Development of Emergency Department Quality Indicators QI

1. Development of Emergency Department Quality Indicators (QI) Kathryn M. McDonald Center for Health Policy / Center for Primary Care and Outcomes Research, Stanford University September 14, 2009

2. Overview Development of AHRQ QI Using ED Data Patient Safety Indicators (PSI) Prevention Quality Indicators (PQI) AHRQ QI Development Methodology Adapting the AHRQ QI to the ED Potential QI ED Indicators Patient Safety Events Avoidable ED visits Data Issues Summary

3. Development of AHRQ ED QI Purpose of this New Task Develop a set of quality indicators that is applicable to the emergency department setting Incorporate set into the publicly available AHRQ QI software Implement the established AHRQ QI measurement development process Adapt existing AHRQ QI to ED setting Conduct a review of new candidate indicators

4. Existing AHRQ QIs:Patient Safety Indicators (PSI) Death in low mortality DRGs Decubitus ulcer Failure to rescue Foreign body left during procedure * Iatrogenic pneumothorax * Selected infections due to medical care * Postoperative hemorrhage or hematoma Postoperative hip fracture Postoperative physiological and metabolic derangement Postoperative PE or DVT

5. Patient Safety Indicators (cont.) Postoperative respiratory failure Postoperative sepsis Postoperative wound dehiscence * Technical difficulty with procedure * Transfusion reaction * Birth trauma � injury to neonate OB trauma � vaginal delivery with instrument (w/ and w/o 3rd degree lacerations) OB trauma � vaginal delivery without instrument (w/ and w/o 3rd degree lacerations)

6. Existing AHRQ QIs:Prevention Quality Indicators Bacterial pneumonia Dehydration Urinary tract infection Perforated appendix Low birth weight Angina without procedure Congestive heart failure Hypertension Adult asthma COPD Diabetes cx - short term Diabetes cx - long term Uncontrolled diabetes Lower extremity amputation

7. Measure Development and Validation Process

8. Starting Point #1: Adapting the AHRQ QI Developing emergency department PSI shall involve several challenges. Conceptually patient safety issues may manifest themselves at different points in time and in different settings: Within the ER visit, or In an admission to the same hospital (promising area of focus) or Outside of the ER of interest or the same hospital (e.g, home, another ER, another hospital) Development effort might consider the relationship between the PQIs and potential PSIs in the ED context For example, a patient that presents at the emergency department with a Urinary Tract Infection (UTI) and then gets admitted as an inpatient. This patient will flag as a PQI at the ED level and at the inpatient admission level. However, another patient that presents with a UTI and then is sent home, but returns the following day and needs to be admitted might be considered a patient safety problem. Our development effort will consider these issues and relationships to develop indicators of two types � potentially preventable ED visits, and potentially preventable patient safety events.

9. Starting Point #2: Conceptualizing Quality Issues What types of adverse events might occur during an ED admission/encounter? Conditions worsens while waiting (related to ED crowding) Occult GI bleeds, sepsis, hypoglycemia, atypical heart attacks Cardiac arrest in waiting room, death of asthma patient Air embolism from IV lines Medication error Wrong medication to wrong patient (e.g., with too many patients in one treatment room) Incorrect dose (e.g. patient not weighed, transcription errors) Medication give when patient has known allergy Drug interaction reaction (e.g., coumadin with certain common antibiotics) Inadequate monitoring (e.g., hypogylcemia after insulin, resp distress with narcotics) Hemolytic reaction due to administration of incompatible blood or blood products Falls From Stretcher, Bed, Bathroom, Wet floor

10. Patient Safety Events What types of adverse events might occur during an ED admission/encounter or soon after? Alarm malfunctions Not audible to or not seen by nurses IV Pump issues Back up battery failures stops meds, unintentional change of settings, inadequate monitoring Patient specimen errors Patients not fully registered or identified when specimen leaves ED, leading to lags in results communications, or assigning results to wrong patient Infection control failures Incorrect diagnosis & �bounce back� Patient returns to ED for abdominal pain (missed AAA) X rays interpreted as negative, fracture dx on later read or when patient returns Death in a psychiatric patient admitted to psych ward within 72 hours of ED visit (missed organic causes) Missed injuries (Traumatic brain injury)

11. Potentially Avoidable Visits What ED encounters are potentially preventable by high quality outpatient care? Diabetic Complications Hyperglycemia Infections Asthma Acute respiratory event Bronchitis Hypertension Hypertensive urgency Hemorrhagic stroke Colds, Flu & Invasive Pneumococcal Disease Poor hand hygiene Lack of primary care Missed Flu shot Missed Pneumococcal Vaccine

12. Potentially Avoidable Visits What ED encounters are potentially preventable by public health interventions? Falls Hip Fractures, Long bone fractures, Pediatric (e.g., due to poor window guards) Brain injury secondary (not wearing helmets) Fireworks injuries Dehydration ETOH intoxication Overdose/substance abuse Sexually transmitted diseases Obstetric complications Motor vehicle collision Drowning Carbon monoxide poisoning (poorer quality furnaces) Accidental hypothermia (homeless sleeping in cold) Food poisoning (poor restaurant sanitation)

13. Potentially Avoidable Visits What ED encounters are potentially preventable with health care system changes? Primary care provider told patient to go to ED over the phone when office practice is closed Weekend Night Time Inadequate care outside ED for Aging population Unable to provide self care, and inadequate support available Incontinence issues Care given due to lack of adequate insurance for non-ED care Ingrown toe nails with infection Vaginitis Urethritis Otitis Media Running out of home oxygen Possibly due to lack of primary care doctor Sore throat Urinary tract infection

14. Potentially Avoidable Visits What ED encounters are potentially preventable with improvements to post-surgical care processes? Unable to care for self post-operatively (return visit) Outpatient Surgery Complications Wound dehiscence from outpatient surgery Post op Infections Hemorrhaging Other post op complications

15. Data Source & Issues State Emergency Department Datasets (SEDD) Treat and release encounters from 27 states Encounters resulting in subsequent admission to the same hospital from 41 states How do records for the subsequent admissions relate to corresponding hospitalization records in the SID datasets? Diagnosis and Procedure Codes May be that ED diagnosis codes are dropped or incorporated into a longer list when the patient is admitted May be no effective method to evaluate the quality of ED care for patients who were hospitalized from the ED These issues will be evaluated in detail

16. Summary: Project Philosophy Emergency medicine is particularly sensitive to guidelines and quality measures from other specialties (e.g., cardiology, infectious disease, pediatrics). The EM community is not always included in guideline and quality measure development at the initial stages, even though they are affected most. Therefore, a focus on ED quality needs to starts with the EM community (doctors, nurses, department managers). Use existing data sources available from AHRQ Therefore, this project�s indicators will not cover all important ED quality concern (e.g., ambulance diversions from overcrowding) Start with existing AHRQ measures and development approaches

17. Acknowledgments Funded by AHRQ Support for Quality Indicators II (Contract No. 290-04-0020) Mamatha Pancholi, AHRQ Project Officer Jeffrey Geppert, Project Director, Battelle Memorial Institute Sciences Data used for analyses: State Emergency Department Databases (SEDD), 2002-2006. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality