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Quality Improvement and Patient Safety Section Newsletter - March 2016

Through the Quality Lens: Exploring the Many Perspectives of Quality in Emergency Medicine


Chair’s Letter - March 2016

Jeff PothofI recently spent some time sitting on a committee at my health system that was looking to update an old sepsis definition and treatment guideline that would be used by providers across our entire enterprise. As you might suspect, initially, there were few points of agreement, wide variability in what providers believed was best evidence based practice, and difficulty in coming to an agreed upon approach despite the clear desire to do what was best for our patients.

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Breaking Down the IOM Committee Report On Diagnostic Error—Part Two

On September 22, 2015, the Institute of Medicine (IOM) issued the report of its Committee on Diagnostic Error. In the first part of this article, published in the December 2015 QIPS newsletter, I summarized the report’s three key themes and the conceptual model used by the Committee. I will now discuss the eight goals identified by the Committee in their report to improve diagnosis and reduce diagnostic error.

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Preventing Hospital Acquired Conditions- The Road to Compliance is Paved with Good Intentions, Poor Execution, and Bad Outcomes

Risk of FallingIn 2007, I had the privilege of serving as a Medical Officer on a group at the Centers for Medicare and Medicaid Services that was tasked with implementing Section 5001(c) of the Deficit Reduction Act of 20051.

The legislation required the secretary to identify at least two conditions that were (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines.

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Suicidal and Refusing Physical Examination: Clinical Conundrum

On a recent site visit I was asked to opine on the best legal and patient safety response to a particularly challenging ED case.

The case: A 29 year old woman, well known to the Emergency Department for frequent visits for psychiatric complaints and intoxication presented to the ED with a chief complaint of suicidal ideation. Hospital policy required a physical exam and lab work, including a blood alcohol level, to be resulted prior to crisis evaluation. However, the patient was refusing a medical examination and bloodwork. The crisis team refused to evaluate the patient without these completed.

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Editor’s Notes - March 2016

I am excited to bring you the next edition of the QIPS newsletter. Many of you were able to join us on the QIPS all section call, which took place on January 19th. “The Clinician Perspective on Sepsis Care: Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1)” was led by Robert Furno, MD, MPH, MBA, FACEP, Chief Medical Officer for the Upper Midwest Region of the Centers for Medicare and Medicaid Services (CMS) and was rich with pearls that we can all use in achieving compliance with these complex quality measures. If you were not able to make it, I encourage you to listen and have linked it here.

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Sepsis CMS Core Measure (SEP-1) Highlights

JamieSantistevanThe Sepsis CMS Core (SEP-1) Measure has been receiving a lot of recent attention for its complexity. Here are four key points that are important to understand and remember:

1. Lactate >2 or organ dysfunction defines severe sepsis. The definition for sepsis is unchanged: two SIRS criteria plus suspected infection. Severe sepsis is defined as sepsis plus one or more variable of organ dysfunction, which includes a lactate >2. See the below table for other “signs” of organ dysfunction.

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Epinephrine Dosing Errors: An Old Problem with a $imple $olution

Emergency physicians and emergency medical services personnel are the first line providers tasked with the use of epinephrine for life-threatening conditions such as anaphylaxis, obstructive airway disease, and cardiac arrest. Epinephrine is available in different doses and concentrations for delivery by various routes including intramuscular, nebulized racemic, and intravenous forms.1

In addition, emergency medicine providers often encounter patients who are unstable, necessitating rapid administration of epinephrine prior to respiratory failure, hemodynamic collapse, and/or anoxic brain injury. In the midst of this chaos and panic – we administer one of the most confusing medications with a consistent reputation for errors both with dosing and route of administration.2–5 When these errors occur they often have severe consequences for our patients including hypertension, tachydysrhythmias, pulmonary edema, myocardial injury, or even death.4,6,7

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