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Quality Improvement & Patient Safety Section Newsletter - September 2007, Vol 8, #4

Quality Improvement & Patient Safety Section 

circle_arrow  Chair’s Report 
circle_arrow  Nominations for Section Officers 
circle_arrow  Analysis of a Case (Part 2) 
circle_arrow  Measures and Physicians or Physicians Versus Measures 
circle_arrow  Stroke Center Certification 
circle_arrow  Pay for Performance Wrap-Up 
circle_arrow  QIPS Membership Roster 
circle_arrow  Quality and Safety Articles 


Newsletter Index 


Quality Improvement & Patient Safety Section 

 

Chair’s Report

Jack Kelly, DO, FACEPJack Kelly, DO, FACEP 

QIPS members continue to work hard through the summer months on Section projects!

QIPS ANNUAL MEETING AT ACEP SCIENTIFIC ASSEMBLY
We are working on the final plans for our QIPS Section Meeting on Monday 10/8/07 from 1:30pm to 3:30pm, in Room 401 in the Washington State Trade and Convention Center. We have some great speakers that we are planning for the meeting. We also must choose our next Officers, so please think about this and nominate and vote!

NATIONAL QUALITY CURRICULUM
We continue to work on the development of a National Emergency Medicine Quality Curriculum and the task force has been meeting by phone since July. The project is developing slowly, but shows great promise. I hope it comes together as well as our EM Quality Course that was a smash success this past spring!

CMS: CORE MEASURES
Surely each of you have been continuing your pursuit of the Core Measures. I have in my Department. We continue to score well with second decile success in Pneumonia Measures. Our challenge has been to continue to remind everyone that every delay to AB must be matched with a "Diagnostic Uncertainty Caveat" that plainly states that the case did not have all of the key hallmarks of a clear diagnosis of Pneumonia. If they can write this, it helps explain the delay. Obviously, if we miss the 4hr door-to-AB core measure because of our own operational/system inefficiencies it is on us! If you haven't educated your team about this "Diagnostic Uncertainty Caveat," you are living under a rock!

STEMI Core Measures have been solid during daytime hours when the whole Cath Lab Team is present and the lab operational. Evenings and nights can be a little more difficult for 90-minute Door to Balloon (D2B) times if there are any significant delays in any key step. We remain consistent in times of 100 minutes after hours, but getting to 90 minutes when everyone is home remains tough. I am presenting abstracts at our Pennsylvania ACC D2B Meeting this October and I have attached them to this newsletter.

One abstract reveals that even when there are delays to EKG, if the rest of the system works well we can still have D2B <90minutes. Delay to EKG is common in EM---you know it too! Many patients only say they "feel weak" or "I'm nauseated"...and many precious minutes later an EKG reveals a STEMI!!! Getting the EKG quickly is the toughest "judgment" of this Core Measure...and yet we are nationally scrutinized by this vague indicator. You cannot get an EKG on every single non-specific complaint. I did this study to put to rest this "theory" (aka: accusation) made by Cardiology that said their delays to balloon "all started with the delay to EKG" that made it impossible for them to make the <90-minute goal.

Also, look at the "Philadelphia Story" of how well the Primary PCI Hospitals in the Philly Area have conformed to the November 06 NEJM Article recommendations on the "six system changes" that statistically make PCI Hospitals meet the <90-minute D2B (please see "Abstract Compliance with NEJM"). Have YOU and your Hospital quickly moved to adopt these 6 systems fixes to guarantee <90-minute D2B?

STROKE CENTER 
Finally, the Joint Commission was at Einstein this past week for our Stroke Center Certification. It was a very solid review of our Stroke Processes by the Joint Commission, and overall a solid 2 days of review and feedback. We did very well. I have included a separate report just on this visit, that I hope you find helpful. (Please see article below)

Regards to all, and have a great time enjoying the best part of the Summer! I'll see you in Seattle!

 

 


 

 

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Nominations for Section OfficersHelmut Meisl, MD, FACEP

Helmut Meisl, MD, FACEP 

Fellow QIPS Section members:

It is this time of year again, when we are requesting nominations for officers to our section. We want you to think about becoming more involved with the section and becoming an Officer.

The Section is accepting Nominations for Chair-Elect (who will serve for a year in that capacity before assuming the Chair position) and Secretary/Newsletter Editor, with the terms starting after our meeting in October at the Scientific Assembly. If you wish to nominate a section member or yourself (we are not that formal) for one of these positions, please contact me, Dr. Helmut Meisl, Past Chair (and now responsible for elections) at qips.section@acep.org or our staff liaison, Angela Franklin at qips.section@acep.org. You may also nominate someone or volunteer from the floor at the annual section meeting in Seattle. Elections will be held at that time.

Dr. Dickson Cheung is the present Chair-Elect and will become Chair in October. Dr. Robert Broida is presently our Secretary/Newsletter Editor, with Co-Editors, Drs. Elaine A. Thallner and Geoffrey L. Ruben. Dr. Broida is also our Web Site Editor. This position is assigned and volunteers are always welcome.

I just want to state that as a past chair, being involved in the Section as an Officer is an interesting and exciting experience. One interacts with an enjoyable group of colleagues, and learns much about QI and the College. Some time involvement and commitment is required, but it is spaced out over the year, and prestigious credentials are not required.

If there are any questions, please feel free to contact me.

See you in Seattle at the Scientific Assembly.

 


 

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Analysis of a Case (Part 2)

Dickson Cheung, MD, FACEP 

In QIPS Newsletter #2 (April 2007, Vol 8, #2), I introduced a tool from a recent JCAHO article (Pronovost PJ, Holzmueller CG, Martinez E, et al. "A practical tool to learn from defects in patient care" Jt Comm J Qual Patient Saf 2006 Feb; 32(2):102-8) to aid those involved in analyzing defects in patient care and to help generate solutions. Anyone involved in traditional Morbidity and Mortality conferences will note that the tendency in healthcare is to blame the individual(s) involved and to propose "quick fixes." Unfortunately, this is shortsighted and frequently does not lead to better quality. The strength of the approach offered in this tool is its comprehensive nature, focusing on both caregiver and system problems. I will admit that the difficulty in implementing the solutions often involves changes in culture, practices, equipment and relational patterns that can be costly, time intensive and emotionally exhausting. But in order for the quality improvement to be seriously addressed, issues beneath the surface must be confronted.

For purpose of brevity and saving a few electronic bytes (I can’t even say trees anymore since our newsletter is only published on the web now), I will refer you to QIPS newsletter #2 "Analysis of a Case" which is only a few mouse clicks away for the recount of the case. At the end of this article is the same table with the contributing factors to errors presented in the QIPS 2007 Newsletter #2, but now with the specifics of this case.

The solutions to avoid a future incident include addressing both the structure and processes of this patient’s visit. Obviously, the staffing issues must be confronted. If the hospital is going to be a safe place, it must be adequately staffed at all times. No longer can hospitals shortchange the night shift or cut corners on holidays and weekdays to save a few dollars. Part of the problem in this case has been a traditional over-reliance on physicians in training. With the new pressures and regulations to limit hours of resident physicians, hospitals must come up with new and probably more costly strategies of staffing. This may include additional attending staff in the hospital or hiring experienced midlevel providers.

