Save Lives Now: Five Ways to Improve Patient Safety in the ED

From Hospitals & Health Networks Magazine, part of their Save Lives Now series.

Save Lives Now: Five Ways to Improve Patient Safety in the ED

Hospital emergency departments are the theater of valiant American medicine. Every day, approximately 300,000 patients visit EDs across the country, with conditions ranging from a twisted ankle to severe trauma. The overwhelming majority of these patients are treated quickly, efficiently and successfully. Physicians, nurses and others who staff EDs routinely perform lifesaving care under apparently chaotic, unpredictable conditions, and for this they are often considered heroes.

Yet the same conditions that confer special status on emergency medicine also make it dangerous. “Anything can come in the door at any time,” says Charles Pattavina, M.D., an emergency physician in Worcester, Mass. Decisions have to be made and executed quickly, without time for reflection or even, in many instances, consultation with a patient’s medical record. Consequently, the ED is also home to a high number of medical errors, including many that lead to permanent injury or death—and many of which can be avoided.

Newsweek Article on Resuscitation

Published in this week's Newsweek:

To Treat the Dead: The new science of resuscitation is changing the way doctors think about heart attacks—and death itself.

Consider someone who has just died of a heart attack. His organs are intact, he hasn't lost blood. All that's happened is his heart has stopped beating—the definition of "clinical death"—and his brain has shut down to conserve oxygen. But what has actually died?

Quality Improvement in the ED

A link to an interesting article from Hospitals and Health Networks magazine, "Save lives now: Five ways to improve patient safety in the ED"

Another link, to the Institute for Healthcare Improvement's Operational and Clinical Improvement in the Emergency Department resource page

EM Blogs, in the News

One of our favorite bloggers, GruntDoc, was mentioned in the Annals of Emergency Medicine.

Here are his comments about this honor.

Here's a link to the article and an excerpt:

Dr. Allen Roberts, an attending emergency physician at Harris Methodist Fort Worth Hospital, had a problem. He’d just raised the ire of the nurses who work with him – and many who don’t—by posting a provocative entry to his popular GruntDoc blog (www.gruntdoc.com) titled “The Lifesaving Foley.”

In August of last year, he decided to write about “a peculiar phenomenon” he’d recently noticed with his nursing colleagues. “I’ll be in the middle of a code, look around and see a nurse studiously inserting a catheter into the patient,” he wrote. Then, he added, “We’ll be getting ready to intubate an agitated patient; I look and see the nurse is busy intubating Mr. Johnson.” And then Roberts took a jab he later regretted:

“I have no idea why. Really, I think they’re stressed out, and want to ‘Do Something.’ They see a task they’re comfortable doing, and so they do it. Indication or not, right time or not, utility or not. I’ve taken to calling it The Lifesaving Foley, for obvious reasons, though I don’t think it’s saved a life yet.”

Oops. Comments from, shall we say, moderately peeved nurses came fast and furious to the GruntDoc blog. A week later he posted a mea culpa entry to the blog titled “Some Nurse Love,” and listed a number of reasons why he appreciated nurses.

“I try not to write anything on the blog that I wouldn’t want to see on the front page of the newspaper,” Roberts said. “But in that case I don’t think the nurses were amused.”

Crocs Cause Medical Machinery Malfunctions?

From Medgadget:

Blekinge hospital in southern Sweden suspects the slip-on shoes, made by US firm Crocs Inc, are to blame for at least three incidents in which respirators and other machines malfunctioned. The mishaps caused no injuries.
Hospital spokesman Bjorn Lofqvist said staff wearing the clogs could turn into "a cloud of lighting" because of the static electricity.

Use Criteria to Manage Febrile Infants in the ED Without Antibiotics

From ACEP:

Screening criteria can predict which febrile infants presenting to an emergency department will not have serious bacterial infections and can be safely discharged home without antibiotics. This conclusion was drawn from a retrospective analysis reported by Dr. Taj Madiwale and colleagues at the southern regional meeting of the American Federation for Medical Research.

The study included 552 infants, aged 29-60 days, who presented to a tertiary care children’s hospital ED between January 2001 and December 2004 with a chief complaint of fever. A fever, defined as 100.4° F or higher rectally, was present in 434 infants.

