Conf Review – Patient Safety, Observation Care

Thanks Chad Garthe for these conference reviews!

Patient Safety and Quality Improvement

Patient safety and a shared culture incorporates everyone from doctors, nurses, and medical technitions to take responsibility for patient safety. This responsibility is shared between everyone providing care for the patient.

If you encounter a situation that you believe to be unsafe à SAY SOMETHING

Be comfortable to speak up even in front of superiors

Use maneuvers to excuse yourself from the patient’s room to express concerns

You can report patient safety concerns on One Source even after they happen

Quality Improvement:

Finding a good QI project would be something you have difficulty with in the department on a daily basis. There are endless opportunities for QI in the ED.

Root Cause Analysis- evaluate the root cause to an issue/problem in order to identify the root cause and set up intuitional barriers to prevent future issues/problems

Six Sigma

DMAIC Phase Steps

Define Phase: Define the project goals and customer (internal and external) deliverables

Measure Phase: Measure the process to determine current performance; quantify the problem

Analyze Phase: Analyze and determine the root cause of the defects

Improve Phase: Improve the process by eliminating defects.

Control Phase: Control future process performance


Observation Care

Rationale is to provide an extended stay in the emergency department for reassessment of a patient at a later time or to wait for a diagnostic test (i.e MRI, Cardiac Stress Test, Physician Consultation).

Lower admission rates

Provide cost effective care for the patient

Specific protocols: Several protocol are instituted to provide better care for the patient

Go to Order Set à Type CDU à Order-set for specific protocols can be found here

ED Observation for TIA

Definition TIA: Transient Ischemic Attack, hemiplegia or dysarthria for a period of time with complete resolution of symptoms thought to be ischemic in nature.

Appropriate for Observation Appropriate for Inpatient Admission
Sx w/i 72 hours and ABCD2 > 3 Pt with > 1 symptomatic episode in 24 hour period
Sx w/i 72 hours and ABCD2 0-2 w/ no outpatient workup in the next 2 days Crescendo of symptoms
Sx w/i 72 hours and ABCD2 0-2 w/ likely focal ischemia New onset atrial fibrillation
  TIA w/ >70% known stenosis of the carotid artery


Benefits of Inpatient Admission:

More observation time

Better management of patient’s with multiple co-morbidities

Benefits of CDU/Observation stay:

Less cost with similar outcomes (Nair et al)


More efficient and less costly (Ross et al)

ABCD2 Score

ABCD2 0 +1 +2
Age > 60 No Yes N/A
BP > 140/90 mmHg No Yes N/A
Clinical Features Other symptoms Speech disturbance w/o weakness Unilateral Weakness
Duration of Symptoms <10 minutes 10-59 minutes > 60 mintues
History of Diabetes No Yes N/A


– Estimates risk of stroke after a TIA

– The largest prospective study of using the ABCD2 score in the emergency department found that the score performed poorly (low sensitivity for identifying low risk patients, low specificity for identifying high risk patients).

– Multiple studies have shown that as the ABCD2 score increases the risk of a subsequent stroke also increases.

– Patients with a low baseline risk of stroke (≤ 2%) with a low ABCD2 score (0-2) are at low risk for having a stroke within the next 7 days (0.4-0.8%).

– The ABCD2 score was developed in the outpatient (non-emergency department) setting. It has been shown to have lower accuracy when used by non-specialists (primary care or emergency physicians). The ABCD2 has less impact on risk stratification when applied in settings where the patients were at low baseline risk of stroke.

Chest Pain Observation

Risk stratify patient’s based on the HEART Score

HEART Score – Predicts Major Adverse Cardiac Event (MACE) in the next 6 weeks

HEART Score 0 +1 +2
History Slightly Suspicious Moderately Suspicious Highly Suspicious
EKG Normal Nonspecific repolarization disturbance Significant ST-Depressioni
Age < 45 45-65 > 65
Risk Factors* No risk factors 1-2 risk factors > 3 risk factors
Troponin < normal limit 1-3x normal limit > 3x normal limit


*Risk Factors Include: Hypercholesterolemia, HTN, DM, Smoking, Positive Family History, Obesity

0-3 0.9-1.7%
4-6 12-16.6%
7-10 50-60%


Please note that HEART Score should never make the decision for you rather give you evidence to support your disposition.

Thorough Chest Pain Rule-out includes EKG, Troponin, Physician risk stratification, Provocative heart test





  • Acute MI within 2 days, or

active unstable angina

  • Symptomatic severe aortic


  • Decompensated heart failure
  • Aortic dissection
  • Acute myocarditis or


  • Uncontrolled arrhythmias
  • Acute PE


  • Left main disease
  • Severe uncontrolled


  • Hypertrophic obstructive


  • High degree AV block