Emergency Department Quality Assurance Research Articles

Characterization of Emergency Department Quality Assurance Cases Seen Within a Midwestern United States Health System.

Hospital quality-assurance (QA) processes, including peer-review committees, seek to identify high-risk areas. To characterize emergency department (ED) cases sent for QA review. A retrospective observational study was conducted of ED cases sent to a QA committee from November 2018 through July 2022 at three midwestern US hospitals. The QA records analyzed for these cases included the original incident report, case summary, and the committee determinations. One hundred and forty-seven cases were reviewed by the ED QA Committee. The most frequent referrals came from physicians. Common diagnostic categories included infectious (21%), cardiac (16%), gastrointestinal (11%), and neurologic (10%) concerns. Of the cases, 51% were considered nonpreventable, 33% were potentially preventable, and 9% were preventable. Inpatient boarding in the ED was explicitly implicated as a contributing factor in 6% of case reports. Peer physician reporting represent the largest referral source sent for review with the most frequent diagnostic categories, including infectious, cardiac, gastrointestinal, and neurological conditions. Preventable concerns were rare. This study provides a better understanding of the referral sources, diagnostic categories, and committee determinations in ED quality concerns. These results can target future investigations into case reporting and patient safety.

54 Characterization of Emergency Department Quality Assurance Cases Seen Within a Midwestern United States Health System

54 Characterization of Emergency Department Quality Assurance Cases Seen Within a Midwestern United States Health System

Quantifying Clinically Meaningful Point-of-Care Ultrasound Interpretation Discrepancies Using an Emergency Department Quality Assurance Program.

Emergency medicine professional associations recommend that quality assurance (QA) programs be implemented wherever emergency department (ED) point-of-care ultrasound (POCUS) is in use. The purpose of this study is to identify the rate of clinically meaningful interpretation discrepancies between initial ED POCUS interpretation and a gold standard using a QA program in a Canadian academic ED. All POCUS examinations completed in our ED are subject to a QA process. The results of all POCUS examinations undergoing this process from July 1, 2014, to June 30, 2015, were retrospectively reviewed. Four blinded abstractors collected data with a standardized tool after a training session. Information regarding patient demographics, POCUS indication, emergency physician initial POCUS interpretation, physician POCUS expertise, the presence of an interpretation discrepancy, and whether the discrepancy was clinically meaningful was abstracted. The proportion of interpretation discrepancies, clinically meaningful discrepancies, discrepancies requiring remedial action, and differences in discrepancy rates between non-expert and expert sonographers were analyzed. A total of 2,869 POCUS studies were included for review, with 2,668 in the final data set after exclusions. In total, only 1.4% of all scans contained an interpretation discrepancy. The rate of clinically meaningful discrepancies was 0.5%, and the rate of scans requiring remedial action was 0.1%. Overall, 85.5% of all scans were performed by four POCUS expert physicians, with the remainder by a non-expert. Scans performed by non-expert sonographers were significantly more prone to discrepancies than those performed by experts. No single scan indication was more prone to discrepancy. The overall ED POCUS interpretation discrepancy rate and clinically meaningful discrepancy rate identified using our QA process were very low. The findings are limited by the small group of expert sonographers completing most scans.

Acute Appendicitis: Clinical Clues and Conundrums Related to the Greatest Misses.

IntroductionIn the United States (US), appendicitis is the most common acute abdominal emergency requiring surgery. Patients with appendicitis continue to display a complex and atypical range of clinical manifestations, providing a subsequent high risk for emergency physicians to miss acute abdominal pathology on a patient’s initial visits. Due to the risk of potential perforation, the proper and timely clinical identification of acute appendicitis is vital. The current study aims to identify clinical characteristics that could be useful in identifying patients at risk for having acute appendicitis that was misdiagnosed on their initial visits.MethodsMedical charts consisting of patients between the ages of 19 and 55 years on their second visit were flagged and reviewed by the emergency department quality assurance (EDQA) committee. The retrospective chart review included patients who presented to the emergency department (ED) with the chief complaint of an abdominal-related complaint, were discharged, returned within 72 hours, and were diagnosed with a pathologically confirmed appendicitis. All patients were managed operatively, with pathology results reviewed for evidence of acute appendicitis. Those with confirmed pathologic appendicitis upon return were considered to have a “misdiagnosis.” Any patients managed nonoperatively and those with negative pathology were excluded from the study and considered not to have appendicitis.ResultsFifty-five patients were identified through the EDQA committee from May 2011 to January 2014. After exclusion criteria were applied, 18 patients met the inclusion criteria for this study (7 males, 11 females). The mean age was 36.2 (range: 19-55). The most common presenting complaint on the initial visit was pain in the epigastric region of the abdomen (50%, n = 9). Twenty-two percent (n = 4) of patients had pain in the right lower quadrant documented in the physician’s note on the initial visit and 83% (n = 15) had right lower quadrant pain documented on the second visit. Two patients (11%) did not have right lower quadrant tenderness on either visit. The most common discharge diagnosis on the initial visit was undifferentiated abdominal pain (50%), followed by gastritis (28%). Opioid pain medication was administered or prescribed to 39% (n = 7) of the patients. The average return time was 23.9 hours.ConclusionThe administration of opioid pain medication is associated with many of the return visits to the emergency department for missed appendicitis. Finally, discharge diagnosis and planning are imperative, as detailed early appendicitis instructions or extended ED observation can include more cases and decrease litigation risk.

Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error

BackgroundIt is believed that patients who return to the Emergency Department (ED) and require admission are thought to represent failures in diagnosis, treatment or discharge planning. Screening readmission rates or patients who return within 72 h have been used in ED Quality Assurance efforts. These metrics require significant effort in chart review and only rarely identify care deviations. ObjectiveThis study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. We planned to assess if the return visits with ICU admission were associated with deviations in care, and secondarily, to understand the common causes of error in this group. MethodsRetrospective review of patients presenting to a university affiliated ED between January 1, 2005 and December 31, 2015 and returned within 14 days requiring ICU admission. ResultsFrom 1,106,606 ED visits, 511 patients returned within 14 days and were admitted to an ICU. 223 patients returned for a reason related to the index visit (43.6%). Of these related returns, 31 (13.9%) had a deviation in care on the index visit. When a standard diagnostic process of care framework was applied to these 31 cases, 47.3% represented failures in the initial diagnostic pathway. ConclusionReviewing 14-day returns leading to ICU admission, while an uncommon event, has a higher yield in the understanding of quality issues involving diagnostic as well as systems errors.

P093: Quality assurance programs for tests pending at discharge from emergency departments: a systematic review

Introduction: Emergency department (ED) care allows for the rapid assessment of patient concerns, but often leads to tests being performed that are not finalized or reviewed prior to patients leaving the ED. The follow-up for these tests pending at discharge (TPADs), most commonly final diagnostic imaging (DI) reports and microbiology cultures, is a major medico-legal concern for ED providers and significant safety concern for patients. We therefore performed a systematic review of the literature to identify existing ED quality assurance (QA) processes to address TPADs relating to final DI reports and microbiology cultures. Methods: Comprehensive literature searches were developed with a medical librarian and conducted in Ovid Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL from inception through May 8, 2018. Studies were included if they described an intervention or program designed to follow-up relevant ED TPADs, and excluded if they pertained to communication between departments or clinicians only rather than with patients. Study selection was performed independently by two reviewers in two steps (title and abstract review, then full-text review), with all discrepancies resolved by consensus with a senior reviewer. The primary outcome was the description of any QA process to follow-up on TPADs and secondary outcomes included quantifiable results of successful interventions or programs. Results: From the 11,685 articles identified, 58 were selected for full-text review, and 12 met eligibility criteria. In the included studies, the responsibility for following up on TPADs was owned by different members of the care team (e.g., ED physicians, nurses or radiologists) and recorded in a variety of ways (e.g., electronic medical record, paper chart, system designed for TPADs). Follow-up pathways with variable standardization were described, ranging from dedicated assignment for TPAD duties with protected/remunerated time to do so, to follow-up completion done by the first clinician to receive the TPAD result. Studies that evaluated their QA process implementation found that more patients were notified of abnormal test results, follow-up times decreased, and fewer unnecessary antibiotics were used. Conclusion: A variety of QA processes have been implemented to follow up on ED TPADs in terms of personnel involved, charting and logistics, and when evaluated, they have improved patient care.