The inclusion criteria for absence of serious bacterial infection were based on previous research and included the following:
• Well appearance.
• CBC white-cell count of 5,000-20,000/mm3 with a band/neutrophil ratio of less than 0.2.
• Urine specimen with no more than 10 white cells per high power field, and negative for leukocyte esterase and nitrate.
• Cerebrospinal fluid with a white-cell count of less than 10/mm3, a negative gram stain, a glucose level greater than 40 mg/dL, and protein less than 120 mg/dL.

Exclusion criteria were:
• Ill appearance.
• Previous surgery, except circumcision.
• History of antibiotics.
• Immune deficiency syndromes.
• Signs of bacterial infection.

Also on the list of exclusion criteria was previous vaccination, other than hepatitis B, as this could cause a transient fever, said Dr. Madiwale, a pediatric emergency medicine fellow with the Children’s Hospital of Alabama at Birmingham.

Quick, Cheap & Easy Bedside Diagnosis of Brain Injury

From Medgadget:

Infrascanner™ is a hand-held, non-invasive, near-infrared (NIR) based mobile imaging device to detect brain hematoma at the site of injury within the "golden hour". This refers to the period following head trauma when pre-hospital analysis is needed to rapidly assess the neurological condition of a victim. Pending FDA clearance, the Infrascanner™ will be an affordable, accurate and clinically effective screening solution for head trauma patients in settings where timely triage is critical. It is intended to aid the decision to proceed with other tests such as head Computed Tomography (CT) scans. In environments where access to CT scan is restricted or not available, Infrascanner™ will facilitate surgical intervention decisions.

Quint Studer's Blog: Supporting and Appreciating Emergency Departments

From the blog of Quint Studer of the Studer Group:

After spending time on Saturday, February 24, 2007, with more than 1,400 emergency nurses at the Emergency Nurses Association meeting in Boston, I feel so much better. I saw such dedication to the health care calling, motivation to learn how to be even better leaders, and perseverance to keep striving to make a difference in health care. My flame got brighter thanks to these 1,400 difference makers.

At the session, I described something I was part of years ago that worked to improve outcomes. We had all department directors and members of the senior team spend one full shift working in the emergency department shadowing an emergency department staff member. At times working in an emergency department is similar to working at a desk at an airport. Both emergency staff and airport staff report delays, changes, and cancellations. While these are caused by other factors, the people at the desk take the brunt of others’ frustrations.

After experiencing a shift in the emergency department, many leaders went back to their own departments and fixed things to make service better for the emergency department; some leaders took ideas from the emergency department and improved their areas. All leaders left the emergency department with better relationships with emergency staff members.

Have leaders spend a shift in the emergency department and it will create better outcomes.

The Call Schedule at Community Hospital

A blog post from Dr. Edwin Leap: The Call Schedule at Community Hospital

An excerpt:

This weekend’s call schedule is as follows:

Surgery: Dr. Johansen is on call for general surgery. Please remember that he does not like to operate on children or the uninsured. He also considers trauma an enormous inconvenience. If you have gall-bladder patients, patients with appendicitis or patients with acute diverticulitis, you may contact him after the CT scan has been read and the patient sedated and prepped. Please remember, as Dr. Johansen says, ‘If it isn’t on the CT scan, I won’t operate on it’. Anything else that is marginally surgical should be admitted to family medicine, who may consult him after lengthy discussions by phone. Dr. Johansen is covering for Dr. Michaels and Dr. Pugh, but not Dr. Delacore, who has pissed everyone off. Dr. Delacore, incidentally, will not be available as he will be intoxicated this weekend. All of his patients should be transferred to anyone who will accept them.

ACEP Responds to JACHO RE: First Dose

From ACEP:

Joint Commission Reinstates First Dose Medication Review
April 13, 2007

Medications administered in an emergency department must once again be reviewed prospectively by a pharmacist, according to a notification sent to hospitals last week by the Joint Commission. But a conversation with the Joint Commission president indicates that the reversal may not be permanent.

ACEP President Brian Keaton, MD, spoke with Dennis O’Leary, MD, the Joint Commission president, on April 13. According to Marilyn Bromley, RN, Director of ACEP’s EM Practice Department, Dr. O’Leary indicated that he would convene an internal task force to revisit the many concerns presented to the Joint Commission.

“Dr. O’Leary suggested a conference call and we’re anticipating some action on this issue in the next several weeks,” Ms. Bromley said.

ACEP is working with the American Academy of Emergency Medicine (AAEM) and the Emergency Nurses Association (ENA) to present a united and unwavering opposition to this potentially detrimental accreditation standard.

