Article

Measuring antibiotic timing for pneumonia in the emergency department: another nail in the coffin.

Annals of emergency medicine (Impact Factor: 4.33). 06/2007; 49(5):561-3. DOI: 10.1016/j.annemergmed.2006.12.007
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    ABSTRACT: Background. The Centers for Medicare and Medicaid Services' (CMS's) Hospital Inpatient Quality Reporting program includes the initial selection of antibiotics for adult community-acquired pneumonia (CAP) patients as a performance measure. A multidisciplinary team defined opportunities for improving performance in appropriate antibiotic use among CAP patients. The team consisted of personnel from the emergency department (ED), the antimicrobial stewardship program (infectious disease, pharmacy), and performance improvement. Design. Quasi-experimental before-after study. Setting. A large, urban, multicampus academic medical center. Interventions. Interventions included an algorithm for ED providers identifying appropriate antibiotic selections, development of a CAP kit consisting of appropriate antibiotics and dosing regimens bundled with the treatment algorithm, and preloading an automated ED medication dispensing and management system. A quality improvement methodology ("plan, do, check, act") was used to pilot stewardship interventions at one ED campus and later at a second ED campus. Results. In the pilot ED, appropriate antibiotic selection for CAP improved from 54.9% before the intervention in 2008 to 93.4% after the intervention in 2011 ([Formula: see text]). Subsequently, in the second ED appropriate antibiotic regimens for CAP improved from 64.6% before the intervention in 2008 to 91.3% after the intervention in 2011 ([Formula: see text]). The rates of another CMS measure, antibiotic administration within 6 hours, were not statistically different before and after the interventions. In an interrupted time series logistic regression analysis, the intervention was found to be significantly associated with the improved prescribing ([Formula: see text]). Discussion. The combination of interdisciplinary teamwork, antibiotic stewardship, education, and information technology is associated with replicable and sustained prescribing improvements.
    Infection Control and Hospital Epidemiology 06/2013; 34(6):566-72. · 4.02 Impact Factor
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    ABSTRACT: As a safety net for the health care system, quality and safety performance in emergency medicine (EM) is important for policy makers, insurers, researchers, health care providers, and patients. Developing performance indicators that are relevant, valid, feasible, and easy to measure has proven difficult. To monitor progress, patient safety should be measured objectively. Although conceptual frameworks and error taxonomies have been proposed, a practical scorecard for measuring patient safety over time in EM has been lacking. This article proposes a framework that measures safety through 4 major domains: (1) how often patients are harmed, (2) how often appropriate interventions are delivered, (3) how well errors in the system are identified and corrected, and (4) emergency department (ED) safety culture. Examples of specific measures for each of these domains are provided, but the EM community should reach consensus on what measures are important for the ED environment and patients.
    American Journal of Medical Quality 05/2013; · 1.78 Impact Factor
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    ABSTRACT: Introduction: Conflicting data exist regarding the association between the length of stay (LOS) of critically ill patients in the emergency department (ED) and their subsequent outcome. However, such patients are an overall heterogeneous group, and we therefore sought to study the association between EDLOS and outcomes in a specific subgroup of critically ill patients, namely those with acute ischemic stroke/transient ischemic attack (AIS/TIA). Methods: This was a retrospective review of adult patients with a discharge diagnosis of AIS/TIA presenting to an ED between July 2009 and February 2010. We collected demographics, EDLOS, arrival stroke severity (National Institutes of Health Stroke Scale - NIHSS), intravenous tissue plasminogen activator (IV tPA) use, functional outcome at discharge, discharge destination and hospital-LOS. We analyzed relationship between EDLOS, outcomes and discharge destination after controlling for confounders. Results: 190 patients were included in the cohort. Median EDLOS was 332 minutes (Inter-Quartile Range -IQR: 250.3-557.8). There was a significant inverse linear association between EDLOS and hospital-LOS (p=0.049). Patients who received IV tPA had a shorter median EDLOS (238 minutes, IQR: 194-299) than patients who did not (median: 387 minutes, IQR: 285-588 minutes; p<0.0001). There was no significant association between EDLOS and poor outcome (p=0.40), discharge destination (p=0.20), or death (p=0.44). This remained true even after controlling for IV tPA use, NIHSS and hospital-LOS; and did not change even when analysis was restricted to AIS patients alone. Conclusion: There was no significant association between prolonged EDLOS and outcome for AIS/TIA patients at our institution. We therefore suggest that EDLOS alone is an insufficient indicator of stroke care in the ED, and that the ED can provide appropriate acute care for AIS/TIA patients. [West J Emerg Med. 2014;15(3):267-275.].
    The western journal of emergency medicine 05/2014; 15(3):267-75.