72 h returns: A trigger tool for diagnostic error

BackgroundPatients who return to the Emergency Department (ED) within 72h of discharge are often used for ED Quality Assurance efforts, however little is known about the yield of this kind of review and the types of errors it identifies. Our objective was to identify the prevalence, types and severity of errors in these cases. MethodsRetrospective review of patients who presented to an urban, university affiliated ED between 10/1/2012–9/30/2015 who returned within 72 h requiring hospital admission. ResultsThere were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72h and were admitted to the hospital. An event requiring further investigation was identified in 59 (2.95%) of these patients and 50 (2.49%) of them were deemed to represent a deviation from optimal care. Of these, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%). When Error Severity Codes were applied, 16 (32%) resulted in minor harm and 34 (68%) resulted in major harm or death. ConclusionScreening of 72h ED returns has low yield in identifying suboptimal care, with less than 3% of cases representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. These reviews may be useful as a tool for Ongoing Professional Practice Evaluation of individual clinicians, however likely serve less value in identifying systems issues contributing to unsafe care.

P003: Emergency department quality assurance sepsis project: why are more people dying in southwestern Ontario?

Introduction: London Health Sciences Centre (LHSC) includes two academic, urban hospitals in London, Canada. The hospital-standardized mortality ratio (HSMR) is consistently higher than provincial and national averages. Unpublished data reveals that sepsis contributes the largest number of statistically unexpected deaths to LHSC’s HSMR calculation. Factors contributing to in-hospital sepsis mortality are hypothesized to include demography, emergency department (ED) flow or sepsis treatment. Methods: Retrospective chart review of patients aged >=18 years, presenting to an LHSC ED between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis (ICD-10 diagnostic codes A4xx and R65). Data were abstracted from electronic health records. Regional, provincial and national data was retrieved from CIHI and Statistics Canada. Results: Median age and sex in London and across Canada are similar (48.2 years vs 48.9 years; 48% male vs 49% male). Baseline prevalences of diabetes, hypertension, COPD and mood disorders were similar in the Local Health Integration Network and Ontario (6% vs 7%, 19% vs 19%, 3% vs 4%, and 10% vs 8%). Median “Physician Initial Assessment,” (PIA) times for sepsis patients at LHSC were faster than median Canadian PIA times for CTAS I and II patients (CTAS I: 7 min vs 11 min, CTAS II: 34 min vs 54 min), and slower for CTAS III-V patients (CTAS III: 98 min vs 79 min, CTAS IV: 99 min vs 66 min, CTAS V: 132 min vs 53 min). Median ED length of stay for admitted, high acuity (CTAS I-III) patients was 6 h at LHSC versus 10 h across Canada.Median [IQR] time to intravenous fluid resuscitation was 60.5 min [29.8-101.2] for septic shock patients and 77.0 min [36.0-127.0] for expired patients. Median [IQR] time to antibiotics was 130 min [73.0-229.0] for sepsis patients, 106 min [60.0-189.0] for severe sepsis patients, and 82 min [42.2-142] for septic shock patients. Conclusion: Excess sepsis-related mortality at LHSC is not convincingly related to patient demographics or ED flow. Gains may be made by improving time to antibiotics and IV fluids.

