Chest Pain – EPIC Principles

7:30-8:15 Registration, Welcome and Continental Breakfast

8:15-8:30 SATURDAY NIGHT AT THE ER Video presentation Place: Seattle General Hospital Time: Saturday evening around 9:00 p.m., with a full moon

Players Characters Karl Tjerandsen Alan Shore, JD Claire Hagan Sam Taggart, RN Cindy Jacobs Abby Lockhart, MD Heath Fox Hugh Emmaigh/Hugh Ahriu Michael Lloyd Theo Kojak Lance S. McKenzie As himself (security officer)

Written by: Cindy Jacobs Produced by: Kathy Cochran Thank you: Providence Everett Medical Center

8:30-9:30 LEGISLATIVE UPDATE WHCRMS Legislative Committee

9:30-11:00 Emerging Risks in the ED: Improving the Risk Profile Michelle Hoppes RN, MS, DFASHRM CEO, Patient Safety and Risk Solutions LLC

11:00-11:15 Break

11:15-12:00 Overcrowding/Boarders in the ER Chris Martin, RN Director, Emergency Services Harborview Medical Center 12:00-1:00 Lunch – Provided in WAC dining room on 1st floor

1:00-2:00 Patient and Staff Safety: Caring for Behavioral Health and/or Substance Abuse Patients in the ED Leigh Cooley, RN, MN, CPHQ, CPHRM General Oncology/Hematology Manager Seattle Cancer Center Alliance 2:00-2:30 EMTALA UPDATE Rob Brown Assistant Director of Compliance and Privacy Officer University of Washington Medical Center

Cindy Jacobs, RN, JD, CPHRM Director, Risk Management University of Washington Medical Center

2:30-2:45 Break 2:45-4:15 LAW ENFORCEMENT MANAGEMENT PANEL ATTORNEY AND MODERATOR: Taya Briley, RN, MN, JD Senior Policy Analyst Washington State Hospital Association

SEXUAL ASSAULT NURSE EXAMINER: Lynne Berthiaume, RN, BSN, CLNC Clinical Nurse Specialist/Forensic Nurse Examiner Certified Legal Nurse Consultant Multicare Health System Forensic Nurse Examiner Services

HOSPITAL RISK MANAGER/ATTORNEY: Dianne Garcia, JD Risk & Claim Administrator, Risk Management Providence Health & Services

PRIVACY OFFICER: Rob Brown Assistant Director of Compliance and Privacy Officer University of Washington Medical Center

LAW ENFORCEMENT REPRESENTATIVE: TBA

4:15-4:30 Video “out-takes,” Door Prizes and Adjourn

2007 Officers: President: Heath Fox, JD Johnson, Graffe, Keay, Moniz & Wick, LLP President Elect: Philip M. deMaine, JD Johnson, Graffe, Keay, Moniz & Wick, LLP Secretary: Michelle (Shelly) Garzon, JD Williams, Kastner & Gibbs PLLC Treasurer: Gemalee Morrison Marsh USA

2007 WCHRMS Conference Committee: Cindy Jacobs, Chair University of Washington Medical Center

Leigh Cooley Seattle Cancer Care Alliance

Heath Fox Johnson, Graffe, Keay, Moniz & Wick, LLP

Marianne McCrary Willis of Seattle

Leslie Moore Holy Family Hospital, Spokane

Gemalee Morrison Marsh USA

Marianne Vivona Structured Financial Associates

Risk Management Challenges: Behavioral Health and Substance Abuse Patients in the ED

WHCRMS May 2007

Leigh McDonnell Cooley RN MN CPHQ CPHRM By the end of this presentation the participant will be able to:

1. List five risk management issues related to treatment of behavioral health and/or substance abuse patients in the ED. 2. Identify three organizational strategies to minimize risk to patients and staff, and 3. Describe two potential regulatory risks and the clinical documentation that would demonstrate compliance with the intent of the regulation. Behavioral Health and Substance Abuse patients vary by age, sex, socioeconomic status, mode of origin, chief complaint and many other factors. During the last decade, hospital EDs have shouldered an increasing proportion of mental health as state cutbacks and declining reimbursements have forced inpatient psychiatric units to close. The lack of adequate outpatient psychiatric services, especially for the uninsured and underinsured patients, has rendered EDs one of the few remaining options for psychiatric patients. Baraff et al What is the scope of behavioral health patients in the ED?

 Most common diagnoses  1992 to 2001, there were 53  Substance related disorders million mental health related (22%) ED visits,  Mood disorders (17%)  Anxiety disorders (16%)  Increase from 4.9 to 6.3% of all ED visits Medication prescriptions increased from 22% to 31% of visits during this decade.  Increase from 17.1 to 23.6 visits per 1,000 U.S.

population across decade

 National Hospital Ambulatory  Increase in all regions except Medical Care Survey as described in Midwest Larkin et al.

What is the scope of substance related ED or dual diagnosis visits?

According to 2004 Drug Abuse  “…As many as 69% of Warning Network (DAWN) trauma patients meet reports: diagnostic criteria for  2004- an estimated 192,690 substance abuse or patients with drug-related dependence. When ED visits were diagnosed screened, over 40% of with co-occurring disorders trauma patients test positive for chronic alcohol abuse.”  AADAC – Alberta Alcohol  When ED visits with co- and Drug Abuse occurring disorders were Commission diagnosed, nearly as many patients were treated and released as were admitted to inpatient units (40.4% vs. 42.2% of visits).

Common Risk Management Concerns

 Patient safety from self  Role clarity for working harm with outside agencies

 Misdiagnosis and/or professions

 Privacy  Individual rights vs. societal rights  Staffing  Security issues  Limited availability of specialized clinical  Prioritizing care expertise or services  Disposition options

 Repetitive visits  Safe transport and follow up Regulatory and Legal Issues

 EMTALA  HIPPA  Commitment Laws  Age Related issues  Consent issues  Suicide risk assessment  Drug and substance abuse assessment  Prevention of Workplace (ED) Violence

Hospital Support Systems

 Important to keep  Education and the issue on the guidelines

organizational radar  Mental health, and devote sufficient suicide risk and resources to substance abuse maintain clear triage guidelines and documentation tools support structure  Orientation, training and debrief

ED Triage – the first contact

 Many hospitals have guidelines that all physical complaints receive faster triage  This can lead to delayed diagnosis or safety concerns

 Effective triage can facilitate faster assessment and treatment – and reduce likelihood of elopement and/or violence.

 Evidence suggests screening for dementia and past psychiatric history could improve initial triage accuracy (Bazarian et al).

 Initial suicide risk assessment is not substitute for in depth clinical assessment

Ruling out medical causes when presented by behavioral symptoms …

What testing is necessary in order to “Altered mental status presents as determine medical stability in alert, a disorder of mentation, cooperative patients with normal including impaired cognition, vital signs, a noncontributory history and physical examination and diminished attention, reduced psychiatric symptoms? awareness and/or altered levels of consciousness. Diagnosis is  Level B rec: In adult ED patients with primary best made after consideration of psychiatric complaints, the history of the present event, medical history and a physical  diagnostic evaluation should be directed by the history and examination. Research has physical examination. Routine shown that laboratory and lab testing of all patients is of radiographic studies may have very low yield and need not be little value in the diagnosis of performed as part of the ED altered mental status compared assessment. to a mental status assessment.” --Clinical policy on adult  --Kanich et al as cited in ASHRM Pearls for Psychiatric Care Across the Continuum) psychiatric patient in ED

Elements of a Thorough Exam

 General appearance  Vital signs (especially (nourishment, hygiene, temperature, which may tremors etc.) indicate toxic overdose or infection)  Obvious trauma  Full neurological exam  Orientation, affect,  Odors (alcohol, ketones) cognition, appearance, hallucinations, delusions and  Pupil size and reactivity suicidal or homicidal tendencies. Evaluate for S/S of acute drug  Skin for presence of needle or ETOH intoxication tracks ASHRM Pearls

Hospital Guidelines should promote safe care and regulatory compliance

 National Guideline Clearinghouse:  Hospital guidelines or protocols recommended:  Critical issues in the diagnosis and management of adult  Physical and verbal de- psychiatric patient in the escalation techniques emergency department  Back up staffing options (security, sitters)  Practice Guideline for the  Restraint, seclusion, and assessment and treatment of sedation patients with suicidal behaviors  Security precautions  Detoxification and substance  Obtaining samples when abuse treatment: physical medically necessary or detoxification services for requested by law withdrawal from specific enforcement substances

Hospital Clinical Forms & Guidelines

 Designed to reinforce desired assessment or treatment

 Just in time reminders for clinical staff re. screening and referral criteria

 Support effective communication within the team over time

 Ensure regulatory compliance

Staff and Patient Safety Considerations in ED Care

Factors in evaluating staff and patient safety A few essential tips:  Designate a room for moderate to high risk patients and create safe  “Past violence is the best predictor of physical environment (no potential future violence and should alert staff weapons in room, good to implement a plan to deal with the observation capability, etc.) possibility before it occurs.” – ASHRM Pearls  Do not let the patient come between staff and an exit

 Do not enter the room without  Clinicians cannot always accurately informing other staff predict violence so risk reduction techniques and rapid response  Keep hands visible and avoid protocols should be developed and sudden movements enforced  Establish rapport and do not argue with patient  Notify other staff of risk level and follow established patient assessment and monitoring

A few safety considerations for your hospital practice guidelines

 When should a behavioral health patient be required to wear a gown and have his/her belongings searched for weapons? Can friends or relatives bring in items?

