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
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
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
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)
|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
|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
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