Lehigh Valley Health NetworkLVHN Scholarly Works

USF-LVHN SELECT

ED Hospital Medicine Observation Project: AQuality Improvement InitiativeRachel Appelbaum BSUSF MCOM-LVHN Campus, Rachel.Appelbaum@lvhn.org

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Published In/Presented AtAppelbaum, R. (2015, March). ED Hospital Medicine Observation Project: A Quality Improvement Initiative. Poster presented at: TheSELECT Capstone Project in the Kasych Conference Room, Lehigh Valley Health Network, Allentown, PA.

© 2015 Lehigh Valley Health Network

• Problem:Inefficiencyintriage,labelingasobservationvs.inpatientadmission,andtimelycommunicationbetweenproviders

• Equatingtocountlessworkhoursspentandincreasedcostforthenetwork

• Opportunitytobettermanageobservationpatientsanddecreasetheiroveralllengthofstay

• ThenewCMS“2midnightrule”hasincreasedtheneedforobservationpatientstobecloselymonitoredtoensurecasesthatexceed48hoursareduetomedicalnecessity

• TheObservationProjectisaqualityimprovementinitiativeandcollaborationoftheDepartmentofEmergencyMedicine,theDepartmentofHospitalMedicineandancillaryservices

• Thefocusofthisinitiativeisonexpansionoftheobservationcohorting,establishmentofunifiedobservationprotocols,providereducationandlengthofstaymanagement

• TheObservationprojecthasbeenadoptedbyLVHNasoneofthenetwork’smainobjectivesoffiscalyear2015.

Background

Methods

Conclusions

FormationofEBMguidelinescanbeaccomplishedrelativelyexpediently;however,changingthedailypracticeofwell-seasonedclinicianscanbedifficultandtakestime.

1. Knowyouraudienceandhowtheyneedtoreceivenewinformation

2. Gainbuy-infromkeystakeholders(bestwayofcreatinginfluence)

3. Improvementisacontinualprocessthatisneverendingandtakestime

Future Applications• Enhancestandardizationamongproviders• Providesafer,mostcurrent,evidencebasedcare• Limitunnecessaryadmissionsanddiagnosticstudies

tosaveonthebottomline• Createdialogueamongproviderswhosharedifferent

approachestosyncopeandchestpainworkup

Results Discussion

• Determineifyourpatientisathighriskbycompletingathoroughhistoryandphysicalexamaswellas3preliminarytests

Project Goals• Definesyncopeandchestpainobservationand

inpatientadmissioninclusion/exclusioncriteria

• Reviseuniversaltestingtoofferimmediateidentificationofriskfactorsandcriticalclinicalvariables

• Developeducationalmessagingonobservationalpatientwork-ups

• Reducedelaysfortestinganddischarge

Metrics for Success• Increasethepercentageofcohortingtodedicated

observationunits

• Reducelengthofstay

• Reducethenumberofunnecessarytests

• Reduceconversionrates,inpatienttoobservationorviceversa

• Reducereadmissionrates

• EvidenceBasedMedicine(EBM)researchandnationaldatabasereviewfornationalclinicalpracticeguidelinesandexclusioncriteria

• DevelopmentofclinicalpracticeguidelinesforLVHNwhichEMphysiciansandHMhospitalistsagreeuponforatleasttwooutofsixpresentingpatientsymptoms:chestpainandsyncope

• Futureeducationsessionswithphysicians,residentsandancillaryservicestopresentthenewstandardizedclinicalpracticeguidelines.

• Futureimplementationandfeedbacksessions

Definition Pain in the thorax region.

Differential Diagnosis

Cardiac Causes (15-18%) Unstable angina, MI, pericarditis and myopericarditis, aortic dissection

Pulmonary Causes (5-10%) Pneumonia, pleuritis, tension pneumothorax, PE, PHT

GI Causes(8-19%) Esophageal reflux, esophageal spasm, Mallory-Weiss, Boerhaave, peptic ulcer disease, biliary disease, pancreatitis

Musculoskeletal and Miscellaneous Causes

(36-49%) Chostocondritis, muscular strain, herpes zoster

Psychiatric (8-11%) Anxiety

REFERENCES1. (2010).“NationalClinicalGuidelineCentreforAcuteandChronicConditions.Chestpainofrecentonset:assessmentanddiagnosisof

recentonsetchestpainordiscomfortofsuspectedcardiacorigin.”London (UK): National Institute for Health and Clinical Excellence (NICE).Retrievedfromhttp://www.guideline.gov/content.aspx?id=16392.

2. Qassem,A.etal.(2012).“DiagnosisofStableIschemicHeartDisease:SummaryofaClinicalPracticeGuidelinefromtheAmericanCollegeofPhysicians/AmericanCollegeofCardiologyFoundation/AmericanHeartAssociation/AmericanAssociationforThoracicSurgery/PreventiveCardiovascularNursesAssociation/SocietyofThoracicSurgery.”Ann Intern Med.Retrievedfromhttp://www.guideline.gov/content.aspx?id=39253.

3. Gibbons,R.etal.(1999).“ACC/AHA/ACP–ASIMGuidelinesfortheManagementofPatientsWithChronicStableAngina:ExecutiveSummaryandRecommendations:AReportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(CommitteeonManagementofPatientsWithChronicStableAngina).”Journal of the American Heart Association.Retrievedfromhttp://circ.ahajournals.org/content/99/21/2829.full.