A clear call list needs to be established with redundant failsafe mechanisms. Rather than scramble in the middle of the night trying to find that on call specialist, it is more prudent to establish at the beginning of the day that the on call providers are correct and available. This may include preset deadlines for publishing a schedule change as well as protocols for the daily monitoring and checking of the on call physician. For example, at the beginning of each day, the operator calls each person on the list to verify that they indeed are on call and ready to provide coverage for the entire day. If an on call provider cannot be reached, an established policy of calling the clinical director of that department should be implemented. Home and alternate phone numbers should be made available to the operator or to the medical staff. EMTALA (Emergency Medical Treatment and Active Labor Act) regulations should be taught to all hospital staff. This would remind department chiefs that they have a legal responsibility to jointly staff an on call list with their hospital. They must learn that if an on call provider or department does not readily make available an on call provider, then stiff penalties and disincentives should be implemented.

Overcrowding in the emergency department also needs to be addressed by senior hospital executives. The constant overflow and holding of admitted patients in the ED make it a highly stressful and vulnerable department. Senior administration must realize that ED overcrowding is not a problem limited to the emergency department. Policies must be developed to unload the ED as quickly as possible including the holding of admitted patients in the ED and working up patients in the ED that should go to the floor or ICU. A clear policy including lines of accountability, time limits and penalties must be established to reduce the likelihood of errors occurring in the ED. (For those interested, ACEP and QIPS is now examining a referendum regarding time limits on holding patients in the ED).

Hospitals must make it easier to implement new guidelines and operationalize best practices when they become available. This is best done through standardized order sets and protocols. In this example of septic shock, there is good evidence that following certain protocols can decrease mortality by up to 30%. This is includes adequate hydration, early antibiotics, pressor agents and blood transfusions as needed. Currently, most hospitals do not have computer provider order entry (CPOE) to support to make protocols operational. Advocates of CPOE programs such as the Leap Frog Consortium sponsor this intervention precisely for patients like Mrs. Pear. The actual orders and protocols for septic shock are quite intricate and expecting an inexperienced provider to recall all the details for the order set in the middle of the night is not a recipe for success. In this case, the hospital did have a CPOE system but it was unusable in the emergency department environment. Care must be taken in choosing CPOE systems to ensure that they are user friendly and indeed fulfill their intended function.

Finally, hospital leaders must recognize that a safety culture within the hospital does exist and must not be ignored. This includes reporting unsafe conditions, teamwork and communication. The animosity that exists between different services and the self-sufficiency attitude among providers must be addressed. Their impact was clearly felt in this case. There are teamwork issues both within and between departments. Nurses need to work with physicians and training physicians need to work more effectively with attending physicians. These work dynamics need to be addressed formally in conferences and training sessions and should not be ignored. The relations between departments need to be enhanced to provide optimal patient care. It can no longer be a mentality of "us" versus "them." The patient’s best interest is served when we view the patient as "ours." Activities that may enhance interdepartmental relations include joint conferences, joint research projects and metrics that can only be achieved by a cooperative effort. Even joint social events would help break down the barriers between departments. Talking about other departments in a dismissive or derogatory manner must not be tolerated. Departmental leaders and chairmen must model this behavior. The solution to these human factors is not easy, but must not be ignored.

In the end, the solutions include structural changes and process changes. Senior leadership must recognize that it is their responsibility to adequately staff departments and provide adequate resources for clinicians to function effectively. Process changes require more ingenuity and include strategies to better train, communicate and expedite care. And the safety culture of the institution must not be ignored. Although intangible, it is the mindset and the resolve of the individuals and units that will ultimately make the hospital a safer place.

Contributing Factors (Example) 
Patient Factors: 
Patient was acutely ill or agitated (Elderly patient unfamiliar with academic environment.)
There was a language barrier (No language barrier.)
There were personal or social issues (No personal or social issues.)
Task Factors: 
Was there a protocol available to guide therapy? (Sepsis protocol.) 
Contributing Factors (Example) 
Were test results available to help make care decision? (CT scan and reading delay.)
Were tests results accurate? (Tests were accurate.)
Caregiver Factors 
Was the caregiver fatigued? (In the middle of the night, everyone is fatigued. Seventh night shift in a row for the ED and surgical housestaff.)
Did the caregiver’s outlook/perception of own professional role impact on this event? (Housestaff afraid to involve their attendings because they did not want to look "weak." Considerable peer and superior pressure not to admit patients to their service.)
Was the physical or mental health of the provider a factor? (No physical or mental health factor.)
Team Factors 
Was verbal or written communication during hand offs clear, accurate, clinically relevant and goal directed? (Poor ED communication during shift change that patient in bed #4 was sick and needed immediate CT scan and surgical consult.)
Was verbal or written communication during care clear, accurate, clinically relevant and goal directed? (Sign out was via verbal communications and the details of the case were forgotten.)
Was verbal or written communication during crisis clear, accurate, clinically relevant and goal directed? (Poor transfer of plans of surgical consult to the ED staff.)
Was there a cohesive team structure with an identified and communicative leader? (Reluctance of surgical attending to take responsible for the consult in the ED.)
Training & Education Factors 
Was provider knowledgeable, skilled & competent? (ED staff not trained to recognize and institute sepsis protocol.)
Did provider follow the established protocol? (There was no protocol.)
Did the provider seek supervision or help? (ED resident afraid to involve ED attending early to circumvent the political quandary of finding space for the patient.)
Information Technology/CPOE Factors 
Did the computer/software program generate an error? (Computer did not generate an error.)
Local Environment 
Was there adequate equipment available and was the equipment working properly? (Not enough CT scans and techs to handle a busy night in the ED.)
Was there adequate operational (administrative and managerial) support? (No contingency plan when IR specialist is unable to be found.)
Was the physical environment conducive to enhancing patient care? (Patient in bed #4 which was not readily visible from the nurse’s station.)
Was there enough staff on the unit to care for patient volume? (Not enough radiology housestaff led to delay in reading of CT scan. Not enough surgical housestaff led to delay in initial consult. Not enough ED staff and capacity to handle the volume during peak hours.)
Was there a good mix of skilled with new staff? (Only one ED attending for thirty patients at night with a mix or new midlevels and residents. No surgical attending in house at night.) 
Did workload impact the provision of good care? (Surgical and ED staff overworked so time slips by.)
Institutional Environment 
Were adequate financial resources available? (Financial resources to staff attending physicians.)
Were laboratory technicians adequately in-serviced/ educated? (IR techs need to be better educated for on-call procedures.)
Was there adequate staffing in the laboratory to run results? (Yes.)
Were pharmacists adequately in-service/educated? (Better training of ED staff and nurses to recognize and treat sepsis.)
Does hospital administration work with the units regarding what and how to support their needs? (Better policies on what to do if initial consult service or inpatient service refuses admission i.e. responsible to transfer the patient to another service.)

 


 

 

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Measures and Physicians or Physicians Versus Measures

Helmut Meisl, MD, FACEP 

Data collection and monitoring of some type has been a part of our Emergency Practice and QI processes for years, from the rudimentary tabulation of the chart reviews to more sophisticated measurements of ED physician utilization, productivity, procedures, radiology variances, and adherence to ED guidelines. We ED physicians have always evaluated our care carefully, and more than other specialty groups, probably because we work in a more tightly knit group, have a medical or QI director, and very importantly are under the constant scrutiny of the rest of the medical staff and administration. Most every patient we see goes to another provider as an in- or out-patient, where our care is scrutinized and often criticized.