342 72-Hour Returns: A Trigger Tool for Diagnostic Error

Patients who return to the emergency department (ED) within 72 hours of discharge are thought to represent failures in diagnosis, treatment and discharge planning. As a result, this metric is often seen as a surrogate for quality and used for ED quality assurance efforts. Little is known about the yield of this kind of review and the types of errors it identifies. The objective of this study was to identify the prevalence of error deficient care in patients who return within 72 hours and require admission, as well as the types and severity of harm in these patients. Retrospective review of all patients who presented to an urban, university-affiliated ED between October 1st, 2012 and September 30th, 2015 who were evaluated, discharged, and returned within 72 hours requiring hospital admission. As a part of departmental quality assurance activities, the records were reviewed by attending physician members of the Quality and Safety Committee. Any visit felt to represent substandard care was flagged for further investigation. These cases then received a secondary review by a different ED attending who classified the deviation in care for this study, if present, using a standard classification system. There were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72 hours and were admitted to the hospital. An event requiring further investigation was identified in 59 of these patients (2.95% of all 72-hour returns), and 50 of them (2.49% of all 72-hour returns and 0.0119% of all ED visit) were deemed to represent a deviation from optimal care (see Figure 1). Of these cases, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these 48 encounters, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%), including a failure to obtain a complete history and conduct a complete physical exam (3 cases, 6.2%), failure of ongoing monitoring of clinical status (4 cases, 8.3%), failure to establish a differential diagnosis (20 cases, 41.6%) and failure to order the appropriate diagnostic test (2 cases, 4.1%). The remainder of the cases represented failures in completing testing and results processing (13 cases, 27%), and failures in follow-up and coordination (6 cases, 12.5%). When the National Patient Safety Foundation’s Error Severity Codes were applied to the 50 cases that represented deviations from optimal care, 12 (24%) resulted in minor temporary harm, 30 (60%) in major temporary harm, 4 (8%) in minor permanent harm, 1 (2%) in major permanent harm and 3 (6%) resulted in death. Standard screening methodology of 72-hour ED returns resulting in admission has relatively low yield in identifying suboptimal care, with less than 3% of cases reviewed representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. As such, these reviews may be useful as a tool for ongoing professional practice evaluation of individual clinicians, however likely serve less value in identifying departmental systems issues contributing to unsafe care. Future study should focus on understanding the yield of other departmental QA triggers such as safety reports and morbidity and mortality conferences.

Can medical record reviewers reliably identify errors and adverse events in the ED?

BackgroundChart review has been the mainstay of medical quality assurance practices since its introduction more than a century ago. The validity of chart review, however, has been vitiated by a lack of methodological rigor. ObjectivesBy measuring the degree of interrater agreement among a 13-member review board of emergency physicians, we sought to validate the reliability of a chart review–based quality assurance process using computerized screening based on explicit case parameters. MethodsAll patients presenting to an urban, tertiary care academic medical center emergency department (annual volume of 57,000 patients) between November 2012 and November 2013 were screened electronically. Cases were programmatically flagged for review according to explicit criteria: return within 72hours, procedural evaluation, floor-to-ICU transfer within 24hours of admission, death within 24hours of admission, physician complaints, and patient complaints. Each case was reviewed independently by a 13-member emergency department quality assurance committee all of whom were board certified in emergency medicine and trained in the use of the tool. None of the reviewers were involved in the care of the specific patients reviewed by them. Reviewers used a previously validated 8-point Likert scale to rate the (1) coordination of patient care, (2) presence and severity of adverse events, (3) degree of medical error, and (4) quality of medical judgment. Agreement among reviewers was assessed with the intraclass correlation coefficient (ICC) for each parameter. ResultsAgreement and the degree of significance for each parameter were as follows: coordination of patient care (ICC=0.67; P<.001), presence and severity of adverse events (ICC=0.52; P=.001), degree of medical error (ICC=0.72; P<.001), and quality of medical judgment (ICC=0.67; P<.001). ConclusionAgreement in the chart review process can be achieved among physician-reviewers. The degree of agreement attainable is comparable to or superior to that of similar studies reported to date. These results highlight the potential for the use of computerized screening, explicit criteria, and training of expert reviewers to improve the reliability and validity of chart review–based quality assurance.

