The Development of Emergency Department Patient Quality/Safety Indicators

On September 21, 2011, Patrick S. Romano made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (3 MB). Plugin Software Help.

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The Development of Emergency Department Patient Quality/Safety Indicators

Patrick S. Romano, MD MPH
UC Davis Center for Healthcare Policy and Research
AHRQ Annual Conference
September 21, 2011

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Overview

• Goals and scope of current project.
• Conceptual frameworks.
• Literature review.
• Matrix of potential indicators.
• Specification.
• Preliminary results.
• Recommendations and next steps.

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AHRQ Quality Indicators (QIs)

• Developed through contract with UCSF-Stanford Evidence-based Practice Center & UC Davis, maintained and extended through contract with Battelle.
• Use existing HCUP (hospital discharge) data, based on readily available data elements.
• Incorporate a range of severity adjustment methods, including APR-DRGs* and comorbidity groupings.
• Disseminate software and support materials free via http://www.qualityindicators.ahrq.gov.
• Provide technical support to users.
• Continuous improvement through user feedback, annual coding updates, validation projects.

* All Patient Refined—Diagnosis Related Groups

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Evidence-based Indicator Development

1. Literature review user suggestions.
2. Initial empirical analyses and definition.
3. Panel evaluation (modified Delphi Process).
4. Further empirical analyses refined definition.
5. Further review? Final definition.

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The HCUP Partnership: A Voluntary Federal-State-Private Collaboration

40+ states.
90% of all discharges.
24+ states submit ED encounters.

Image: A map of the United States showing participating states is shown.

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Types of HCUP Databases

State Inpatient Databases (SID).

• Nationwide Inpatient Sample (NIS).
• Kids' Inpatient Database (KID).
• Nationwide Emergency Department Sample (NEDS).

State Ambulatory Surgery Databases (SASD).

State Emergency Department Databases (SEDD).

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Goals and Scope

• Goals:
  • Develop quality/safety indicators, using HCUP data, that are applicable to the emergency department setting of care.
  • Set the stage for future incorporation into publicly available AHRQ QI software.
• Scope:
  • Implement the established AHRQ QI measure development process.
  • Adapt existing AHRQ QI to ED setting when possible.
  • Identify and evaluate new candidate indicators based on established measurement concepts.

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IOM Committee on the Future of Emergency Care in the United States Health System (2007)

• Called for "a standard national approach to the development of performance indicators."
• "The measures developed should include structure and process measures, but evolve toward outcome measures over time... (and) should be nationally standardized so that comparisons can be made across regions and states."
• "Measures should evaluate the performance of individual providers within the system, as well as that of the system as a whole... (and) be sensitive to the interdependence among the components of the system."
• "Performance data should be collected on a regular basis from all of the emergency care providers in a community" and then publicly disseminated..."

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Conceptual framework for prioritization: Institute of Medicine, 2007

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Conceptual Framework for Prioritization: Institute of Medicine, 2010

Image: The Conceptual framework for prioritization: Institute of Medicine, 2010 is shown.

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Conceptual Framework for Prioritization: ICES/Alberta Quality Matrix for Health, 2010

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Conceptual Framework for Prioritization: American College of Emergency Physicians, 2009

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Application of Conceptual Framework

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Literature review: strategy

Search goal:

• To find studies that introduced or used quality of care measures to assess patient safety in hospital emergency departments.

Search strategy using MESH headings in PubMed:

• ("Quality Assurance, Health Care"[Mesh] OR "Quality Indicators, Health Care"[Mesh] OR "Quality of Health Care"[Mesh] OR "Health Care Quality, Access, and Evaluation"[Mesh] OR "United States Agency for Healthcare Research and Quality"[Mesh] OR "Outcome Assessment (Health Care)"[Mesh])
  AND "Emergency Service, Hospital"[Mesh] AND ("Medical Errors"[Mesh] OR "Malpractice"[Mesh] OR "Safety"[Mesh] OR "Equipment Safety"[Mesh] OR "Safety Management"[Mesh]).

Validation using title and/or abstract keywords:

• "patient safety" OR "adverse event" OR "avoidable condition" AND "quality" AND ("emergency room" OR "emergency department").
• For the most important papers, we searched for 'all related articles.'