Over the years came various external quality measurements, including ORYX, CHIOS, or NRMI, followed by CMS Core Measures and now the PQRI program. Questions remain as to the validity of these measures and how much they actually improve the care to patients. Some articles on this topic have been published with varying results. For example, regarding hospitals, one article (Peterson et al, JAMA 2006; 295: 1912-1920) showed that hospitals that adhered to ACC/AHA Guidelines had lower mortality rates, while another (Snyder, Anderson JAMA 2005; 2900-2907) demonstrated that hospital participating in quality improvement organizations are not more likely to show improvement on quality indicators, as hospitals that do not participate.

Another article (Peterson et al, Ann Intern Med, 2006; 145: 265-272) reviewed the literature on pay for performance or financial incentives and 17 studies were found, most were for preventive measures. The conclusion was that there was too limited information to assess the quality and cost-effectiveness results. The authors provide a excellent proposed research agenda. As for physicians, there is the recent article about Pay for Performance programs in the United Kingdom (Doran et al, N Engl J Med 2006; 355: 375-384) which showed that reasonably generous levels of financial incentives achieved high levels of achievement (97%) for clinical indicators, from asthma to stroke. However some high scores were achieved with larger numbers of exceptions, especially in the more difficult disease categories, such as mental health, with concern of some manipulation of the system.

The above sample of articles just emphasize the scientific confusion and infancy in this area, and in turn, the difficulty in convincing physicians about the validity and necessity for any such measurement of any practitioner’s work and quality. My goal in this newsletter is not to provide a comprehensive literature review, but to provide an assessment as to how we arrived at all these quality measures with financial incentives or disincentives. I will go back a few years and give a somewhat personal opinion of the course of events. I am sure that others will have varied to different opinions. So let me start.

Physicians as a whole are generally quite independent individuals, especially those who were in community practice, being able to determine their office hours and what type of patients they would see, being selective of insurance status. Even 20 to 30 years ago, we ED physicians were less constrained by the ED environment, availability of on-call physicians, and the uninsured and under-insured people. At that time, it was still relatively easy to transfer these patients to the local county facility, while the on-call physicians generally took the Indemnity Insurance patients. However, trouble was brewing and some transfers did not go well for the patients, and also the fact that health care costs were rising almost exponentially.

Governments, newspapers, and the public started talking about the need for some solutions, including a single payer system. The AMA responded by a publicity campaign stating that there may be problems in the US system, but "is still the finest in the world", together with advertisements alerting the public to the dangers of the Canadian system. A letter from the president of the AMA to physicians stated " If you disagree with certain leaders in our government who think bureaucrats can run the nation’s health care system better than we can, here’s your opportunity to do something about it" (AMA material, 1989). The AMA made some modest proposals, but no true effort or co-ordination with the government or attempt at cost containment was undertaken. Insurance selectivity by hospitals and on-call physicians remained and costs continue to rise.

The government then stepped in with more rigid Medicare payment schedules as well as the famous EMTALA legislation and the private insurance sector produced a maze of confusing to onerous insurance plans, from PPO’s to HMO’s. We all know the results, and physicians have been grappling with these external mandates ever since, accompanied by a great deal of bitterness and complaint. I do not want to be overly critical of organized medicine, but there was a definite feeling at that time that all was generally well, and that no major change from the medical profession was necessary. We ED physicians already knew otherwise and the true reality.

So what has this to do with quality and core measures? Actually in my opinion, it is a similar process. Physicians and specialty organizations assumed that the care provided by the practitioners was good and perhaps the finest, and measurement, assessment, improvement, and perhaps enforcement was not necessary. Again the government, payers, as well as patients had other opinions and wanted more information about quality and outcomes. The IOM Report about Medical Errors and comparison to jumbo airliner crashes was a major stimulant to these external agencies. So, for example, we have the various Core Measures, devised by various government agencies and the National Patient Safety Goals, devised by the Joint Commission. Though each had some physician input, these measures are still perceived as external to medicine and bureaucratic mandates, often resented by physicians. There is a great deal of legitimate debate about the validity of these measures, but I believe they would have been much better designed, if they had been instigated and produced by the physician organizations. Also acceptance by physicians would be better if not coming from perceived government sources with an alphabet soup of designations, IOM, AHRQ, NPSF, IHI, NQF, Leapfrog, PRVP, and PQRI.

My presentations to the Medical Staff about Medication Safety and Unapproved Abbreviations with numerous real examples on totally illegible handwriting and a ten-fold insulin doses would have been much better accepted if they would have come from the AMA or California Medical Association, rather than being from JCAHO NPSG Number X. Hand-washing among the Medical Staff remains the lowest among all hospital groups, hindered again by physician behavior and being another JCAHO NPSG Number Y.

We need the presence of a Dr. Semmelweiss, a true physician leader. Where were all the specialty organizations years ago monitoring the care of their members? Granted this is not easy, and ACEP is one of the leaders with regard to ongoing certification. However, for example, some guidelines for pneumonia treatment and perhaps initial voluntary reporting instigated by the American Thoracic Society in the past may have made these particular Core Measures unnecessary.

Physician specialty organizations were generally involved in certification (education and monitoring were not mandatory) and state medical boards with regulatory and punitive issues. However now the American College of Cardiology is becoming more involved, as with their PCI Guidelines, and has already improved our PCI times, which tended to be longer with a diverse group of community physicians. The cardiologists who "always answer my pager right away", and "always come in right away" are being scrutinized, and actually changing their behavior for the benefit of patients.

Peer pressure does help. I know in our own ED, as we look at the various numbers of patient satisfaction or complaints, I focus right away on my standing. Granted, I make some excuses about having more difficult patients than other ED doctors, but I do become motivated to improve.

Now to summarize this non-scientific treatise, independent thinking physicians with their specialty organizations in the past were resistant to change but appear to be slowly realizing the need for co-operation with regulatory agencies in assessing quality of patient care and monitoring of their physician members. I welcome this change, and look forward when physicians are the leaders, rather than the regulatory agencies.


 

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Stroke Center Certification

Jack Kelly, DO, FACEP 

This past week, the Joint Commission came to Einstein. We applied for Stroke Center Certification about 18 months ago, and have been working very hard every week to develop a better approach---a sophisticated and state-of-the-art team approach for stroke care.

The Joint Commission (JC) conducts these "disease-specific" visits in a much different way than the usual JC Survey. They approach the visit with prenotification (weeks before) of their arrival dates for Survey.

They take the whole review process in a more friendly and less "tense" approach...more coaching, and less threatening. The reviewer was a Stroke Center RN for many years, and was a definite expert in her field. We were told immediately of "issues" and many comments were framed in "how have you dealt with the issue of...".

The whole Stroke Council QA Group met at the large Administration Meeting Table, and welcomed the JC Reviewer at 8am on the first day. We introduced ourselves, and each detailed our role in the Stroke Care Process, and how we helped build the Stroke Program. The COO spent a few minutes describing the Medical Center and Hospital Network structure. The Neurology Chairman then spent 10 minutes with a brief PowerPoint Presentation defining Vision, Mission, Stroke Council and Mandatory Quality Indicator Review of our data (i.e: DVT prophylaxis, discharge on antithrombotics, dysphagia screening test before given PO, stat Lab turn-around-time, etc.), a description of our patient demographics, an important discussion of "who are the Champions" of this group, etc.

The JC reviewer poked around with leading questions often...

  • "Do you get a lot of Stroke Transfers?"
  • "With such a busy ED, I bet you have a lot of patients in the hallways?"
  • "What is your Hemorrhage rate?"

Then we began the "take me thru a typical stroke case"... "When a patient comes thru the ED.....How are they treated?"

My Chair and I double-teamed each question and left no issue without definitive systemic process answers.