Emergency medicine task shifting: Quick dash outcome scores of upper extremity injury management

Study Objectives This is a pilot study using the Quick DASH Survey (disabilities of arm, shoulder and hand), a validated outcome measurement tool. Our primary objective was to assess functional outcomes of patients with acute upper extremity injuries who were cared for by non-physician clinicians as part of a task-shifting program. Secondarily, we determined if the Quick DASH can be successfully utilized in a non-traditional low-resourced setting. Methods This pilot was administered by the Global Emergency Care Collaborative (GECC) at the Karoli Lwanga Hospital Emergency Department (ED) in Uganda. Patients were identified retrospectively by querying the ED quality assurance database. An initial list of all patients who sustained traumatic injury (RTA, Assault or Accident) between March 2012 and February 2013 was narrowed to patients with upper extremity trauma, those 18 yrs and older, and those with cellular phone access. This subset of patients was called and administered the Quick DASH. The results were subsequently analyzed using the standardized DASH metrics. These outcome measures were further analysed based upon injury type (simple laceration, complex laceration, fracture, subluxation), laceration location (finger, palm, wrist), age at presentation (18–69), and time from initial presentation to follow up (1–11 months). Results and conclusions There were a total of 25 initial candidates, of which only 17 were able to complete the survey. Using the Quick DASH Outcome Measure, our 17 patients had a mean score of 29.5 (range 5.0– 56.8). When compared to the standardized Quick DASH outcomes (no work limitation at 27.5 vs. work limited by injury at 52.6) the non-physician clinicians appear to be performing upper extremity repairs with good outcomes. The key variable to successful repair was the initial injury type. Although accommodations needed to be made to the standard Quick DASH protocol, the tool appears to be usable in non-traditional settings.

Who leaves the emergency department without being seen? A public hospital experience in Georgetown, Guyana

BackgroundLeft without being seen (LWBS) proportions are commonly used as quality control indicators, but little data is available on LWBS proportions in the developing world. This study sought to determine the proportion and characteristics of patients who LWBS from the emergency department (ED) of the main public hospital in Georgetown, Guyana.MethodsThis is a retrospective cross-sectional analysis of an ED quality assurance database. Registration personnel collected demographic information on patients presenting to the ED over a 2-week period in July 2010. Both univariate and multivariate analysis were conducted to determine patient characteristics associated with LWBS.ResultsThe LWBS proportion was 5.7%. In univariate analysis, patients 18 or older (OR 1.48, 95%CI 1.03-2.12), presenting during the 4PM-12AM shift (OR 2.15, 95%CI 1.53-3.01), with non-urgent triage classification (OR 1.88, 95%CI 1.76-4.66), with non-traumatic chief complaints (OR 1.70, 95%CI 1.14-2.55), or who were not transferred (OR 2.13, 95%CI 1.00-4.55) had significantly higher odds of LWBS. On multivariate analysis, only patients 18 or older (OR 1.54, 95%CI 1.02-2.33), presenting during the 4PM-12AM shift (OR 2.29, 95%CI 1.54-3.40), and with non-traumatic chief complaints (OR 2.39, 95%CI 1.43-4.02) were found to be significantly associated with LWBS. Sex, residence in the capital city, time to triage, transfer status, use of EMS, and triage classification were not statistically associated with LWBS.ConclusionsLWBS proportions are used as quality control indicators and this study determined the LWBS proportion at a public hospital in a developing country and some of the patient characteristics associated with LWBS. This can be helpful to develop strategies to decrease LWBS proportions and to assess progress over time.

