The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) Potentially Inappropriate Medication Dashboard: A Suitable Alternative to the In-person Academic Detailing and Standardized Feedback Reports of Traditional EQUIPPED?

PurposeThe Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) program is a quality improvement initiative that combines education, clinical decision support (ie, geriatric pharmacy order sets), and in-person academic detailing coupled with audit and feedback in an effort to improve appropriate prescribing to older veterans discharged from the emergency department. Although the EQUIPPED program is effective at reducing the prescribing of potentially inappropriate medications, the reliance on in-person academic detailing may be a limitation for broader dissemination. The EQUIPPED dashboard is a passive yet continuous audit and feedback mechanism developed to potentially replace the in-person academic detailing of the traditional EQUIPPED program. We describe the development process of the EQUIPPED dashboard and the key audit and feedback components found within.MethodsThe Veterans Affairs (VA) Corporate Data Warehouse (CDW) serves as the underlying data source for the EQUIPPED dashboard. SQL Server Integration Services was used to build the backend data architecture. Data were isolated from the CDW for reporting purposes using an extract, load, transform (ELT) approach. The team used SQL Server Reporting Services to produce the user interface and add interactive functionality. The team used an agile development approach when designing the user interface, engaging end users at 2 VA EQUIPPED implementation sites by providing printed screenshots of a beta version of the dashboard.FindingsThe EQUIPPED dashboard ELT process executes nightly to provide dashboard end users with a near real-time data experience and the potential for daily audit and feedback. The following dashboard components were identified as necessary for the EQUIPPED dashboard to be a suitable audit and feedback tool: key performance indicators, peer-to-peer benchmarking, individual patient or encounter drill down, educational decision support, and longitudinal performance tracking.ImplicationsTo our knowledge, the EQUIPPED dashboard is the first information display of its kind with built-in audit and feedback that has been developed for VA emergency department practitioners as the primary end users. Further investigation is warranted to determine whether the EQUIPPED dashboard is a suitable alternative to in-person academic detailing. The EQUIPPED dashboard will be leveraged in a formal implementation trial that will entail the randomization of multiple VA sites to either (1) traditional EQUIPPED with in-person academic detailing coupled with audit and feedback or (2) EQUIPPED with passive audit and feedback delivered through the EQUIPPED dashboard without in-person prescribing outreach.     

Improving adherence to asthma clinical guidelines and discharge documentation from emergency departments: Implementation of a dynamic and integrated electronic decision support system†

Objective: The authors previously developed a dynamic and integrated electronic decision support system called ACAFE (Asthma Clinical Assessment Form and Electronic decision support). The objective of this present study was to evaluate the effectiveness of this system on asthma management and documentation in an ED. Method: Observational study using a pre‐ and post‐intervention design, comparing patients managed using ACAFE after its implementation with historical controls. A systematic data abstraction process was used to compare patient records. Results: A total of 50 patients were enrolled in the study group. These were compared with 50 historical controls. Use of ACAFE was associated with significantly higher rates of documentation of asthma severity (98% vs 18%, P < 0.01), as well as other clinically important variables, such as asthma precipitants, intensive care admission history and smoking history. ACAFE was also associated with significantly higher rate of asthma discharge plan documentation (76% vs 16%, P < 0.01), and this remained significant after adjustment for triage category and seniority of treating doctor in a regression model. Conclusion: The use of this decision support system in patients presenting to emergency with asthma was associated with improvements in clinical documentation and discharge management plans. Electronic decision support systems developed collaboratively with clinicians should play an important part of system‐wide efforts to improve guideline adherence and compliance in ED.     

Use of a collaborative database for epidemiological analyses and professional practice evaluation

Rationale In nephrology, the NEOERICA project assessed the feasibility of the diagnosis scheme based on a general practice database. This approach opened a new area where routinely collected data could be used for purposes other than patient management, such as epidemiological analysis and professional practice evaluation. In Lyon, the TIRCEL network is made up of a coordination team and an online database. In 2008, a total of 468 professionals participated and 983 patients were in the database corresponding to 4114 consultations and 9250 biological assessments. Objective To investigate the impact of a quality control process on the data from operational databases. Methods We set up a quality control process and we described the impact of this process on data. We also specifically investigated the role of measurement scales in error frequency and we studied the impact of data quality on variables which could be used for professional practice evaluation. Results Quality control allowed us to detect as inconsistent data 7.5% of tested data. This rate is linked to the parameters and varied from less than 1% (weight, diastolic blood pressure and urinary sodium) to more than 30% (serum iron and ferritin). Quality control led mainly to the validation of the identified data for 80.4%, a direct correction was realized for 12.9%, 5.6% by the lab and only 1.2% were set to missing. Average proteinuria was modified with the quality control process (2.09 g per 24 hours vs. 0.82 g per 24 hours); however, the median remained stable (0.21 g per 24 hours). Conclusion Specialty databases such as TIRCEL could not be used for epidemiological research or for the extraction of indicators for professional practice evaluation without strict quality control or the set‐up of data‐entering limits and alarms.     

Computerized Physician Order Entry and Online Decision Support

Computerized physician order entry (CPOE) and decision support systems (DSS) can reduce certain types of error but often slow clinicians and may increase other types of error. The net effect of these systems on an emergency department (ED) is unknown. The consensus participants combined published evidence with expert opinion to outline recommendations for success. These include seamless integration of CPOE and DSS into systems and workflow; ensuring access to Internet-based and other online support material in the clinical arena; designing systems specifically for the ED and measuring their impact to ensure an overall benefit; ensuring that CPOE systems provide error and interaction checking and facilitate weight- and physiology-based dosing; using interruptive alerts only for the highest-severity events; providing a simple, vendor-independent interface for institutional customization of CPOE alert thresholds; maximizing the use of automated systems and passive data capture; and ensuring the widespread availability of CPOE and DSS using secure wireless and portable technologies where appropriate. Decisions regarding CPOE and DSS in the ED should be guided by the ED chair or designee. Much of what is believed to be true regarding CPOE and DSS has not been adequately studied. Additional CPOE and DSS research is needed quickly, and this research should receive funding priority. DSS and CPOE hold great promise to improve patient care, but not all systems are equal. Evidence must guide these efforts, and the measured outcomes must consider the many factors of quality care.     