  • "Do you weigh your patients? You know weight estimation is largely a poor guess...you may be surprised at how much we mis-estimate weights!" she said.
  • "How do you interpret the CT? Do you have PACS? Do you use a Nighthawk CT interpretation process?"
  • "How do you prevent aspiration? Who does the dysphagia screening?"
  • "After the ED, tell me where they go? All to the Neuro ICU?" , "Who is on the team upstairs?---PT, OT, Speech?"
  • "What are the Auto-triggers for Nutrition and Clergy?"
  • "How do you do Rounds upstairs?"
  • "How do you educate your patients?"
  • "How do you each Hand-Off your patients?"
  • "What Stroke-related research are you doing?"
  • "What has been your biggest hurdle as you pulled this together?"
  • "How do you manage your TIAs?"----we overcall them, and manage them the same way as Strokes, we said...and TIA admits are included on the same Stroke Orders Sheet---so they really do get the same exact care process!
  • "Who staffs your Rapid Response Team?"
  • "Diagnosing Stroke is hard---tell me how you do it"---we use the NIH Stroke Scale for every focal deficit case, and we liberally use the immediate "Stroke Alert" system to get the patient immediately examined, labs, ECG, CXR and to CT — (our door to CT is <20 minutes), and discussion with Stroke Neurologist on-call.

Then that was it for our morning session ....the JC Reviewer thanked the group and moved on to "Current Patients Review", list of all Strokes in last 4 months, and used Tracer Methodology (as always). They spent the rest of the morning reviewing open records/data. They also spent a lot of time looking at the Stroke Team's Credential Files, including Board Certification and Licensure and addressing Staff Competencies. "How did you hire and educate your team?---and how do you keep them competent?" They looked at our compliance with the National Patient safety Goals, asked what we do if an Adverse Event occurs, and asked about EMS Leadership and Pre-Hospital education for the EMT-Ps.

Later that afternoon, the JC Reviewer came to the ED. We were told at 12 noon, be available in the ED after 1230pm"... The Reviewer asked to be "taken thru a Stroke Patient care process---from the Front Door". We showed her the EMS entrance, and Walk-in/Triage area, the into an Acute Care room, then to CT Scan---where the reviewer interviewed the CT Tech! about the "Stroke Alert Process"---and his role as CT tech, then a lot of questions to our ED Nurse Manager regarding RN turnover, RN Education and competency, and then finally asked us about our Stroke Alert Policies...this was easy, for we have all of this on our ED Web-based Intranet (EDWIN)...and it is great to quickly click on this from any computer and show each of the policies, protocols, documentation guidelines, ordersets, etc...she loved it!

The ED came thru unscathed....our combined work with Clerks, Techs, Nurses, Residents, Attendings, and everyone else...all paid off: the ED was crisp and clean (the painters had been hard at work for the last 3 weeks!), and our 7am walk-arounds that morning made sure the cleanup crew left the ED spotless...and that all of the ED Staff had the appropriate uniforms, ID badges, and knew the key National Patient safety Goals (although they never asked any of the ED staff at pt's bedside).

The next day, the JC Reviewer went to our 2 other EDs and reviewed our processes there, and made sure all were consistent with the policies. Having the Clinical Operations Leaders there to be the host is key, and all went well. Again, making sure each ED is sparkling clean/spotless is very important.

An afternoon meeting on the second day invited all of the Stroke Council Team back to the table, and a wrap-up discussion followed for about 75 minutes. "Your hard work is evident!.You have done well" is how the Reviewer started...

The Reviewer described her inner strategies:

  • Overarching Programs/Categories
  • How do you use your data
  • Who leads
  • How integrated is your Stroke team in the Community/the ED/the hospital/Rehab.
  • They review the Hospital Website.
  • They broadly look at our compliance with the National Patient Safety Goals.
  • They look at our Vaccination data and process.
  • They look at how we assess a patient's risk for fall.

Overarching Categories mainly included: "Delivery and Facilitating Care"....making sure we were competent practitioners, use standardized process, standard order sets, good discharge instructions and education, etc.

The Reviewer did mention that she found that not all RN assessments were competed on one of the Stoke Charts that got TPA (and did emphasize this was a small issue). "Performance Measurement and Improvement"...PDSA cycles, Patient's perception of Care----very important, Self-supporting Management, Teachers for the patient and family. "Program Management"....Who is in charge, who do you treat, P&P and references immediately available, Clinical Information Management ---how do the charts look?

The Reviewer asked us to focus more on "Perception of Care". She revealed that the fixes would be simple for us. We could expect a report from the JC within 2 weeks, and a return Stroke Center visit by JC in 2 years. They also looked forward to our Research efforts.

Overall, the visit went extremely well! (and was easier somehow...compared to other JC Visits). The Reviewer (from Michigan State/Sparrow Hospital) really was excellent and may have personally made it easier because of her professionalism and communication excellence.

I know we met each of the key requirements and will be granted Stroke Center Certification!.It was an amazing Team Effort, and when we get that letter there is going to be a big Team celebration....a celebration of our work as a team to make Stroke care better at our Medical Center!
 

 


 

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angelafranklinPay for Performance Wrap-Up

Angela Franklin, Staff Liaison 

This article provides a summary of activities this year relating to physician quality initiatives (PQRI) and hospital quality initiatives. 

Physician Quality Initiatives - PQRI 

Reporting for the 2007 Physician Quality Reporting Initiative (PQRI) began on July 1 for claims with dates of service in the Medicare FFS Program starting July 1 through December 31, 2007. Additional details on the pay for reporting program may be found at: www.cms.hhs.gov/PQRI, which hosts Frequently Asked Questions (FAQs), tools and educational products. ACEP participated in the process to ensure that eleven (11) measures appropriate for emergency physicians were eligible for the program. A list of measures emergency physicians may choose can be found on the  ACEP website .

CMS FAQ # 8622 

Question: Can eligible professionals append the same modifiers (CPT I or HCPCS Level II) used for payable procedure codes on the PQRI line item?

Answer: No, the only appropriate modifier(s) that can be appended to the PQRI code is one of the CPT II modifiers, i.e. 1P, 2P, 3P or 8P. If any other modifier (CPT I or HCPCS Level II modifier, i.e., 25, 50, LT, TC…) is placed on the PQRI code line item, the claim may be returned or denied for an invalid procedure/modifier combination. In those instances the provider must work with the local carrier on re-opening or adjusting the claim.

http://www.cms.hhs.gov/pqri 
August 8, 2007

Looking Ahead: 2008. Information about the 2008 PQRI was recently released in the Notice of Proposed Rulemaking (NPRM) for the 2008 Medicare Physician Fee Schedule ("MPFS"; Federal Register, Vol. 72 , No. 133, Thursday, July 12 , 2007, Proposed Rules, 38196). The NPRM includes proposed measures that would be appropriate for eligible professionals to use in 2008; the seven broad categories of proposed 2008 PQRI measures include:

  1. National Quality Forum (NQF)-endorsed 2007 PQRI Quality Measures
  2. Measures developed through the AMA’s Physician Consortium for Performance Improvement (AMA-PCPI)
  3. Measures for non-physician eligible professionals developed by Quality Insights of Pennsylvania
  4. Structural measures developed by Quality Insights of Pennsylvania (re: health IT use by physicians)
  5. Measures from the AQA Alliance "Starter Set" of quality measures that apply to Medicare covered services that were not included in 2007 PQRI measures
  6. Measures endorsed by the NQF that were not included in the 2007 PQRI quality measures but are relevant to Medicare beneficiaries, address overuse/misuse of pharmacologic therapy, and that expand the specialty applicability and/or patient population, and
  7. Measures currently under development by the American Podiatric Medical Association. (Source: CMS)

The final set of PQRI measures for 2008 will published in the Federal Register before November 15, 2007. HHS is also seeking comment on CMS plans to consider and test submission via registries or electronic health records (EHRs) in 2008. A summary of the PQRI provisions in the MPFS NPRM is available on the CMS PQRI website. Comments must be submitted by Friday, August 31, 2007; ACEP will be submitting comments on the measures.