389: Emergency Department Quality Assurance Referral Patterns

389: Emergency Department Quality Assurance Referral Patterns

Accuracy of radiographic readings in the emergency department

Objectives A review of radiology discrepancies of emergency department (ED) radiograph interpretations was undertaken to examine the types of error made by emergency physicians (EPs). Methods An ED quality assurance database containing all radiology discrepancies between the EP and radiology from June 1996 to May 2005 was reviewed. The discrepancies were categorized as bone, chest (CXR), and abdomen (AXR) radiographs and examined to identify abnormalities missed by EPs. Results During the study period, the ED ordered approximately 151 693 radiographs. Of the total, 4605 studies were identified by radiology as having a total of 5308 abnormalities discordant from the EP interpretation. Three hundred fifty-nine of these abnormalities were not confirmed by the radiologist (false positive). The remainder of the discordant studies represented abnormalities identified by the radiologist and missed by the EP (false negatives). Of these false-negative studies, 1954 bone radiographs (2.4% of bone x-rays ordered) had missed findings with 2050 abnormalities; the most common missed findings were fractures and dislocations. Of the 220 AXRs (3.7% of AXRs ordered) with missed findings, 240 abnormalities were missed; the most common of these was bowel obstruction. Of the 2431 CXRs (3.8% of CXRs ordered), 2659 abnormalities were missed; the most common were air-space disease and pulmonary nodules. The rate of discrepancies potentially needing emergent change in management based solely on a radiographic discrepancy was 85 of 151 693 x-rays (0.056%). Conclusions Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules. Continuing education should focus on these areas to attempt to further reduce this error rate.

Biliary ultrasonography for cholelithiasis: A retrospective analysis of the first two years of an emergency ultrasonography training program

Study objectives: Traditional diagnostic evaluation for patients presenting to the emergency department (ED) with right upper quadrant (RUQ) pain involves an ultrasonography performed by a sonographer and interpreted by a radiologist, which can result in long delays, higher costs, and patient dissatisfaction. Emergency physicians performing the initial RUQ ultrasonography to investigate for cholelithiasis can potentially shorten this evaluation. Previous studies in the emergency medicine literature report the accuracy of emergency physicians performing RUQ ultrasonography but have relatively small sample sizes. The study objective is to analyze the accuracy of bedside RUQ ultrasonography for evaluation of cholelithiasis by emergency physicians. Methods: A retrospective study was conducted on patients presenting to the ED who received a focused RUQ ultrasonography performed by an emergency medicine resident or attending physician between July 2001 and November 2003 in our urban, university, Level I trauma center. Physicians performing bedside ultrasonography were given various lectures on abdominal ultrasonography, including hands-on practice with quality assurance follow-up of videotaped scans. Emergency ultrasonographic examinations were performed using a 3.5-Mhz microconvex probe. All scans included in this study were reviewed by the quality assurance committee consisting of an emergency ultrasonography fellowship–trained attending physician and an emergency ultrasonography fellow. The quality assurance committee was blinded to the findings of the radiology ultrasonographs. Emergency ultrasonographic findings were limited to the presence or absence of gallstones. Three sets of comparisons were made: (1) emergency ultrasonographic findings versus the ED quality assurance committee's findings; (2) emergency ultrasonographic findings versus the radiology ultrasonographic findings; and (3) ED quality assurance committee's findings versus the radiology ultrasonographic findings. Results: Of a total of 1,577 emergency RUQ ultrasonographs during the study period, a total of 1,191 scans met inclusion criteria. Three hundred eighty-six scans were excluded because of documentation errors and poor image quality. Overall, 411 (35%) patients were confirmed to have gallstones, and 780 (65%) were without gallstones. Emergency resident interpretation had an 88% sensitivity, 97% specificity, and 93% accuracy when compared when compared with the ED quality assurance committee's findings. Of the 1,191 patients in the study, 429 (36%) patients also had a radiology ultrasonograph. From these, 257 (60%) patients were confirmed to have gallstones, and 172 (40%)patients were without gallstones. Compared with a radiology ultrasonograph as the criterion standard, emergency resident interpretation had an 88% sensitivity, 87% specificity, and 88% accuracy. When comparing the ED quality assurance committee's findings of this same subset against the radiology ultrasonograph (the criterion standard), the ED quality assurance committee was found to have a 91% sensitivity, 91% specificity, and 91% accuracy. Conclusion: Emergency bedside RUQ ultrasonography is an effective method of diagnosing cholelithiasis. Emergency physicians with a moderate amount of training have a high sensitivity and specificity for diagnosing cholelithiasis compared with radiology-performed ultrasonography. Furthermore, we demonstrate that review of recorded ultrasonographs from the ED by a fellowship-trained quality assurance committee can increase the accuracy of diagnosing cholelithiasis and serve as an important educational tool. These data add to a growing support for the use of bedside ultrasonography in the ED.