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Literature Review: Process

• PubMed®:
  • 1,050 abstracts, decreased to 687 when limited to human subjects, English language, date within 10 yrs.
  • All abstracts were reviewed for relevance (i.e., describing one or more measures of ED quality/safety).
• Similar review by Alessandrini et al. for PECARN.
• Organizations and Web sites:
  • National Quality Measures Clearinghouse™ (AHRQ).
  • National Quality Forum.
  • Federal: AHRQ QIs and CMS/QualityNet.
  • ED: ACEP and SAEM.
  • AMA: Physician Consortium for Performance Improvement.
  • Other developers: NCQA and The Joint Commission.
  • Institute of Medicine/National Academy of Sciences.
  • Canada: Institute for Clinical Evaluative Sciences, Canadian Institute for Health Information.

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Literature Review: Key Themes
40 Journal Papers, 23 Documents and Reports

• Some TJC Core Measures address processes of care in ED management of pneumonia or myocardial infarction.
• Critical trauma or shock care, generally based on detailed "peer" review of medical records to assess appropriateness and timeliness of diagnostic and therapeutic interventions.
• Time-based measures of waiting time, total LOS in the ED, ED disposition time for admitted/transferred patients.
• Appropriate prescribing and avoidance of medication errors for common conditions: asthma, bronchiolitis, acute GE, laceration.
• Appropriate use of imaging studies, laboratory, ECG.
• Appropriate assessment of pain, oxygenation, cognition.
• "Left without being seen" or "left AMA" (premature ED discharge).
• "Missed diagnosis" identified by return within defined time window for a serious condition.
• Revisits to ED within time window for same or related condition.

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Matrix of Potential Indicators: Inclusion/exclusion Criteria

• Identified from published source:
  • Literature review (40 journal articles).
  • Organizations and Web sites (if a consensus-based approach and/or modified Delphi approach was used).
• Address the domains of effectiveness and/or safety:
  • A few measures of timeliness were included because the measure developer characterized them as having implications for safety in the ED.
• Focus on care provided in the ED (not pre-hospital care).
• Clinical guidelines, standards of care, and ED decision rules were not included unless operationalized as indicators.
• Can be implemented in at least one HCUP partner state using available HCUP data.
• When ≥2 indicators addressed the same outcome, only the more recent and/or more clearly specified indicator was retained.
• Excluded measures that were evaluated and discarded or rejected through a consensus-based expert panel process.

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Matrix of potential indicators
Application of existing inpatient PSIs

• Foreign body left in.
• Iatrogenic pneumothorax.
• "Postoperative" hip fracture.
• "Postoperative" hemorrhage or hematoma.
• Accidental puncture or laceration.
• Transfusion reaction.

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Matrix of potential indicators
35 new candidate indicators

• Age range:
  • 12 for children only.
  • 10 for adults only.
  • 13 for both children and adults.
• Donabedian's typology:
  • 11 process.
  • 17 outcome (or proxy outcome such as revisit).
  • 6 hybrid ("missed serious diagnosis").
  • 1 patient experience or health risk behavior ("left AMA").
• Developer(s):
  • 20 Institute for Clinical Evaluative Sciences, specified in ICD-10-CA.
  • 3 ACEP and/or PCPI.
  • 3 CMS.
  • 4 other organizations.
  • 5 researchers.
• Endorsement—6 endorsed by NQF.

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Matrix of potential indicators
35 new candidate indicators

• Revisits—13:
  • 4 within 24 hours (1 specified as 24 hrs or 72 hrs).
  • 3 within 48 hours (2 specified as 48 hrs or 72 hrs).
  • 6 within 72 hours (1 specified as 72 hrs or 1 week).
• Missed serious diagnoses—7:
  • 1 unanticipated death within 7 days following ED care.
  • 6 admission for missed diagnosis (AMI/ACS, SAH, ectopic pregnancy, traumatic injury, appendicitis).
• Appropriate use of diagnostic test or imaging—5.
• Acute complications of ED procedures—3.
• Time within ED awaiting definitive care—3.
• Appropriate admission for inpatient care—2.
• Appropriate use of treatment or intervention—1.
• Left "against medical advice"—1.

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Challenges in specification and testing with HCUP data

• Identification of patients "at risk":
  • What procedures place patients at risk for hemorrhage, pneumothorax, or accidental puncture/laceration?
• Timing:
  • Only 5 states (GA, MA, MN, NJ, TN) have POA in SEDD; only MA and TN also have PNUM.
  • In SID, POA means "present at the time the order for inpatient admission occurs" and ED dx may be lost.
• Low frequency with "true" frequency unknown:
  • Unable to choose "best" specification.
• Uncertain validity of utilization flag variables to identify patients who had specific procedures (US, ECG, CT).
• Unable to operationalize all specifications:
  • Exclusion of "planned" (or "invited") return visits to ED.
  • All presenting symptoms for "missed diagnoses."