"This bill provides an opportunity to thoughtfully and carefully develop effective quality measures that reflect differences in practice patterns, to share our findings, and to determine and encourage the most cost-effective methods of providing the highest quality care." 

– Sen. Benjamin Cardin, (D-MD), introducing S.1519. 

Congressional Record—Senate, p.S6890, May 24, 2007 

Federal Legislation. ACEP is supporting legislation introduced by Senators Ben Cardin (D-MD) and Arlen Specter (R-PA), the "Voluntary Medicare Quality Reporting Act of 2007" (S. 1519). The legislation would amend a provision of the "Tax Relief and Health Care Act of 2006" (PL 109-432) that requires CMS, through the rule-making process, to develop a new physician quality reporting system by 2008. Reps. Bart Gordon (D-TN) and John Shadegg (R-AZ) introduced the companion bill, HR 2759 in the House.

ACEP and the Alliance of Specialty Medicine worked closely with the legislators to develop this legislation, which would establish a more responsible timeline for physicians to report on the quality measures. Instead of requiring CMS to develop a new reporting system in 2008, without an analysis of the trial 2007 PQRI, the legislation would make January 1, 2010, the starting date of the reporting system. The reporting initiative would establish a clearly defined process for developing and endorsing evidence-based quality measures. Medical specialty organizations will be an important part of the process, helping to determine quality measures for the specialties affected through AMA-PCPI.

Hospital Quality Initiatives 

Pay for Reporting-proposed hospital outpatient rule includes ED Measures. The proposed Hospital Outpatient Prospective Payment System ("OPPS"; Federal Register, Vol. 72, No. 148, Thursday, August 2, 2007, Proposed Rules) rule provides that hospitals must report on outpatient measures for service beginning January 1, 2008, in order to receive a full payment update. The measures include:

ED-AMI-1 - Aspirin at Arrival (at NQF)
ED-AMI-2 - Median Time to Fibrinolysis (at NQF)
ED-AMI-3 - Fibrinolytic Therapy Received Within 30 Minutes of Arrival (at NQF)
ED-AMI-4 - Median Time to ECG (at NQF)
ED-AMI-5 - Median Time to Transfer for Primary PCI (at NQF)
PQRI #58 - Assessment of Mental Status for Community-acquired Pneumonia (NQF 2-Year Endorsement)
PQRI #59 - Empiric Antibiotic for Community-Acquired Pneumonia (NQF 2-Year Endorsement)
EC–01: Electrocardiogram (ECG) for Patients with Non-Traumatic Chest Pain (NQF 2-Year Endorsement)
EC-03: ECG Performed for Patients with Syncope (NQF 2-Year Endorsement)
EC-04: Vital Signs Recorded and Reviewed for Patients with Community-Acquired Bacterial Pneumonia (NQF 2-Year Endorsement)

Please see the relevant Federal Register pages (pp. 42800-42803). Comments are due on September 14; ACEP will be submitting comments on the rule.

ED Measures Under Review at NQF: Phase One. The National Quality Forum (NQF) is considering measures addressing emergency department transfers to another acute care hospital or emergency department. This is "phase one" of the NQF Hospital-based Emergency Care project, funded by CMS. This work relates to several ED measures proposed in the OPPS rule above: ED-AMI-1 through -5, and public comments on the measures are due by September 14th. The measures for consideration are:

  1. Aspirin at Arrival (from CMS)

     
  2. Median Time to Fibrinolysis (CMS)

     
  3. Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (CMS)

     
  4. Median Time to ECG (CMS)
  1. Administrative Communication (from University of Minnesota Rural Health Research Center (UMRHRC)) - Nurse Communication with receiving hospital staff; Physician communication with receiving professional

     
  2. Patient Information (UMRHRC) - Patient Demographics

     
  3. Vital Signs (from UMRHRC)

     
  4. Medication Information (from UMRHRC) - Medication history; Medications Given (MAR); Allergies

     
  5. Physician Information (from UMRHRC) - Physician’s history and physical; Physician’s orders and reason for transfer

     
  6. Nursing Information (from UMRHRC) - Nurse documentation: interventions/response to care; Impairments; Immobility; Respiratory support given; Oral restrictions; Catheters

     
  7. Procedure and Test Measure (from University of Minnesota Rural Health Research Center) - Tests and procedures done; Tests and procedures sent.
 

The NQF will vote on the measures October 1 through 31, and the NQF Board will consider endorsing the measures on November 13.

ED Measures Under Review at NQF: Phase Two and Beyond. NQF has also issued a notice of intent to call for comprehensive measures regarding wait times, overcrowding, boarding and diversions in the Fall, which also relate to the measures in the OPPS rule. NQF has also proposed and is seeking funding for an expansion of the project to include all emergency based services, including pre-hospital care, disaster planning and response. ACEP is working with CMS and the NQF on all of these measures and will be submitting comments.

HOSPITAL PROCESS OF CARE MEASURE SET 

Heart Attack (AMI) 

  • Aspirin at Arrival
  • Aspirin at Discharge
  • ACE Inhibitor or ARB for LVS Dysfunction
  • Beta Blocker at Arrival
  • Beta Blocker at Discharge
  • Fibrinolytic Within 30 Minutes Of Arrival
  • PCI Within 90 Minutes of Hospital Arrival
  • Smoking Cessation Advice/Counseling

Heart Failure 

  • Evaluation of LVS Function
  • ACE Inhibitor or ARB for LVS Dysfunction
  • Discharge Instructions
  • Smoking Cessation Advice/Counseling

Pneumonia 

  • Oxygenation Assessment
  • Initial Antibiotic Timing
  • Pneumococcal Vaccination
  • Influenza Vaccination
  • Blood Culture Performed in the ED Prior to Initial Antibiotic Received in Hospital
  • Appropriate Initial Antibiotic Selection
  • Smoking Cessation Advice/Counseling

Surgical Care Improv./Surgical Infection Prevention 

  • Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
  • Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
  • Prophylactic Antibiotic Selection

Source: CMS, www.qualitynet.org 

*For Medicare Advantage and non-Medicare Patients only

Pay for Reporting-Public Cardiac Mortality Data. Hospitals that voluntarily report quality measures adopted by the Hospital Quality Alliance (HQA) may receive a full payment update annually (see inset for measures). In June, CMS and HQA began publicly reporting 30-day mortality measures for acute myocardial infarction (AMI) and heart failure on Hospital Compare. The data is compiled from claims and enrollment data for patients in fee-for-service Medicare for 30 days after admission for heart failure or heart attack. A third measurement for pneumonia will be added in 2008, pending approval by the NQF and adoption by the HQA. Hospitals fall into one of three categories: "as expected", "better than expected" or "worse than expected." CMS hopes publication of the information will encourage improvement. CMS will only highlight a small percentage of hospitals with the best and worst death rates compared to the national average.