A Two-Year experience with bedside emergency ultrasonography for acute scrotal pain in the emergency department

Study objectives: Acute scrotal pain is a modestly common emergency department (ED) complaint. Because of increasing limitations in imaging services, emergency physicians are using their bedside ultrasonographic skills for more difficult diagnoses such as scrotal pain. We describe the practice pattern and sensitivity of bedside ED ultrasonography performed by emergency physicians for acute scrotal pain during a 2-year period. Methods: This was a retrospective quality assurance study performed at an urban ED with a residency program, an active ultrasonographic education program including an emergency ultrasonographic fellowship. The facility has an annual census of 75,000 patients. The ED quality assurance log was searched for all scrotal ultrasonographic studies performed for complaints of scrotal pain presenting within 24 hours of onset. A 12-MHz linear array transducer with pulsed wave and power Doppler capability was used to scan the scrotum. Diagnoses were verified by radiology ultrasonography, nuclear medicine, surgical evaluation, and patient follow-up. Descriptive statistics, sensitivity, and specificity with 95% confidence intervals (CIs) were calculated. Results: Eight emergency physicians performed a total of 146 scrotal ultrasonographic studies. Comparison with follow-up data with emergency physician ultrasonographic results yielded a sensitivity of 95% (95% CI 0.78% to 0.99%) and a specificity of 94% (95% CI 0.72% to 0.99%). Diagnoses included 14 (10%) testicular torsions, 41 (28%) cases of epididymitis, 16 (11%) cases of orchitis, 6 (4%) testicular fractures from trauma, 8 (6%) hernias presenting as acute scrotal pain and swelling, 21 (14%) hydroceles without other pathology, 7 (5%) cases of torsion of the appendix testes, 9 (6%) scrotal infections including Fournier's gangrene, and 24 (16%) normal examinations on which no pathology was noted. Conclusion: Emergency physicians using bedside emergency ultrasonography encounter a variety of causes of acute scrotal pain and are accurate in their diagnosis compared with traditions imaging and surgical services. Most important, they appear able to differentiate between surgical emergencies such as testicular torsion and other etiologies that require medical or supportive treatment. Study objectives: Acute scrotal pain is a modestly common emergency department (ED) complaint. Because of increasing limitations in imaging services, emergency physicians are using their bedside ultrasonographic skills for more difficult diagnoses such as scrotal pain. We describe the practice pattern and sensitivity of bedside ED ultrasonography performed by emergency physicians for acute scrotal pain during a 2-year period. Methods: This was a retrospective quality assurance study performed at an urban ED with a residency program, an active ultrasonographic education program including an emergency ultrasonographic fellowship. The facility has an annual census of 75,000 patients. The ED quality assurance log was searched for all scrotal ultrasonographic studies performed for complaints of scrotal pain presenting within 24 hours of onset. A 12-MHz linear array transducer with pulsed wave and power Doppler capability was used to scan the scrotum. Diagnoses were verified by radiology ultrasonography, nuclear medicine, surgical evaluation, and patient follow-up. Descriptive statistics, sensitivity, and specificity with 95% confidence intervals (CIs) were calculated. Results: Eight emergency physicians performed a total of 146 scrotal ultrasonographic studies. Comparison with follow-up data with emergency physician ultrasonographic results yielded a sensitivity of 95% (95% CI 0.78% to 0.99%) and a specificity of 94% (95% CI 0.72% to 0.99%). Diagnoses included 14 (10%) testicular torsions, 41 (28%) cases of epididymitis, 16 (11%) cases of orchitis, 6 (4%) testicular fractures from trauma, 8 (6%) hernias presenting as acute scrotal pain and swelling, 21 (14%) hydroceles without other pathology, 7 (5%) cases of torsion of the appendix testes, 9 (6%) scrotal infections including Fournier's gangrene, and 24 (16%) normal examinations on which no pathology was noted. Conclusion: Emergency physicians using bedside emergency ultrasonography encounter a variety of causes of acute scrotal pain and are accurate in their diagnosis compared with traditions imaging and surgical services. Most important, they appear able to differentiate between surgical emergencies such as testicular torsion and other etiologies that require medical or supportive treatment.