 What level of observation should be required for patients expressing mood disorders?

 Should all patients be escorted for bathroom or cigarette breaks?

Staffing Considerations

 Is social work available (patients often present evening and/or weekend). MSW very effective in evaluating support systems and coping skills.  Options for providing continuous monitoring?  Staffing rapid response to potential and actual physically aggressive behavior

Privacy and consent issues Clarify the following and make available to staff in hospital guidelines:  What information you can share with concerned friends or family without patient permission?  In what circumstances and at what age can patients consent to their own psychiatric care?  How should we handle billing when patient requests full confidentiality but financial guarantor is parent or spouse?  When can patients can refuse medication?

Specialty Services

 Security Staff are not available in all settings

Other Options  Identify facility staff, safety committee or other individual or groups responsible for facility safety review and staff training on verbal and physical de- escalation.

Working with other involved Agencies

 Police and other law enforcement

 Community mental health services or outpatient follow up

 Hospitals with inpatient behavioral health and/or detox units

 Designated Crisis Responders Police and law enforcement

Law enforcement Health care  Primary responsibility  Primary responsibility for for civil order assessment, diagnosis, stabilize and treat  Often bring patients to ED for fit for jail  Often work with law assessment enforcement in trauma, MVA and other circumstances Potential areas of conflict  Sometimes depend upon of interest police for security back up  financial conflict for  Often close working transport or financial relationships responsibility  May request information for criminal investigation

Collaborating with Hospitals with established short term behavioral health or substance abuse treatment units

 Different units will have own admission criteria and focus

 Clear communication, careful work up and good documentation often key to acceptance and ongoing trust

 Document who provided information, when and summarize their response.

Designated Crisis Responders

 Primary role is to determine if voluntary or involuntary commitment – NOT diagnosis  In many communities, more options for mental health than substance abuse. Very difficult to sort out dual diagnosis  Good initial work up and documentation is invaluable for facilitating appropriate and timely determination  Currently state pilot program of having same examiner and process for substance abuse and behavioral health

Approaches for working effectively with community agencies

 Understand their primary role, interests and potential conflicts  Keep lists of resources and contacts up to date  Work with local community agencies proactively on areas of mutual concern and how the two organizations can best support each other  Work with distant agencies to resolve concerns if and when they arise  Keep the focus on what is best for patient care How well does your organization provide for safe and effective care of these patients?

Are roles and Options to evaluate deployment responsibilities clear? and practice:

 Include behavioral health Do guidelines, training and patient in ED in upcoming references exist to disaster drills or mock codes assist staff?  Debrief after actual violent events, near miss incidents Are there effective and interesting cases working relationships with other community  Periodic review of hospital agencies and their guidelines and representatives? documentation

In conclusion

 Behavioral health patients in EDs provide an ongoing challenge to staff

 Our ongoing efforts are a measure of our compassion and commitment to helping the entire community

 Proactive is better than reactive. The more we support our staff to do the right thing, the more often the right thing will be done. QUESTIONS?

[email protected]

Chest Pain – EPIC Principles

Authors: Robert A. Bitterman, MD, JD, FACEP, PC and Stephen Colucciello, MD

Contributors / Editors: Michelle M. Hoppes, RN, MS, AHRMQR, DFASHRM, CEO, Patient Safety and Risk Solutions LLC. and Graham Billingham, MD, FACEP, CEO, Emergency Physicians Insurance Company RRG

Overview

Misdiagnosis of chest pain represents a major health risk for patients and legal risk for emergency physicians. The most common pitfall occurs when the emergency physician mistakes an acute coronary syndrome for a gastrointestinal or chest wall problem. To a lesser extent, emergency physicians may overlook other life-threatening causes of chest pain such as aortic dissection and pulmonary embolism.

The following algorithm and tools will decrease the risk of misdiagnosis. They are derived from recent literature and incorporate medical decision-making based on history, physical and diagnostic studies. The most important studies include the ECG, cardiac enzymes, and provocative cardiac testing (stress tests). Medical decisions are driven by simple “Yes” versus “No” answers in the algorithm.