The American Hospital Association (AHA) issued a Quality Advisory (PDF) on how to deal with the expected interest from consumers. The advisory generally urges hospitals to:

Pay for Performance: Medicare Won’t Pay for Errors in 2008. Beginning October 2008, Medicare will no longer reimburse hospitals for costs associated with eight (8) conditions. Three are "never" events: object left in patient during surgery, blood incompatibility, air embolism; and five are other conditions: catheter-associated UTI; pressure ulcer, catheter-associated vascular infection, mediastinitis and patient fall. CMS is also considering adding three more conditions to list next year: Ventilator Associated Pneumonia (VAP), Staphylococcus Aureus Septicemia, and DVT/PE. The new regulations were outlined as part of the agency's final inpatient prospective payment system rule for FY 2008 (list on p. 368). Hospitals must begin reporting secondary diagnoses present on admissions beginning this October. Private insurers have said they will consider adopting similar policies.

Toward Value-Based Healthcare 

The above activities consistent with HHS’ strategic plan to build "a system of healthcare centered on value" and are in keeping with President Bush’s plan to advance value-driven healthcare in America. Health and Human Services (HHS) Secretary Michael O. Leavitt recently released a report that summarizes the progress of all the government’s initiatives, including physician and hospital quality measure reporting initiatives. The report may be accessed at: http://www.hhs.gov/valuedriven/federal/eoreport.pdf.

 


 

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QIPS Membership Roster

Robert I. Broida, MD, FACEP 

Robert I. Broida, MD, FACEPThe ACEP Section on Quality Improvement and Patient Safety (QIPS) is always looking for prospective new members. If you know of anyone in your group who has an interest in QI/PS (or has had it thrust upon them), please encourage them to join our section. We endeavor to keep our membership updated on the latest in the field – and the $35 per year cost is significantly less than ANY publication on the market. I would like to issue a personal challenge to those of you in states with only one or two members: Contact your colleagues. Contact your ACEP state chapter executive. There have to be other emergency physicians from your state who are interested in quality!.In fact, if we desire to take a leadership role (see Dr. Meisl’s article-Measures, above), our goal should be to have at least one member (the quality "guru") from each hospital in the US!. Click here for information on membership.

QIPS Stats

  • Total Membership: 235 

  • Rank: 13th Largest Section 

 

Welcome New QIPS Members!
Robert B Rowland, Jr, MD, FACEP, Bedford, TX
Laura J Snyder, MD, Freehold, NJ
Jamira Jones, MD, Dallas, TX
John I Cheng, MD, Atlanta, GA
Dennis M Beck, MD, FACEP, Aurora, CO
Thomas C Falvo, DO, FACEP, York, PA
William E Baker, MD, FACEP, Boston, MA
Jesse Pines, MD, Philadelphia, PA
Amanda C Rodski, MD, New York, NY

QIPS Membership Roster 
The QIPS section enjoys the participation of members from all across the country: Alabama, Arkansas, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Massachusetts, Maryland, Michigan, Minnesota, Missouri, Mississippi, North Carolina, New Hampshire, New Jersey, New Mexico, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Vermont, Washington, Wisconsin, Wyoming, as well as international members, . 

Alabama 
Marjorie Lee White, MD Birmingham AL

 
Arkansas 
Judy E Borland, MD, FACEP Hot Springs AR

 
Arizona 
Forrest DeWitt Holden, MD, FACEP Phoenix AZ
Michael Wayne Rada, MD, FACEP Gilbert AZ
Peter L Sawchuk, MD Lake Havasu City AZ

 
California 
David Josef Amin, MD Rolling Hills Estate CA
Graham T Billingham, MD, FACEP Auburn CA
Therese Eden Chan, MD San Luis Obispo CA
Brian Farr Chinnock, MD, FACEP Clovis CA
Michael A Dorso, MD Granite Bay CA
Steven B Ernst, MD Claremont CA
Douglas J Evans, MD Mill Valley CA
Claudia R Gold, MD, FACEP Laguna Niguel CA
Gregory T Guldner, MD, FACEP Corona CA
Maya R Heinert, MD Sacramento CA
Nobuaki Inoue, MD Redlands CA
E Scott Isbell, MD, FACEP Glendora CA
Jack D Kennis, MD, FACEP Yorba Linda CA
David Kovacik, MD, FACEP Victorville CA
Raghavendra Kulkarni, MD, FACEP Glendora CA
Terry Bruce Lapid, MD, FACEP Aptos CA
David L Lebell, MD, FACEP Santa Barbara CA
James J Loftus, MD, FACEP Los Angeles CA
Guisou Mahmoud, MD, FACEP Santa Ana CA
James McCormick, III, MD Woodland Hills CA
Helmut W Meisl, MD, FACEP Woodside CA
Gregg A Miller, MD Hermosa Beach CA
Bernice Rodrigues, MD, FACEP Castro Valley CA
Dorcas J Sandness, MD Huntington Beach CA
Thomas Jerome Sugarman, MD, FACEP Berkeley CA
Ellen H Taliaferro, MD, FACEP Half Moon Bay CA
Prentice A Tom, MD, FACEP Los Gatos CA
Thomas Alan Utecht, MD, FACEP Clovis CA
Brian Donald Wippermann, MD Newcastle CA
Todd W Zaayer, MD, FACEP Encinitas CA

 
Colorado 
Dennis M Beck, MD, FACEP Aurora CO
Dickson S Cheung, MD Lone Tree CO
John C Farrin, MD JD FACEP Golden CO
David T Matero, MD Aurora CO

 
Connecticut 
Louis G Graff, MD, FACEP Unionville CT
Thomas J Holmes, Jr, MD, FACEP Old Saybrook CT
Peter J Jacoby, MD, FACEP Woodbury CT
David Peter John, MD, FACEP Middletown CT
Edward Monico, MD,JD,FACEP New Haven CT
Thomas W Turbiak, MD, FACEP Canton CT

 
Florida 
Ian W Cummings, MD, PhD Fort Pierce FL
Donald R Kamens, MD, FACEP Ponte Vedra Bch FL
Wayne Lee, MD, FACEP Ft Lauderdale FL
Clayton E Linkous, Jr, MD, FACEP Lakeland FL
John Ramey McPherson, MD, FACEP Melbourne Bch FL
John J Parker, MD, FACEP Melbourne Bch FL
Mark Lawrence Remz, DO, FACEP West Palm Beach FL
Steven Robert Scott, MD Wilton Manors FL
Henry E Smoak, III, MD, FACEP Indian Rks Bch FL
Kristine Thompson, MD St Augustine FL
Robert L Wears, MD MS FACEP Orange Park FL

 
Georgia 
John I Cheng, MD Atlanta GA
Robert J Cox, MD, FACEP Barnesville GA
Raymond Eric Harrison, MD, FACEP Carrollton GA

 
Illinois 
Geoffrey Bauer, MD Chicago IL
Christopher B Beach, MD, FACEP Glenview IL
Neal J Edelson, MD, FACEP Chicago IL
Catherine Johnson, MD, FACEP Clarendon Hls IL
James J Kambol, MD, FACEP Vernon Hills IL
Rao H Kilaru, MD, FACEP Joliet IL
Susan Marie Nedza, MD MBA FACEP Chicago IL
Beatrice D Probst, MD, FACEP Burr Ridge IL
Stewart Barry Reingold, MD, FACEP Chicago IL
Sharolyn Rhees Medina, MD, FACEP Chicago IL
Steven Taller, MD, FACEP Morris IL
John Albert Vozenilek, III, MD, FACEP Park Ridge IL
James J Walter, MD, FACEP Burr Ridge IL
Kevin Brady Whatley, MD, FACEP Chicago IL