Emergency Department Quality Assurance/Improvement Practices for the Pediatric Patient

Study objective: To describe emergency department quality assurance (QA)/improvement (QI) practices for pediatric patients. Design: Mail survey of a cohort of emergency physicians. Participants: Pediatric Section members of the American College of Emergency Physicians and a computer-generated random sample of general ACEP members. Results: Pediatric Section and general ACEP physicians were mailed a 13-question QA survey. Of the 500 surveys distributed, 207 (41.4%) were returned. Three emergency care settings for pediatric patients seen in the ED were identified: (1) children's hospital ED (14%), (2) general ED with a separate area designated for the evaluation of pediatric patients (12%), and (3) general ED where pediatric and adult patients are evaluated in the same area (74%). Separate QA indicators were used to monitor care of the pediatric patients seen in the ED by 61% of the respondents; 39% used "adult" indicators only. High pediatric census was associated with pediatric representation on the ED QA/QI Committee, the use of separate pediatric indicators to monitor care of pediatric patients in the ED, the separation of pediatric and adult patient care areas and satisfaction with the respondent's ED QA/QI plan. Conclusion: The bulk of pediatric emergency patients are cared for in a general ED. Most ACEP members surveyed reported the use of separate QA indicators to monitor the care of pediatric patients seen in the ED. This survey provides the first description of QA/QI practices for pediatric patients by EDs nationwide. [Gausche M, Rutherford M, Lewis RL: Emergency department quality assurance/improvement practices for the pediatric patient. Ann Emerg Med June 1995;25:804-808.]

Use of autopsy results in the emergency department quality assurance plan

Traditionally, the autopsy is viewed as the ultimate quality assurance indicator in clinical medicine, yet very few clinical departments actually incorporate autopsy results in their formal quality assurance plans. Consequently, to investigate how autopsy results can be included on our emergency department plan, the clinical and autopsy diagnoses of 244 patients were reviewed retrospectively and compared to identify conditions that were unapparent or misdiagnosed at the time of death. The study period was from January 1984 through June 1988. The average yearly ED census was 33,266. Differences between clinical and autopsy diagnoses were categorized as class 1, 2, 3, or 4 findings. Major unexpected findings (classes 1 and 2) were found in ten patients (4%); the most common missed diagnoses were aortic dissection 3 (1.2%) and pulmonary embolus 2 (0.8%). Minor unexpected findings (classes 3 and 4) were discovered in 14 patients (5.8%). The results clearly identify unexpected findings and point to the need for more aggressive evaluations of certain conditions. Systematic review of autopsy data as presented has led to meaningful changes and delivery of care to emergency patients. Autopsies are a vital source of outcome-based information that should be part of every ED's quality assurance and risk management plan.

A Computerized Log and Integrated Quality Assessment Program for the Small Emergency Department

Emergency department staff at Valley View Medical Center, a 48-bed rural hospital in Utah, implemented a computerized log and integrated a quality assessment program within their small department. A microcomputerized relational data base format is used to keep and cross-reference patient logs and audits. The system stores data for use in emergency department quality assurance (QA) activities, for monitoring trends in patient care, and for recredentialing decisions. The computerized program allows staff to significantly increase the amount of information they can collect for QA activities. It also provides rapid, flexible reporting functions for staff and patient feedback and aids in the collection and dissemination of data to regulatory agencies. The system minimizes physician and nurse time spent in recording and collecting data, while simultaneously increasing their QA involvement.

Use of autopsy results in the emergency department's quality assurance plan

Use of autopsy results in the emergency department's quality assurance plan