4. Huff,S.etal.(2007)“ClinicalPolicy:ManagementofSyncope.”Clinical & Practice Management: ACEP News.Retrievedfromhttp://www.acep.org/Clinical---Practice-Management/Clinical-Policy--Management-of-Syncope/.

5. Reed,M.etal.(2007).“TheRiskstratificationOfSyncopeintheEmergencydepartment(ROSE)pilotstudy:acomparisonofexistingsyncopeguidelines.”Emergency Medicine Journal.Retrievedfromhttp://www.acep.org/content.aspx?id=48303.

6. Reed,M.etal.(2010)“TheROSE(RiskStratificationofSyncopeintheEmergencyDepartment)Study.”Journal of the American College of Cardiology.Retrievedfromhttp://www.ncbi.nlm.nih.gov/pubmed/20170806.

7. Huff,S.etal.(2007)“ClinicalPolicy:CriticalIssuesintheEvaluationandManagementofAdultPatientsPresentingtotheEmergencyDepartmentwithSyncope.”American College of Emergency Physicians.Retrievedfromhttp://www.mayo.edu/research/documents/clin-pol-crit-issuespdf/DOC-10026672.

8. Arrigo,T.(2013)“Syncopeunits:Onesolutiontoanexpensiveproblem:Approachmayhelpavoidunnecessarytesting,enhancediagnosis.” ACP Hospitalist.Retrievedfromhttp://www.acphospitalist.org/archives/2013/11/yp.htm.

9. Strickberger,S.A.etal.(2006).“AHA/ACCFScientificStatementontheEvaluationofSyncope:FromtheAmericanHeartAssociationCouncilsonClinicalCardiology,CardiovascularNursing,CardiovascularDiseaseintheYoung,andStroke,andtheQualityofCareandOutcomesResearchInterdisciplinaryWorkingGroup;andtheAmericanCollegeofCardiologyFoundation:InCollaborationWiththeHeartRhythmSociety;EndorsedbytheAmericanAutonomicSociety.”Circulation:Journal of the American Heart Association. Retrievedfromhttp://circ.ahajournals.org/content/113/2/316.full.

10. Sabatine,M.(2011).“SyncopeandChestPain.”Pocket Medicine: Fourth Edition.Retrievedfrombook.Worcester,S.(2010).“RoseRuleCouldSimplifySyncopeRiskAssessment.”ACEPNews:ElsevierGlobalMedicalNews.Retrievedfromhttp://www.acep.org/content.aspx?id=48303.

11. (2011).“Qualityimprovement.”US Department of Health and Human Services: Health Resources and Services Administration.Retrievedfromhttp://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/.

12. (1994).“ChestPainUnitsinEmergencyDepartments.”Retrievedfromhttp://www.acep.org/Clinical---Practice-Management/Chest-Pain-Units-in-Emergency-Departments/.

13. (2014).“QualityInitiatives–GeneralInformation.”Center for Medicare and Medicaid Services.Retrievedfromhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/.

14. (2010).HEART.Retrievedfromhttp://heartscore.nl/score/.

Example Clinical PracticeGuidelines for Chest Pain

• Stratifiedyourpatient’sriskandmanageaccordingly.HighRiskpatientsshouldbeadmitted.IntermediateRiskpatientsshouldbeobserved.LowRiskpatientsshouldbedischargedwithoutpatientfollow-up.Seebelow.

HistoryObtainfrompatientandwitnessifavailable

Include:HPI–Quality,severity,location,radiation,provokingandpalliatingfactors,duration,frequency,andpatter,settinginwhichitoccurred,associatedsymptomsPMH–PriorepisodesofchestpainMedications–ListofalltakenincludingrecentchangesFamilyHistory–Specificallycardiac(MIetc)

Physical ExamVitalsigns(BPinbotharms)Inspection,palpation(seeifreproducespain),auscultation,percussionFullycardiacevaluation(auscultateformurmurs,rubs,gallops)Signsofvasculardisease(bruits)Signsofheartfailure(peripheral/pulmedema,JVDetc)

Other Initial Studies12LeadEKG,Cardiactroponins,CXR

Is your patient at high risk?

HistoryandPhysicalExamFindings

12LeadEKG,Cardiactroponins,CXR

High Risk =Admit

Intermediate Risk =Observe

Low Risk =Discharge

Atleastoneofthefollowingfeaturesmustbepresent:Prolonged,ongoing

(>20min)painatrest,Pulmonaryedema,mostlikelyrelatedtoischemia;AnginaatrestwithdynamicSTsegmentchanges>1mm;Anginawithneworworsening

mitralregurgitationmurmur;AnginawithS3ornew/worseningrales;Anginawith

hypotension

Nohighriskfeaturesbutmusthaveanyofthefollowing:Prolonged(>20min)restangina,nowresolved,withmoderatetohighlikelihoodofCAD;Restangina(>20minorresolvedwith

sublingualnitro);Nocturnalangina;AnginawithdynamicTwavechanges;NewonsetCCSC3or4anginainthepast2wkswithmoderateorhighlikelihoodofCAD;PathologicQwavesorrestingSTsegdepression<1minormultiple

leadgroups;Age>65yrs

Nohighorintermediateriskfeaturesbutmay

haveanyofthefollowing:Increasedangina

frequency,severity,orduration;Anginaprovokedatalowerthreshold;Newonsetanginawithonset2wkto2monthbefore

presentation;NormalorunchangedECG

Lehigh Valley Health Network, Allentown, PA

Emergency and Hospital Medicine Observation Project: A Quality Improvement Initiative

Rachel Applebaum, MS4Mentor - Ada Rivera, Department of Medicine