The internal logic of the algorithm has remained true to the original studies. For this reason, certain decision points may involve 2 hour delta makers, while others use 6 hour markers, and for cocaine- related chest pain, 8 hour markers. The reason for this discrepancy is that different studies used a variety of different time intervals depending upon the population enrolled (age under 40, age over 40, cocaine-related chest pain, etc.) Most studies involving delta markers involved troponin I (rather than troponin T)

It is expected that these protocols will be adapted according to local circumstance. Emergency Departments with Chest Pain Observation Units will admit fewer patients to the hospital than those without such units. The choice of provocative tests should be discussed with local primary care providers and cardiologists, as should the timing of such tests. The safest strategy would involve a stress test scheduled within the next several days; a next workday stress would be ideal but not always feasible. While this may be practical if the patient presents to the ED on Sunday through Thursday, it may be impossible if they initially present on a Friday, Saturday, or holiday. Practical Impact of Protocols:

More patients will be tested for ACS

Lower threshold for early ECG ordered by the triage nurse

Increased use of cardiac enzymes and repeat enzyme testing

Traditionally, chest pain centers have drawn one set of enzymes on arrival and another set in 8 to 12 hours. However, a single set of cardiac enzymes drawn at least 6 hours from pain onset (ACEP Clinical policy states 8-12 hours), or 2 hour delta markers (measured change in the 2 hour CK-MB and Troponin I compared to arrival enzymes) can increase the number of same-day provocative tests and to help identify low-risk patients suitable for outpatient stress testing. The use of the 2 hour delta marker will allow chest pain patients who present to the ED before 3 PM to undergo stress testing before the end of the business day.

Increased number of provocative tests – In the following algorithm, Emergency Physicians will routinely order stress tests or arrange for outpatient testing; most likely, several stress tests per day. This may represent a significant change in practice for many physicians.

Low-risk patients will have same-day stress tests if appropriate or outpatient stress testing within one week (preferably within 72 hours).

Intermediate-risk patients will have same day testing if available or will await the next available stress test. Patients may wait in a chest pain center, kept in the ED on a monitor, or admitted to hospital during this waiting period.

Most high-risk patients will be admitted to the hospital, although a certain subset of these patients (such as those with atypical pain) may be suitable for a chest pain center evaluation.

Fewer patients will be diagnosed in ED with Chest Pain-Related GI problems

No Diagnoses of “Esophageal Reflux”, “GERD”, “Peptic Ulcer Disease”, or “Gastritis” in patients with a complaint of chest pain UNLESS evaluated for Acute Coronary Syndrome OR Documented negative cardiac catheterization in past year or Documented negative cardiac stress test in past 6 months

If chief complaint of “Abdominal Pain” in upper abdomen, patients over 30 years of age should have significant abdominal tenderness for diagnosis of GI condition.

Patients with chest-pain possibly related to GI disorders (or upper abdominal pain without tenderness) will need ECG, enzyme testing and provocative testing (unless recent cath or provocative test). Low-risk patients (see below) may have provocative test as outpatient within one week (preferably within 72 hours).

© 2007 Patient Safety and Risk Solutions, LLC. All rights reserved Tool 1- Chest Pain Order Sheet Order set begins at triage and is instituted by nurse without need for physician approval Inclusion Criteria: Age > 30 with chest pain (excluding respiratory infection or trauma) Age > 30 with jaw, neck, shoulder, or arm pain unrelated to movement or position Age > 30 with persistent upper abdominal pain and no abdominal tenderness Standing Nurse Orders Vital signs including pulse oximetry ____ (Initials) ____ Time done PRN adapter ____ (Initials) ____ Time done O2 at 2 liters nasal canula (or higher to maintain O2 sat at 95%) ____ (Initials) ____ Time done 4 baby aspirin (if not allergic and no ASA w/in 12 hours) ____ (Initials) ____ Time done Place on cardiac monitor ____ (Initials) ____ Time done ECG shown to MD w/in 10 -15 min of patient arrival ____ (Initials) ____ Time done Repeat ECG if return of pain ____ (Initials) ____ Time done Order old ECG if available and attach to chart ____ (Initials) ____ Time done CK-MB, Troponin on arrival ____ (Initials) ____ Time done Portable CXR ____ (Initials) ____ Time done Additional physician orders (Circle)