The Joint Commission’s latest action reverses an interim action that allowed medications to be retrospectively reviewed by a pharmacist within 48 hours. Read the Joint Commission’s notification to hospitals here.

In May 2006 and January 2007, ACEP, AAEM and ENA jointly expressed their concerns about the Joint Commission’s standard requiring pharmacists’ prospective review in the ED. In addition, the American Medical Association approved a policy earlier this year opposing the requirement of first dose review by a pharmacist.

ACEP believes the standard poses a challenge to patient safety. Several ACEP Board members said the potential delay in patient care caused by a pharmacist review could be far more harmful than the amount of medication errors in the ED, the Joint Commission’s stated reason for the standard.

As the situation unfolds, ACEP will continue to keep its members up-to-date with the latest information.

Joint Commission Changes Rx Review - Again

From ACEP:

Joint Commission Changes Rx Review - Again

The Joint Commission notified hospitals on April 9 that medications administered in an emergency department must once again be reviewed prospectively by a pharmacist. The action went into effect immediately.

The Joint Commission had issued an interim action on January 1 that allowed medications to be retrospectively reviewed by a pharmacist. This new announcement overturns that previous action.

The statement sent by the Joint Commission on April 9 follows:

Effective immediately!

The Interim Action for Standard MM.4.10 EP 1 for Emergency Departments has been suspended for an indefinite period of time. This Interim Action was implemented on January 1, 2007 for Emergency Departments in hospitals and critical access hospitals. With its suspension, MM.4.10 EP 1, as it is defined in your accreditation manuals, is back in effect for Emergency Departments.

Therefore in accordance with MM.4.10 EP 1 in the manuals, prior to dispensing, removal from floor stock, or removal from an automated storage and distribution device, a prospective pharmacy review is expected for all medication orders unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status. Please remember that licensed independent practitioner control means that the licensed independent practitioner is physically present with the patient while the medication is being administered. With the suspension of the Interim Action, we are no longer requiring retrospective review for all medications in the ED that are not prospectively reviewed.

Please note, however, that Standard MM.4.10 EP 1 in the accreditation manuals is likely to be modified in the future as described in the January 2007 issue of Perspectives. The Joint Commission is currently developing revisions to MM.4.10 EP 1. Another field review will be forthcoming before the revisions are finalized, and it is anticipated that the revised standard/ EP will not be effective until 2008.

The reinterpretation of ' licensed independent practitioner control' for Radiology departments that are hospital based (including hospital-associated ambulatory radiology) remains in effect and is not impacted by the suspension of the Interim Action. You should continue to follow the defined aspects of THE reinterpretation: The organization is allowed to define, through protocol or policy, the role of the licensed independent practitioner in the direct supervision of a patient during and after IV contrast media is administered. The protocol/policy is to be approved by the medical staff and the role of the licensed independent practitioner is to be defined so that there can be timely intervention by the licensed independent practitioner in the event of patient emergency. The Joint Commission recommends that organizations refer to the American College of Radiology Practice Guidelines for the Use of Intravascular Contrast Media, 2001 during the development of the protocol/policy.

If you have questions, please contact the Standards Interpretation Group at 630-792-5900, Option 6 or through our online submission form at:http://www.jointcommission.org/Standards/OnlineQuestionForm/

Rescue Robot

From Medgadget

Well, unlike last week's EMSResponder, this robot does not cut through concrete. The new Japanese unmanned rescue robot is made to scoop people off places where it might be too hazardous for trained rescuers to be. According to the manufacturer's site, the Robokiyu approaches a collapsed person, extends its metal arms to grasp the clothes, and pulls the victim to rescue.

For Profit Hospitals and Emergencies

From the New York Times, via Symtym

"Some Hospitals Call 911 to Save Their Patients"

Should a hospital be able to handle a medical emergency?

The answer may seem self-evident. But patients at some hospitals may find the staff resorting to what someone might do at home in a crisis: call 911 for an ambulance.

That happened recently in Texas, where a 44-year-old man named Steve Spivey developed breathing problems after spine surgery. No physician was working there when the staff first recognized he was in trouble. They phoned 911, and he was taken to a nearby full-service hospital, where he was pronounced dead a short time later.

The episode occurred at a small hospital that is owned and run by doctors — one of roughly 140 such hospitals around the country, with nearly two dozen more under development, that are set up to specialize in certain types of procedures like heart surgery, back operations and hip replacements.