Emergency Triage: Comparing a Novel Computer Triage Program with Standard Triage

Background: Emergency department (ED) triage prioritizes patients based on urgency of care; however, little previous testing of triage tools in a live ED environment has been performed. Objectives: To determine the agreement between a computer decision tool and memory‐based triage. Methods: Consecutive patients presenting to a large, urban, tertiary care ED were assessed in the usual fashion and by a blinded study nurse using a computerized decision support tool. Triage score distribution and agreement between the two triage methods were reported. A random subset of patients was selected and reviewed by a blinded expert panel as a consensus standard. Results: Over five weeks, 722 ED patients were assessed; complete data were available from 693 (96%) score pairs. Agreement between the two methods was poor (κ= 0.202; 95% confidence interval [95% CI] = 0.150 to 0.254); however, agreement improved when using weighted κ (0.360; 95% CI = 0.305 to 0.415) or “within one” level κ (0.732; 95% CI = 0.644 to 0.821). When compared with the expert panel, the nurse triage scores showed lower agreement (0.263; 95% CI = 0.133 to 0.394) than the tool (κ= 0.426; 95% CI = 0.289 to 0.564). There was a significant down‐triaging of patients when patients were triaged without the computerized tool. Admission rates also differed between the triage systems. Conclusions: There was significant discrepancy by nurses using memory‐based triage when compared with a computer tool. Triage decision support tools can mitigate this drift, which has administrative implications for EDs.     

Supporting Clinical Practice at the Bedside Using Wireless Technology

OBJECTIVES: Despite studies that show improvements in both standards of care and outcomes with the judicious application of clinical practice guidelines (CPGs), their clinical utilization remains low. This randomized controlled trial examined the use of a wirelessly networked mobile computer (MC) by physicians at the bedside with access to an emergency department information system, decision support tools (DSTs), and other software options. METHODS: Each of ten volunteer emergency physicians was randomized using a matched-pair design to work five shifts in standard fashion (desktop computer [DC] access) and five shifts with a wirelessly networked MC. Work pattern issues and electronic CPG/DST use were compared using end-of-shift satisfaction questionnaires and review of a CPG/DST database. Repeated-measures analysis of variance was used to examine between-shift differences. RESULTS: A total of 100 eight-hour shifts were evaluated; 99% compliance with postshift questionnaires was achieved. Using a seven-point Likert scale (MC values first), MCs were rated as being as fast (5.04 vs. 4.54; p=0.13) and convenient (5.08 vs. 4.14; p=0.07) as DCs. Overall, physicians rated MCs to be less efficient (3.18 vs. 4.30; p=0.02) but encouraged more frequent use of DSTs (4.10 vs. 3.47; p=0.03) without impacting doctor-patient communication (2.78 vs. 2.96; p=0.51). During the study period, physician use of an intranet Web application (eCPG) was more frequent during shifts assigned to the MC when compared with the DC (eCPG uses/shift, 3.6 vs. 2.0; p=0.033). CONCLUSIONS: The MC technology permitted physicians to access information at the bedside and increased the use of CPG/DST tools. According to physicians, patients appeared to accept their use of information technology to assist in decision making. Development of improved computer technology may address the major limitation of MC portability.     

Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department

Background

Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP).

A Survey of Academic Departments of Emergency Medicine Regarding Operation and Clinical Practice: Two Years Later

OBJECTIVES: To survey academic departments of emergency medicine (ADEMs) concerning their operation and clinical practice. METHODS: A survey was mailed to the chairs of the 53 ADEMs in the United States established prior to 1999 (as listed on the Society for Academic Emergency Medicine website) requesting information on operations and clinical activity in budget year 1999-2000 compared with 1997-1998. These results were then compared with results of similar surveys conducted in the autumns of 1996 and 1998. RESULTS: Forty-eight ADEMs (91%) responded. For 1999-2000, compared with 1997-1998, 38 ADEMs (79%) reported an increase in emergency department (ED) patient volume; five (10%) reported a decrease. Thirty-one (65%) ADEMs reported an increase in ED patient severity of illness, whereas only one (2%) reported a decrease. Thirty-two ADEMs (67%) reported an increase in net clinical revenue, and eight (17%) reported a decrease. Only five ADEMs (10%) said that other academic departments within their university/medical center aggressively directed patients away from the ED, compared with nine (22%) in the 1998 study. The percentage of ADEMs using mid-level providers remained essentially unchanged over the three studies-31 (66%) in 1996 versus 28 (68%) in 1998 and 31 (65%) in the present study. For all the studies, mid-level providers were most commonly used in a fast-track setting. The number of ADEMs with an observation unit has also remained relatively stable-18 (38%) in the current study versus 15 (31%) in the 1998 study. In the current study, only two (4%) ADEMs experienced a merger with another university system, compared with 12 (29%) in 1998. Eight (17%) ADEMs reported that their institution had merged with a private entity in the current study, compared with nine (22%) in 1998. CONCLUSIONS: ADEMs continue to experience some very positive trends, namely, increases in ED patient volume, in severity of patient illness, and in net clinical revenue.