Lab Tests (Circle): CBC Basic Metabolic Pack PT/INR Spot urine for cocaine ______Nitroglycerin ___SL Drip at ____mcg/min ____ (Initials) ____ Time done Nitroglycerine paste ___ inches ____ (Initials) ____ Time done Nitroglycerin contraindicated if sildenafil (Viagra), vardenafil (Levitra) within 24 hrs, or tadalafil (Cialis) within 48 hrs Repeat CK-MB, Troponin 2 hours or ______hours after first set drawn ____ (Initials) ____ Time done

Begin ACS Pathway Heparin, Nitroglycerin drip, morphine, metoprolol, thrombolytics, glycoprotein inhibitors, etc. See separate order sheet. ____ (Initials) ____ Time done

Provocative testing after final set of enzymes shown to MD Testing Location (Circle one): ED Chest Pain Center Hospital Outpatient

Type of Stress test (Circle one): Treadmill ECG Stress Echo Dobutamine Echo Adenosine Myoview Sestamibi

Other ______

______MD Signature

The above order set is meant to serve as a guideline only and not intended as a standard of care or the hospital medical screening process. It should be modified or abandoned as indicated by individual patient circumstance, local practice, and physician judgement.

Possible ischemic pain 1. Obtain ECG, CXR, Cardiac enzymes Pressure, heavy, burning, aching, Yes 2. Obtain 2cd ECG if worsening or indigestion, or squeezing pain (any non- recurrent pain or if initial ECG is movement or non-palpation induced nondiagnostic despite ongoing pain) symptoms. Severe pain or exertional pain 3. If patient presents with < 6- 8 hrs Any radiation to jaw, arms, back, neck, of pain, obtain repeat enzymes.* or shoulder Follow Acute Coronary Syndrome Any associated SOB, nausea, or Pathway as indicated * Hamm 1997 suggests at least one troponin > 6 hours diaphoresis after pain onset. ACEP clinical policy suggests a level drawn at least 8-12 hrs after pain onset if using single draw enzyme testing Aortic Dissection Pain

Yes Sudden pain, severe pain, maximal at onset Consider CT angiography of “Tearing” or “ripping” pain chest to rule out aortic Pain radiating to back dissection. Consider d-dimer. Chest pain plus neurologic deficit (Several studies show nearly all Hx Marfan’s disease pts with dissection have a Family hx of aortic dissection positive d-dimer) No

Pleuritic Pain Consider Pulmonary Embolism See PERC Rule and Charlotte “Definite” or “Possible” that pain is Yes Rule increased with respiration Order D-Dimer and/or CT angiography/venography or VQ scan as indicated (Attachment A)

Yes Draw Cardiac Enzymes on Cocaine use in past week admission and another set at least 8 hours after pain onset. If negative ECG, CXR and enzymes, outpatient F/U No

*Certain of these patients with atypical chest pain may be suitable for Chest Pain Go to next page Center Evaluation if negative enzymes and no acute ECG changes

The algorithm is meant to serve as a guideline only and not intended as a standard of care. It should be modified as 5 indicated by individual patient circumstance, local practice, and physician judgement.

Resuscitate as indicated Consult Cardiologist or PMD for admission Yes Shock or Evidence of Obtain ECG, CXR, cardiac Pulmonary Edema enzymes Consider Cardiac BNP Follow Acute Coronary Syndrome Pathway as indicated

Consider CT angiography of Pulse deficit, Yes Systolic BP > 20 mm Hg chest to rule out aortic difference between arms, dissection. Consider d-dimer. New neurologic deficit (Several studies show nearly all pts with dissection have a positive d-dimer)

Consider Pulmonary Embolism Yes See PERC Rule and Charlotte Calf asymmetry, Rule Venous cord in leg, Order D-Dimer and/or CT Pulmonary friction rub angiography/venography or VQ scan as indicated (Attachment A) No

Go to next page

The algorithm is meant to serve as a guideline only and not intended as a standard of care. It should be modified as indicated by individual patient circumstance, local practice, and physician judgement. 6

© 2007 Patient Safety and Risk Solutions, LLC. All rights reserved Step 3 Diagnostic Studies Consult Cardiologist or PMD ECG shows for admission ST segment elevation or Obtain CXR, cardiac enzymes Yes depression > 1 mm in 2 if not already obtained consecutive leads or Follow STEMI or ACS presumably new LBBB or T Pathway wave inversion (Thrombolytics or PCTA, TNG, ASA, Plavix, beta blockers, heparin as indicated)

CXR shows Yes Consider evaluation for Aortic Wide mediastinum Dissection (CT angiography) Abnormal aortic knob or Other stigmata of aortic dissection