 
Indiana 
John C Johnson, MD, FACEP(E) Valparaiso IN
Sonia Winslett, MD Evansville IN

 
Kentucky 
Rick L Rowe, MD Louisville KY

 
Louisiana 
Atwood L Rice, III, MD JD MPH Lafayette LA
William C Schumacher, MD Lafayette LA

 
Massachusetts 
William E Baker, MD, FACEP Waban MA
Mary C Burke, MD, FACEP Southboro MA
Kimberly Ann Markuns, MD, FACEP Quincy MA
Joseph C Palomba, MD Shrewsbury MA
Jeremiah Schuur, MD Cambridge MA
Chin Chung Tang, MD Shrewsbury MA
Benjamin A White, MD Boston MA

 
Maryland 
Drew C Fuller, MD Baltimore MD
Brett A Gamma, MD, FACEP Gaithersburg MD
Jeffrey Gerton, MD Baltimore MD
Frances Jensen, MD Baltimore MD
David L Meyers, MD, FACEP Baltimore MD
Stephen M Schenkel, MD, MPP Baltimore MD

 
Michigan 
Alan D Bersted, MD, FACEP Grayling MI
Michael Edward Boczar, DO, FACEP Clarkston MI
Steven Kronick, MD Ann Arbor MI
E Jedd Roe, III, MD, FACEP Royal Oak MI
Samina Shahabuddin, MD, FACEP Lansing MI
Anthony C Southall, MD, FACEP Grosse Pte Frms MI
Padraic J Sweeny, MD Dearborn MI
Michael D Thompson, MD, FACEP Ann Arbor MI

 
Minnesota 
Won G Chung, MD, FACEP Shoreview MN
Stuart R Fritz, MD, FACEP Minneapolis MN
Susan Gail Vanpelt, MD Loretto MN

 
Missouri 
Richard Griffey, MD, MPH Richmond Hts MO
Robert F Poirier, Jr, MD, FACEP St Louis MO
Raana J Ponstingl, MD, FACEP St Louis MO

 
Mississippi 
John C Nelson, MD, FACEP Hattiesburg MS
Thomas B Pinson, MD, FACEP Tupelo MS

 
North Carolina 
Victor Adan, MD Franklin NC
Charles Henrichs, MD, FACEP Hendersonville NC
Cherri D Hobgood, MD, FACEP Hurdle Mills NC
Brian A Moore, MD Mooresville NC
Timothy John Reeder, MD, FACEP Grimesland NC
Tina Tamaddon, MD Durham NC
Lisa W Horn Thompson, MD, FACEP Apex NC
Victoria L Thornton, MD MBA FACEP Durham NC
B Vindell Washington, MD, FACEP Mooresville NC
Bruce S Whitman, DO, FACEP Lumberton NC

 
New Hampshire 
Mary Valvano, MD, FACEP Concord NH

 
New Jersey 
Solomon V Alcantara, MD, FACEP Franklin Lakes NJ
Tom-meka Archinard, MD Newark NJ
James A Espinosa, MD, FACEP Voorhees NJ
James E George, MD JD FACEP Woodbury NJ
Stuart Gary Kessler, MD, FACEP Marlboro NJ
Francis L Levin, DO, FACEP Medford NJ
Fredric R Ludwin, DO Medford NJ
Gregory J Rokosz, DO JD FACEP Boonton Twp NJ
David M Siegel, MD JD FACEP Red Bank NJ
Laura J Snyder, MD Freehold NJ
Mark Spektor, DO Morganville NJ
Simon Vichnevetsky, MD, FACEP Flemington NJ

 
New Mexico 
Marcey Gillespie, MD Las Cruces NM

 
Nevada 
Ross Philip Berkeley, MD FACEP Henderson NV

 
New York 
Suzanne K Elliott, MD, FACEP Plattsburgh NY
Rollin Fairbanks, MD, FACEP Rochester NY
Russell J Firman, MD, FACEP Fayetteville NY
Maureen A Gang, MD, FACEP New City NY
Alvin H Goldberg, MD, FACEP New City NY
Stephen D Gomez, MD, FACEP Cortland NY
Jeffrey Hom, MD, FACEP Brooklyn NY
Shkelzen Hoxhaj, MD, FACEP Yonkers NY
Steven Kaplan, MD New York NY
Samuel H Ko Rochester NY
Ronald B Low, MD, FACEP New York NY
Daniel G Murphy, MD MBA FACEP Garden City NY
Amanda C Rodski, MD New York NY
John C Rohe, MD, FACEP Baldwin NY
Gary S Rudolph, MD, FACEP Huntington NY
Annabella Salvador, MD, FACEP New York NY
Alan L Schechter, MD, FACEP Scarsdale NY
Bonnie Simmons, DO, FACEP Brooklyn NY
Matthew F Simons, MD Brooklyn NY
David Procter Thomson, MD, FACEP Syracuse NY
Alfredo Torres, MD Rochester NY

 
Ohio 
Eric Anderson, MD, FACEP Highland Heights OH
Michael S Beeson, MD, FACEP Silver Lake OH
Robert I Broida, MD, FACEP Solon OH
David E Custodio, MD, FACEP Aurora OH
Howard I Dickey-White, MD, FACEP Youngstown OH
Kevin Michael Klauer, DO, FACEP Canton OH
Mark Kubina, MD, FACEP Bolivar OH
Thomas W Lukens, MD PhD FACEP Lakewood OH
David C Pelini, MD, FACEP Westlake OH
David John Peter, MD, FACEP Silver Lake OH
Michael Patrick Phelan, MD, FACEP Shaker Hts OH
S Scott Polsky, MD, FACEP Galena OH
Thomas S Proctor, MD, FACEP Miamisburg OH
Akhil Saklecha, MD, FACEP Fairlawn OH
Elaine A Thallner, MD, FACEP Shaker Heights OH
Robert Wayne Wolford, MD, FACEP Cleveland Hts OH
Warren K Yamarick, MD, FACEP Powell OH

 
Oklahoma 
Carolyn Kay Synovitz, MD MPH FACEP Altus AFB OK

 
Oregon 
Anthony A Ferroggiaro, MD, FACEP Portland OR
Amy Renick Lawrence, MD, FACEP Portland OR

 
Pennsylvania 
Neil B Baum, MD N Huntingdon PA
M Christopher Clarkson, MD Export PA
Teresa Sullivan Dolan, MD State College PA
Kenneth K Doroski, DO, FACEP Wayne PA
Thomas C Falvo, DO, FACEP York Haven PA
Peter Joseph Favini, MD, FACEP E Stroudsburg PA
James J Flowers, DO, FACEP Newtown Square PA
Alan T Forstater, MD, FACEP Philadelphia PA
Kaveh Ilkhanipour, MD, FACEP Pittsburgh PA
John Joseph Kelly, DO, FACEP Philadelphia PA
William G Kristan, MD, FACEP Pittsburgh PA
Richard S MacKenzie, MD, FACEP Allentown PA
Zachary Meisel, MD Philadelphia PA
Jesse Pines, MD Wynnewood PA
David M Richardson, MD, FACEP Fogelsville PA
Saul Francis Rigau, DO Clarks Summit PA
Geoffrey L Ruben, MD Washington PA
Suresh G Wable, MD, FACEP Holland PA

 
South Carolina 
Timothy John Carr, MD, FACEP N Myrtle Bch SC

 
Tennessee 
Chris J Andershock, MD, FACEP Cordova TN
David Aaron Baker, MD Clarksville TN
Francis J Fenaughty, MD, FACEP Memphis TN
Van E Helms, MD, FACEP Knoxville TN
Robert M Hutton, MD Nashville TN