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Iatrogenic Pneumothorax 8 States, 2005-2008

Eligible patients—central venous catheterization (including transvenous pacemaker); thoracentesis; pericardiocentesis; paracentesis; insertion of ETT with or without mechanical ventilation.

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Postoperative Hemorrhage or Hematoma 8 States, 2005-2008

Eligible patients—central venous or arterial catheterization; aspiration or I&D; thoracentesis or thoracostomy; pericardiocentesis; paracentesis; insertion of ETT or rectal tube; LP; nerve block, fecal disimpaction.

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EDPSI #4: Potentially Missed Acute Myocardial Infarction (AMI) 

Numerator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, ages 18 to 95 years, meeting the inclusion and exclusion rules for the denominator and dated no more than 7 days previous to the linked SID record, with an eligible diagnosis code for a chest pain-related condition in ICD-9 CM diagnosis field.

Denominator

State Inpatient Databases: All hospital discharges, ages 18 to 95 years, with an eligible diagnosis code of acute myocardial infarction (AMI) in the ICD-9 principal diagnosis field and HCUP_ED>0.

Excludes all records with:

• Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
• Any AMI diagnosis (ICD-9-CM 410.00-410.92) on any linked SID record in the 12 months before this admission (if linked data are available).

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Variation Across States and Years

Image: A bar graph labeled: Figure 1 Percentage of eligible patients with Unanticipated Worsening of Acute Coronary Syndrome (ED-PSI #4) is shown:

Blue = 2007.
Red = 2008.
CV = 0.38-0.49.
Year-year corr = 0.94.

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EDPSI #5 Electrocardiogram for Non-Traumatic Chest Pain 

Numerator

Emergency department discharges meeting the inclusion and exclusion rules for the denominator with a utilization flag (U_EKG>0) indicating than an electrocardiogram (ECG) was performed and billed (based on an NUBC revenue code of 730 (EKG/ECG), 731 (Holter monitor), or 739 (Other EKG/ECG); or an ICD-9-CM procedure code of 89.51 [rhythm electrocardiogram] or 89.52 [electrocardiogram]).

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 40 years or older, with an eligible diagnosis code of nontraumatic chest pain in any ICD-9-CM diagnosis field and HCUP_ED>0.

Exclude all records with:

• A principal or secondary diagnosis of ventricular fibrillation (427.41), ventricular flutter (427.42), or cardiac arrest (427.5).
• Any procedure of cardiopulmonary resusicitation, not otherwise specified (99.60), or closed chest cardiac massage (99.63).
• Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
• Any documentation indicating death in the ED (DISPUNIFORM=20).
• Any documentation indicating patient left the ED against medical advice (DISPUNIFORM=7).

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Variation Across States and Years

Image: A bar graph labeled: Figure 2. Percentage of eligible patients Electrocardiogram for Non-Traumatic Check Pain (ED-PSI #5) is shown:

Blue = 2007.
Red = 2008.
CV = 0.01-0.03.
Year-year corr = 0.79.

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EDPSI #5 Electrocardiogram for Stroke 

Numerator

Emergency department discharges meeting the inclusion and exclusion rules for the denominator with a utilization flag (U_EKG>0) indicating than an electrocardiogram (ECG) was performed and billed (based on an NUBC revenue code of 730 (EKG/ECG), 731 (Holter monitor), or 739 (Other EKG/ECG); or an ICD-9-CM procedure code for electrocardiogram 89.52 [electrocardiogram]. Exclude numerator records with an ICD-9-CM procedure code for electrocardiogram (89.52) dated after the date of admission to the hospital.

Denominator

State Emergency Department Databases: All "treat and release" emergency department (ED) discharges, age 18 years or older, with an eligible diagnosis code of stroke in any ICD-9-CM diagnosis field and HCUP_ED>0.

Exclude all SED records with:

• A principal or secondary diagnosis of ventricular fibrillation (427.41), ventricular flutter (427.42), or cardiac arrest (427.5).
• Any procedure of cardiopulmonary resusicitation, not otherwise specified (99.60), or closed chest cardiac massage (99.63).
• Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.
• Any documentation indicating death in the ED (DISPUNIFORM=20).
• Any documentation indicating patient left the ED against medical advice (DISPUNIFORM=7).

Exclude all SID records with:

• Any diagnosis code assignable to MDC-14 (Complications of Pregnancy, Childbirth & Puerpurum), including ICD-9-CM-630-677.

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