Yes Ensure Cardiac Enzymes drawn on admission and another set at Positive urine test for cocaine least 8 hours after pain onset. If negative ECG, CXR and enzymes, outpatient F/U

Consult Cardiologist or PMD Yes for admission Cardiac Enzymes Positive CK-MB or Troponin Follow Acute Coronary OR Syndrome Pathway 2 hr Delta CK-MB > 1.5ng/ml OR (TNG, ASA, beta blockers, 2 hr Delta Troponin I > 0.2ng/ml heparin as indicated)

Go to next page

The algorithm is meant to serve as a guideline only and not intended as a standard of care. It should be modified as 7 indicated by individual patient circumstance, local practice, and physician judgement. © 2007 Patient Safety and Risk Solutions, LLC. All rights reserved Step 4 Provocative Testing Low-risk patients will have same-day stress tests if Low Risk Patient Yes appropriate or outpatient stress See Provocative Testing testing within one week Algorithm (preferably within 72 hours).

Same day stress test or hold for Intermediate Risk Patient Yes next available stress test (“Hold” may include Chest Pain Center, prolonged ED See Provocative Testing monitoring, or admit to Algorithm hospital)

Admit to hospital or consult (In Yes some EDs with a chest pain High Risk Patient center, certain “High Risk” patients with no ongoing pain, no acute ST segment changes See Provocative Testing and negative enzymes may be Algorithm “admitted” to the chest pain center rather than the hospital.)

© 2007 Patient Safety and Risk Solutions, LLC. All rights reserved Tool 3 - Provocative Testing Algorithm Low Risk Patients –No ongoing chest pain, no prior history of coronary artery disease AND Younger than 40 years old with normal ECG and negative delta markers (2 hr increase in CK- MB < 1.5ng/ml and 2 hr increase in Troponin < 0.2ng/ml) OR Younger than 40 years old with no cardiac risk factors and negative delta markers (2 hr increase in CK-MB < 1.5ng/ml and 2 hr increase in Troponin < 0.2ng/ml). (ECG may show non-specific changes) OR Any age with normal or near-normal ECG AND negative Troponin 6 -8 hours after pain onset. (ACEP clinical policy suggests negative markers between 8 and 12 hours after pain onset needed to rule out MI)

Same day testing if appropriate or outpatient testing within one week (preferably within 72 hours). For outpatient testing and no Primary Care Provider (PCP), patient may return to ED next weekday AM for stress testing and discussion of results.

Intermediate Risk Patients - No ongoing chest pain plus either negative delta markers (2 hr Delta CK-MB < 1.5ng/ml and 2 hr Delta Troponin < 0.2ng/ml) or negative troponin 6-8 hours after pain onset. AND ECG shows: Left Ventricular Hypertrophy with repolarization abnormalities (LVH with strain) Left Bundle Branch Block (known to be old) Pathological q waves in two or more leads T wave inversion known to be old Non-specific ST or T wave changes

Same day testing if available or admit to chest pain center, keep in ED on monitor, or admit to hospital for next available stress test.

High Risk Patients- History of diagnosed angina, coronary artery stent, angioplasty, MI, or CABG plus “cardiac” pain. OR Any patients with abnormal ECG showing: ST segment elevation > 1 mm in at least 2 adjacent leads ST segment depression > 1 mm in at least 2 adjacent leads T wave inversion not known to be old Left Bundle Branch Block not known to be old Paced rhythm OR Abnormal Cardiac Enzymes Admit to hospital or consult (In some EDs with a chest pain center, certain “High Risk” patients with no ongoing pain, no acute ST segment changes and negative enzymes may be “admitted” to the chest pain center rather than the hospital.)

This algorithm is meant to serve as a guideline only and not intended as a standard of care. It should be modified as indicated by individual patient circumstance, local practice, and physician judgement.

Exercise Treadmill Test (ETT) Able to Exercise and normal or near-normal ECG Exclusion Criteria: Inability to exercise Left ventricular hypertrophy with repolarization changes Significant ST and T wave changes including digoxin effect Biphasic or inverted T waves in anterior leads Left bundle branch block

Exercise Stress Echocardiogram or Exercise Stress Nuclear Medicine Study (Sestamibi or other) May be useful to discuss with local cardiologists for test of choice. Able to exercise but abnormal ECG Exclusion Criteria: Inability to exercise Biphasic or inverted T waves in anterior leads

Pharmacologic Stress Test (Dobutamine Echocardiogram, Adenosine Myoview, or other pharmacologic stress nuclear medicine scan) May be useful to discuss with local cardiologists for test of choice.

