiotic Administration" QIPS Newsletter, June, 2007—Vol. 8, No. 3; "JCAHO Tweaks Emergency Departments' Pneumonia Treatment Standards," JAMA, April 25, 2007—Vol. 297, No. 16, pp 1758-1759.




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Washington Update: NQF Emergency Care Project, 2007 PQRI Results

Angela Franklin, Esq., Staff Liaison

NQF Announces Emergency Care Panel. The National Quality Forum (NQF) has announced the new Emergency Care Steering Committee for Phase 2 of the Emergency Care Project. ACEP is well represented on the 18-person Committee by several members: Drs. John Moorhead (co-chair), Brent Asplin, Stephen Cantrill, James Adams, Evaline Alessandrini, Robert Goodman, David L Levine, and Michael Phelan. Representatives of the Joint Commission, the American Association of Neurological Surgeons, the hospitals, nursing, consumers and other stakeholders are also included on the NQF Committee. CMS is expected to be represented on the Committee. The Committee will begin its work considering measures solicited by NQF's January Call for comprehensive, hospital-based ED measures. Measures endorsed by the NQF may be publicly reported or used in CMS quality and value-based purchasing initiatives. More information is available at

CMS Announces 2007 PQRI Results: EM Leads in Participation. CMS recently announced the results of the 2007 Physician Quality Reporting Initiative (PQRI), and Kerry Weems, Acting Administrator for CMS, has reported that Emergency Medicine was among three specialties with above average participation rates. CMS declined to provide specific data by specialty, but drew their conclusions based on the measures reported. Fortunately, Emergency Medicine had nine (9) measures to report in 2007.



2007 PQRI EM Measures

Aspirin at Arrival for Acute Myocardial Infarction (AMI)

#29 Beta-Blocker at Time of Arrival for Acute Myocardial Infarction (AMI)
#47 Advance Care Plan
#54  ECG Performed for Non-Traumatic Chest Pain
#55 ECG Performed for Syncope
#56 Vital Signs for Community-Acquired Bacterial Pneumonia
#57 Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia
#58 Assessment of Mental Status for Community-Acquired Bacterial Pneumonia, and
#59 Empiric Antibiotic for Community-Acquired Bacterial Pneumonia

The two other specialties with high participation rates were Anesthesiology and Ophthalmology. Overall however, only approximately 16% of eligible clinicians attempted to participate in the 2007 PQRI. Participants will receive a bonus of up to 1.5% of total allowed charges under the 2007 physician fee schedule, and can expect to receive their feedback reports and incentives later in the summer.

PQRI 2008. CMS reports an increase in participation among providers over 2007. The 1.5% incentive will remain the same, but it will be calculated based on the 2008 physician fee schedule. Oversight of the 2008 PQRI program has been given to the Office of Clinical Standards and Quality (OCSQ), and clinicians may report on 119 measures chosen from measures endorsed by several quality groups, including the NQF and the American Medical Association's Physician Consortium for Performance Improvement (AMA PCPI). In 2008, Emergency Medicine has ten (10) measures to report.


2008 PQRI EM Measures

Aspirin at Arrival for Acute Myocardial Infarction (AMI)

#31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage
#34 Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered
#54 Electrocardiogram Performed for Non-Traumatic Chest Pain
#55 Electrocardiogram Performed for Syncope
#56 Vital Signs for Community-Acquired Bacterial Pneumonia
#57 Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia
#58 Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
#59 Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
#76 Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol

Strong Support for PQRI. Weems was responding to a letter from Senate Finance Committee Chairman Max Baucus (D-Mont.) and Ranking Member Chuck Grassley (R-IA), in which they called for improvements to Medicare payments for physician services. The Senators expressed strong support for the Medicare physician bonus program and urged CMS to work with Congress to expand it beyond the current focus on reporting quality data. The two lawmakers suggested that CMS' collaboration with the National Quality Forum, the American Medical Association's Physician Consortium for Performance Improvement, and other groups and officials would "ensure the most meaningful measures are available" for the initiative.

