New research was presented at ACEP 2015, the American College of Emergency Physicians’ annual meeting, from October 26 to 29 in Boston. The features below highlight some of the studies emerging from the conference.
Reducing Pediatric Head CT Use
The Particulars: Prior research suggests that head CT may be over-utilized in pediatric patients with mild head injuries. A program focused on physician education, shared decision making, and clinical decision support tools may help reduce unnecessary head CT use and associated radiation exposure.
Data Breakdown: For a study, researchers compared the year before with the year after the implementation of a quality improvement project to reduce inappropriate head CT use. The project included ED nurse and physician leadership engagement, physician education, a parent-patient shared decision-making model, a clinical decision support tool embedded into the electronic medical record, and importation of all data into clinical notes to reduce keystrokes and drive compliance. Prior to the intervention, head CT was used in 28% of pediatric patients presenting to the ED with mild head injuries, compared with a rate of 21% observed during the year after implementation of the intervention.
Take Home Pearl: Shared decision making and decision support tools appear to significantly reduce head CT utilization in pediatric patients presenting to the ED with mild head injury.
Streamlining ICU Admissions
The Particulars: Studies indicate that boarding of patients in the ED increases ED congestion, length of stay (LOS), and use of limited resources. Boarding can also worsen patient and family satisfaction as well as outcomes. Streamlining the admission of critically ill trauma patients to the ICU may help reduce ED boarding and its associated poor outcomes.
Data Breakdown: A study tested a process that allows critically ill trauma patients leaving ED resuscitation for a CT scan to then go directly to the ICU. Patients admitted to the ICU with this process had an average ED LOS that was 62% shorter than that of matched controls. No identifiable differences were observed between the patient groups with regard to hospital LOS, ICU LOS, mortality, 28-day ventilator-free days, DVT, urinary tract infections, pulmonary embolisms, or wound infections.
Take Home Pearl: A process that streamlines admissions for critically-ill trauma patients to the ICU from the ED appears to significantly decrease ED LOS without adverse outcomes.
Characterizing ED Frequent Visitors
The Particulars: Frequent visiting to the ED has been shown in prior studies to be a pattern of ED use that is linked with inefficiency. A greater understanding of the demographics and visiting characteristics of ED frequent visitors may help direct initiatives to reduce frequent ED use.
Data Breakdown: A retrospective study of adult patients who visited the ED four or more times per year was conducted to better understand the characteristics of occasional visitors (four to nine visits per year), moderately frequent visitors (10 to 19 visits per year), and highly frequent visitors (more than 20 visits per year). Patients who visited the ED four or more times per year made up nearly one-third of total ED visits. The patients were, on average, 39 years of age and were mostly female (54%). The following were also found:
|Occasional||Moderately frequent||Highly frequent|
|Assessed at levels 4 & 5 of Canadian Triage and Acuity Scale||62%||59%||58%|
|Positive history of cardiac disease||~10%||14%||22%|
|Cardiac disease accompanied by hypertension & diabetic history||23%||35%||—|
|ED length of stay of more than 4 hours||36%||43%||43%|
|More than two admissions per year||20%||38%||51%|
Take Home Pearls: Patients who visit the ED four or more times per year appear to constitute a substantial number of total ED visits. The rate of ED visits among this population appears to increase for those with poor health-related patient histories.
Improving Provider Communication in the ED
The Particulars: Studies have shown that checklists are a simple, inexpensive method for decreasing unwarranted variation in healthcare and improving physician adherence to best clinical and communication practices. However, few studies have assessed the utility of checklists in the emergency critical care setting.
Data Breakdown: Study investigators observed the delivery of care before and after implementing a visual checklist that was developed using best practice guidelines and included key activities that ideally occur during each care team huddle. The proportion of emergency physicians (EPs) observed who led a summary team discussion increased by 31% after implementation of the checklist. Significant improvements were also noted in the proportion of EPs discussing current knowledge of the patient, the working diagnosis, the care plan, and the disposition plan. The proportion of EPs observed asking nurses to call with changes in patient status or questions regarding patient care also improved significantly. Nurse ratings of their understanding of care goals, comfort with communication among providers, and feelings of being a valued team member all improved significantly.
Take Home Pearl: Implementation of a visually oriented checklist appears to increase the level or provider communication in the ED.
Analyzing ED Holding Orders
The Particulars: Data indicate that ED holding orders are commonly used to facilitate the transfer of admitted patients from the ED to an inpatient ward prior to admitting services evaluating patients. However, few studies have explored the safety and efficacy of this practice.
Data Breakdown: For a study, outcomes were compared between patients who were admitted to the hospital internal medicine service based on ED holding orders or for whom the ED did not write holding orders. No significant differences were observed between the groups in the rate of transfer to a higher level of care. However, patients with ED holding orders had significantly shorter lengths of stay (257 minutes vs 333 minutes).
Take Home Pearl: Transfer from the ED to an inpatient setting utilizing ED holding orders appears to significantly decrease patients’ length of stay without increasing the rate of transfer to a higher level of care.
For more information on these studies and others that were presented at ACEP 2015, visit http://www.acep.org/sa.