Unable to exercise and abnormal ECG

Normal Stress test --- Follow up PCP or clinic

Abnormal Stress test—Consult PCP or cardiologist

© 2007 Patient Safety and Risk Solutions, LLC. All rights reserved TOOL 6 - CHEST PAIN AUDIT TOOL---FOR QUALITY IMPROVEMENT Audit of charts with Final Diagnosis of “Peptic Ulcer Disease” (PUD), “Reflux”, “Gastroesophageal Reflux Disease” (GERD), Gastritis (State confidentiality statutes…………………..) PHYSICIAN______DATE______MEDICAL RECORD #______PATIENT AGE______PATIENT GENDER______

Yes No N/A 1. Patient with final Dx of “Peptic Ulcer Disease” (PUD), If “yes “Reflux”, “Gastroesophageal Reflux Disease” (GERD), or go to “Gastritis” question 3

2. If chief complaint of “Abdominal Pain” in upper abdomen, if patient over 30 years of age did they have If “Yes”, If “No” significant abdominal tenderness? end of go to audit question 3 3. Documented negative cardiac catheterization in past year or documented negative cardiac stress test in past 6 months?

4. ECG, Cardiac Enzymes, in ED?

5. Provocative testing in ED or arranged as outpatient

6. If outpatient testing, was patient “Low Risk”?

PERC Criteria (Pulmonary Embolism Rule-Out Criteria) If patient meets all of the following criteria, no need for further PE work up (i.e. no D-dimer needed). However, post partum patients may need additional testing if chest pain or shortness of breath.

Age < 50 No estrogens No recent surgery (general anesthesia within 4 weeks) No history of DVT or PE No hemoptysis No unilateral leg edema on visual inspection Pulse Oximetry > 94 % Heart rate less than 100

Kline J Thromb Hemost. 2004

Charlotte Rule A negative D-dimer will essentially rule out pulmonary embolism unless the patient has any two of the following criteria. If patient with pleuritic chest pain or unexplained dyspnea has any two of the following OR a positive D-dimer; perform either a CT angiogram or VQ scan to rule out Pulmonary Embolism.

Age > 50 and Heart Rate > Systolic BP Recent Surgery Unexplained hypoxia (Pulse Ox < 95%) Hemoptysis Unilateral Leg Swelling

Kline Ann Emerg Med 2004

1. Kontos MC, Jesse RL. Evaluation of the emergency department chest pain patient. Am J Cardiol. 2000; 85:32B–9B. 2. Hamm CW. Cardiac biomarkers for rapid evaluation of chest pain. Circulation 2001;104;1454-56. 3. Christianson J, Innes G, et al. Safety and efficiency of emergency department assessment of chest discomfort. CMAJ 2004;170:1803-07. 4. Christenson J, Innes G, et al. A clinical prediction rule for early discharge of patients with chest pain. Ann of Emerg Med 2006;47:1-10. 5. Hamm CW, Goldman BU, Heeschen C, et al. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac Troponin T or Troponin I. N Engl J Med 1997;337:1648-1653. 6. Pope JH, Aufderheide TP, Ruthazen R, et al. Missed diagnosis of acute cardiac ischemia in the ED. N Engl J Med 2000;342:1163-1170. 7. Fesmire F, Percy R, Bardoner J, et al. Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain. Ann Emerg Med 1998;31:3. See also Emerg Med Clin NA 2001;19:269; more than half of AMI patients over the age of 85 do not have chest pain as a presenting complaint. 8. Lau J, Ioannidis JP, et al. Diagnosing acute cardiac ischemia in the emergency department: a systematic review of the accuracy and clinical effect of current technologies. Ann Emerg Medicine 2001 May;37(5)453-460. 9. Evaluation of Technologies for Identifying Acute Cardiac Ischemia in Emergency Departments. Summary, Evidence Report/Technology Assessment: Number 26. AHRQ Publication No. 00-Medicine031, September 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/cardsum.htm. 10. Hollander JE, Hoffman RS, Gennis P, et al. Prospective multicenter evaluation of cocaine-associated chest pain. Acad Emerg Med. 1994; 1:330–9. 11. Bean DB, Roshon M, Garvey JL. Chest pain: diagnostic strategies to save lives, time and money in the ED. Emerg Med Practice. 2003;5:1-30. 12. Higgins GI, Lambrew CT, et al. Expediting the early hospital care of patients with nontraumatic chest pain: impact of a modified ED triage protocol. Am J Emerg Med 1993;11:576-582. 13. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Non–ST- Segment Elevation Acute Coronary Syndromes Ann Emerg Med. 2006;48:270-301.]