In his response to the Senators, Weems also addressed concerns about methodology and participation in the PQRI and the need to better link physician payments to quality of care. Weems indicated that CMS will move quickly to implement the provisions of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) designed to improve the methodologies employed by the program and to encourage broader participation by physicians and other eligible professionals. MMSEA, signed by President Bush in December, provided a funding source, extended the PQRI to 2009, and removed the cap on calculation of incentive payments for reporting in 2008 and 2009.

PQRI 2009. CMS is inviting specialties to submit measures by March 24th to be considered for inclusion in the 2009 program. More information on the PQRI may be found at:




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Quality and Safety Articles

Helmut Meisl MD FACEP

Helmut Meisl, MD, FACEP

Here again is a list of recent articles that may interest you. These are compiled by AHRQ PSNet at ( ). 

Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures. 
West AN, Weeks WB, Bagian JP. Health Serv Res. 2008;43:249-266.

Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement. 
Mello MM, Studdert DM, Thomas EJ, Yoon CS, Brennan TA. J Empirical Leg Stud. 2007;4:835–860.

Innovation in patient safety: a new task design in reducing patient falls. 
Tzeng HM, Yin CY. J Nurs Care Qual. 2008;23:34-42.

Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department.
Etter R, Ludwig R, Lersch F, Takala J, Merz TM. Crit Care Med. 2008 Jan 18; [Epub ahead of print].

Medicare's decision to withhold payment for hospital errors: the devil is in the details. 
Wachter RM, Foster NE, Dudley RA. Jt Comm J Qual Patient Saf. 2008;34:116-123.

Using patient safety indicators to estimate the impact of potential adverse events on outcomes. 
Rivard PE, Luther SL, Christiansen CL, et al. Med Care Res Rev. 2008;65:67-87.

Addressing postdischarge adverse events: a neglected area.
Tsilimingras D, Bates DW. Jt Comm J Qual Patient Saf. 2008;34:85-97.

Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.
Lingard L, Regehr G, Orser B, et al. Arch Surg. 2008;143:12-17.

Lost opportunities: how physicians communicate about medical errors. 
Garbutt J, Waterman AD, Kapp JM, et al. Health Aff (Millwood). 2008;27:246-255.

Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met? 
Ford EW, McAlearney AS, Phillips MT, Menachemi N, Rudolph B. Int J Med Inform. 2007 Nov 27.

Performance of a web-based clinical diagnosis support system for internists. 
Graber ML, Mathew A. J Gen Intern Med. 2008;23(suppl 1):37-40.

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. 
Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23(suppl 1):41-45.

Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals.
Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Arch Intern Med. 2008;168:40-46.

Medication errors associated with code situations in U.S. hospitals: direct and collateral damage. 
Lipshutz AKM, Morlock LL, Shore AD, et al. Jt Comm J Qual Patient Saf. 2008;34:46-56.

Costs of intravenous adverse drug events in academic and nonacademic intensive care units. 
Nuckols TK, Paddock SM, Bower AG, et al. Med Care. 2008;46:17-24.

The effect of drug concentration expression on epinephrine dosing errors: a randomized trial.
Wheeler DW, Carter JJ, Murray LJ, et al. Ann Intern Med. 2008;148:11-14.

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.
Taylor JA, Loan LA, Kamara J, Blackburn S, Whitney D. Pediatrics. 2008;121:123-128.

Systematic evaluation of errors occurring during the preparation of intravenous medication. 
Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A. CMAJ. 2008;178:42-48.

Variation in medication information for elderly patients during initial interventions by emergency department physicians.
Cohen V, Jellinek SP, Likourezos A, Nemeth I, Paul T, Murphy D. Am J Health Syst Pharm. 2008;65:60-64.

Work-arounds in health care settings: literature review and research agenda.
Halbesleben JRB, Wakefield DS, Wakefield BJ. Health Care Manage Rev. 2008;33:2-12.

Managing the prevention of retained surgical instruments: what is the value of counting?
Egorova NN, Moskowitz A, Gelijns A, et al. Ann Surg. 2008;247:13-18.

Development of medical checklists for improved quality of patient care. 
Hales B, Terblanche M, Fowler R, Sibbald W. Int J Qual Health Care. 2007 Dec 11.

How useful are voluntary medication error reports? The case of warfarin-related medication errors.
Zhan C, Smith SR, Keyes MA, Hicks RW, Cousins DD, Clancy CM. Jt Comm J Qual Patient Saf. 2008;34:36-45.

ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:1100-1102.

Fatal errors in nitrous oxide delivery.
Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Anaesthesia. 2007;62:1202-1206.

Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections.
Wald HL, Kramer AM. JAMA. 2007;298:2782-2784.

Identification of inpatient DNR status: a safety hazard begging for standardization.
Sehgal NL, Wachter RM. J Hosp Med. 2007;2:366-371.

Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. 
Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. J Hosp Med. 2007;2:422-432.

Outcomes of care by hospitalists, general internists, and family physicians.
Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. N Engl J Med. 2007;357:2589-2600.

Ventilator-associated pneumonia—the wrong quality measure for benchmarking. 
Klompas M, Platt R. Ann Intern Med. 2007;147:803-805.

Medication use leading to emergency department visits for adverse drug events in older adults. 
Budnitz DS, Shehab N, Kegler SR, Richards CL. Ann Intern Med. 2007;147:755-765.

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.
Bechtold ML, Scott S, Nelson K, Cox KR, Dellsperger KC, Hall LW. Qual Saf Health Care. 2007;16:422-427.

Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital.
Buist M, Harrison J, Abaloz E, Van Dyke S. BMJ. 2007;335:1210-1212.

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.
McAlearney AS, Chisolm DJ, Schweikhart S, Medow MA, Kelleher K. Int J Med Inf. 2007;76:836-842.

A team training program using human factors to enhance patient safety.
Marshall DA, Manus DA. AORN J. 2007;86:994-1011.

Professionalism in medicine: results of a national survey of physicians.
Campbell EG, Regan S, Gruen RL, et al. Ann Intern Med. 2007;147:795-802.

Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.
Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM Jr. J Am Coll Surg. 2007;205:778-784.

Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania.
Marella WM, Finley E, Thomas AD, Clarke JR. J Patient Saf. 2007;3:184-189.

Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. 
Coussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milisen K. J Am Geriatr Soc. 2007 Nov 21.

Surgical adverse outcomes and patients' evaluation of quality of care: inherent risk or reduced quality of care?
Marang-van de Mheen PJ, van Duijn-Bakker N, Kievit J. Qual Saf Health Care. 2007;16:428-433.

A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. 
Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.

Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit.
Grant MJC, Larsen GY. J Patient Saf. 2007;3:195-199.

Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist.
Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Am J Health Syst Pharm. 2007;64:2483-2487.

Medication reconciliation in ambulatory oncology. 
Weingart SN, Cleary A, Seger A, et al. Jt Comm J Qual Patient Saf. 2007;33:750-757.

Medication discrepancies in resident sign-outs and their potential to harm.
Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. J Gen Intern Med. 2007;22:1751-1755.

Duty hours restriction and their effect on resident education and academic departments: the American perspective. 
Swide CE, Kirsch JR. Curr Opin Anaesthesiol. 2007;20:580-584.

Medication administration discrepancies persist despite electronic ordering. 
FitzHenry F, Peterson JF, Arrieta M, Waitman LR, Schildcrout JS, Miller RA. J Am Med Inf Assoc. 2007;14:756-764.

Effective implementation of work-hour limits and systemic improvements.
Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33(suppl 1):19-29.

A process for analysis of sentinel events due to health care–associated infection.
Carrico R, Ramírez J. Am J Infect Control. 2007;35:501-507.

Reasons provided by prescribers when overriding drug–drug interaction alerts.
Grizzle AJ, Mahmood MH, Ko Y, et al. Am J Manag Care. 2007;13:573-580.





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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.

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