 
Texas 
Bernice L Anderson, DO Odessa TX
Hoyt William Frenzel, MD, FACEP Arlington TX
Jamira Jones, MD Dallas TX
Ralph W Kelly, DO, FACEP Plano TX
Robert B Rowland, Jr, MD, FACEP Southlake TX
Kevin B Stacks, MD, FACEP Sherman TX
Ted W Switzer, MD San Antonio TX
J Thomas Ward, Jr, MD, FACEP Plano TX
Arlo F Weltge, MD MPH FACEP Bellaire TX

 
Virginia 
Jean C Ling, MD Great Falls VA
Raymond H Lucas, MD Vienna VA
Renee D Reid, MD Mechanicsville VA
Pamela Andrea Ross, MD, FACEP Troy VA
James Malcolm Schmidt, MD Virginia Beach VA

 
Vermont 
Richard A Marasa, MD MBA FACEP Springfield VT

 
Washington 
Maurice J Montag, Jr, MD, FACEP Issaquah WA

 
Wisconsin 
Azita Hamedani, MD MPH Verona WI
Timothy William Jahn, MD, FACEP Green Bay WI
Martin J Landa, MD, FACEP Oneida WI
Mark Olsky, MD, FACEP Madison WI
John Russo, MD Grafton WI
Bruce E Sands, MD, FACEP Pleasant Prairie WI

 
Wyoming 
Jonathan M Hayden, MD, FACEP Gillette WY
Ronald Iverson, MD, FACEP Casper WY

 
International 
L Corne, MD Brussels BELGIUM
Christopher B Fernandes, MD, FACEP London CANADA
Lyne Filiatrault, MD, FACEP New Westminister CANADA
V Jane Findlater, MD Fredericton CANADA
Tania L Homonchuk, MD, FACEP Whangarei NEW ZEALAND
Bruno C Mangola, MD Macon FRANCE
Charles F Merrill, MD Pembrokeshire WALES
Colman O'Leary, MD Limerick IRELAND
Michael J Schull, MD Toronto CANADA
Sang Do Shin, MD Seoul SOUTH KOREA
Steven Stelts, MD Muriwai Bch Auckland NEW ZEALAND
Edwin Vandewalle, MD Anstelveen NETHERLANDS
Alejandro Villatoro, MD Santa Ma Insurgentes MEXICO
John D Vinen, MD Kingsford AUSTRALIA

 

 


 

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Quality and Safety Articles

Helmut Meisl, MD, FACEP 

Here again is a list of recent articles that may interest you. These are compiled by AHRQ PSNet at http://psnet.ahrq.gov/. 

GENERAL 

Profiles in patient safety: a "perfect storm" in the emergency department. 
Campbell SG, Croskerry P, Bond WF. Acad Emerg Med. 2007 May 30.

Hospital patient safety: characteristics of best-performing hospitals. 
Longo DR, Hewett JE, Ge B, Schubert S. J Healthc Manag. 2007;52:188-204; discussion 204-205.

What whiteboards in a trauma center operating suite can teach us about emergency department communication. 
Xiao Y, Schenkel S, Faraj S, Mackenzie CF, Moss J. Ann Emerg Med. 2007 May 9.

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.
Thomas EJ, Taggart B, Crandell S, et al. J Perinatol. 2007 May 31.

The frequency of missed test results and associated treatment delays in a highly computerized health system. 
Wahls TL, Cram PM. BMC Fam Pract. May 22 2007;8(1):32.

The extent and importance of unintended consequences related to computerized provider order entry.
Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. J Am Med Inform Assoc. 2007 Apr 25.

Rates and types of events reported to established incident reporting systems in two US hospitals.
Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Qual Saf Health Care. 2007;16:164-168.

Patient safety knowledge and its determinants in medical trainees. 
Kerfoot BP, Conlin PR, Travison T, McMahon GT. J Gen Intern Med. 2007 Jun 6.

Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. 
Offner PJ, Heit J, Roberts R. J Trauma. 2007;62:1223-1228.

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. 
Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

What cannot be said on television about health care.
Emanuel EJ. JAMA. 2007;297:2131-2133.

Complication rates on weekends and weekdays in US hospitals. 
Bendavid E, Kaganova Y, Needleman J, Gruenberg L, Weissman JS. Am J Med. 2007;120:422-428.

Communication outcomes of critical imaging results in a computerized notification system.
Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. J Am Med Inform Assoc. 2007 Apr 25.

ERROR DISCLOSURE 

Disclosing medical errors to patients: attitudes and practices of physicians and trainees.
Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. J Gen Intern Med. 2007 May 1.

MEDICATION ERRORS 

A new infusion syringe label system designed to reduce task complexity during drug preparation.
Merry AF, Webster CS, Connell H. Anaesthesia. 2007;62:486-491.

The safety of warfarin therapy in the nursing home setting.
Gurwitz JH, Field TS, Radford MJ, et al. Am J Med. 2007;120:539-544.

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.
Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Cancer. 2007 May 25.

ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:396–399.

Fatal error sparks debate over punitive measures. 
Fernandez J. Drug Topics. May 7, 2007.

A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting.
Handler SM, Altman RL, Perera S, et al. J Am Med Inform Assoc. 2007 Apr 25.

The utility of adding retrospective medication profiling to computerized provider order entry in an ambulatory care population.
Glassman PA, Belperio P, Lanto A, et al. J Am Med Inform Assoc. 2007 Apr 25.

Cost-benefit analysis of a hospital pharmacy bar code solution.
Maviglia SM, Yoo JY, Franz C, et al. Arch Intern Med. 2007;167:788-794.

Improving medication safety in the ICU: the pharmacist's role. 
Lee AJ, Chiao TB, Lam JT, Khan S, Boro MS. Hosp Pharm. 2007;42:337–344.

Evaluation of outpatient computerized physician medication order entry systems: a systematic review.
Eslami S, Abu-Hanna A, de Keizer NF. J Am Med Inform Assoc. 2007 Apr 25.

Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. 
Fu AZ, Jiang JZ, Reeves JH, Fincham JE, Liu GG, Perri M 3rd. Med Care. 2007;45:472-476.

SURGICAL 

The Patient Safety in Surgery Study.
J Am Coll Surg. 2007;204:6:1087-1300.

Distracting communications in the operating theatre. 
Sevdalis N, Healey AN, Vincent CA. J Eval Clin Pract. 2007;13:390-394.

TELEPHONE TRIAGE 

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?
Giesen P, Ferwerda R, Tijssen R, et al. Qual Saf Health Care. 2007;16:181-184.

Patient safety in after-hours telephone medicine. 
Killip S, Ireson CL, Love MM, Fleming ST, Katirai W, Sandford K. Fam Med. 2007;39:404-409.

WORK HOUR REGULATIONS 

Changes in outcomes for internal medicine inpatients after work-hour regulations. 
Horwitz LI, Kosiborod M, Lin Z, Krumholz HM. Ann Intern Med. 2007 Jun 4.

Changes in hospital mortality associated with residency work-hour regulations.
Shetty KD, Bhattacharya J. Ann Intern Med. 2007 Jun 4.

Nurse working conditions and patient safety outcomes. 
Stone PW, Mooney-Kane C, Larson EL, et al. Med Care. 2007;45:571-578.

Resident perceptions of the impact of work hour limitations.
Lin GA, Beck DC, Stewart AL, Garbutt JM. J Gen Intern Med. 2007 Apr 28.

 

 

 

 


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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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