Edited by Michelle M. Hoppes, RN, MS, AHRMQR, DFASHRM, CEO, Patient Safety and Risk Solutions LLC and Graham Billingham, MD, FACEP, Chief Medical Officer, Patient Safety and Risk Solutions LLC

© 2007 Patient Safety and Risk Solutions, LLC. All rights reserved EMERGINGEMERGING RISKSRISKS ININ THETHE EDED IMPROVINGIMPROVING THETHE RISKRISK PROFILEPROFILE Michelle Hoppes RN, MS, AHRMQR, DFASHRM President and CEO, Patient Safety & Risk Solutions May, 2007

Emergency Medicine Today WhatWhat’’ss Emerging?Emerging? FromFrom thethe TrenchesTrenches

““ThereThere continuescontinues toto bebe doomdoom andand gloomgloom atat thethe nationalnational levellevel regardingregarding emergencyemergency medicinemedicine------therethere areare somesome innovativeinnovative solutionssolutions beingbeing triedtried butbut mostmost appearappear toto bebe bandband--aidaid inin lightlight ofof thethe hugehuge economiceconomic challengeschallenges facingfacing healthcarehealthcare ------itit isis clearclear thatthat thethe tirestires areare fallingfalling offoff thethe VolkswagenVolkswagen atat thisthis pointpoint andand thatthat thethe issuesissues ofof overcrowding,overcrowding, decliningdeclining reimbursement,reimbursement, onon callcall panels,panels, hospitalhospital closures,closures, increasedincreased regulation,regulation, nursingnursing andand MDMD staffstaff shortashortagesges areare notnot goinggoing awayaway andand willwill inin factfact bebe muchmuch worseworse”” EDED’’ss ------WeWe areare MoreMore AlikeAlike thanthan DifferentDifferent WhatWhat areare thethe challenges?challenges? EDED’’ss wewe areare Alike!Alike!

Staffing issues On-call response Regulations Overcrowding Patient expectations and satisfaction Capacity and Pt flow issues Drug seekers Language problems Reimbursement decreasing Efficiency issues Top ten clinical areas of high risk to ED TodayToday’’ss ProgramProgram

EM current environment and what is ahead…….. ACEP Media National Initiatives High risk issues---malpractice and medical error trends EM risk profile—what is it? Clinical best practice Chest pain Operations focus Throughput Closed claims review Lessons learned ACEP Priority Objectives

Liability

Access Reimbursement

Quality Crowding Preparedness RallyRally atat thethe USUS CapitolCapitol

To provide a platform for that legislation, ACEP hosted the “Rally at the US Capitol” in Sept. Thousands of emergency physicians, nurses and others joined forces Helped raise the nation’s and Congress’s awareness of EM issues Generated significant national media attention to problems Members Prepare for the Rally in the ED OnOn thethe HillHill

““AccessAccess toto EmergencyEmergency MedicalMedical ServicesServices ActAct ofof 20072007”” ACEP worked with members of the Senate and House to facilitate the introduction of legislation that will: End the boarding of admitted patients in hospital EDs Support emergency medical care as an essential public service

MayMay 0707----StopStop thethe ““gridlockgridlock”” Why? Sicker Uninsured growing What? Access to 24/7 medical specialties---on-call issues “The State of Emergency Medicine Report Card”

ReleasedReleased inin MarchMarch 20062006 RankRank nationnation andand statesstates withwith letterletter gradegrade usingusing objectiveobjective andand crediblecredible measuresmeasures inin fourfour categories:categories: Access Quality and Patient Safety Injury Prevention Medical Liability Environment • ToTo bebe usedused nationallynationally andand statestate--byby--statestate asas aa stimulusstimulus forfor changechange inin thethe emergencyemergency medicinemedicine environmentenvironment EmergencyEmergency MedicineMedicine IOMIOM ReportReport

National crisis Overcrowded Primary source of care for uninsured Less ED’s, more visits Diversions high Care fragmented On-call specialist shortage Lack of disaster preparedness Peds care--shortcomings InIn thethe MediaMedia MIMI MortalityMortality WorseWorse onon WeekendsWeekends “For patients with myocardial infarction, admission on weekends is associated with higher mortality and lower use of invasive cardiac procedures.

Our findings suggest that the higher mortality on weekends is mediated in part by the lower rate of invasive procedures, and we speculate that better access to care on weekends could improve the outcome for patients with acute myocardial infarction”

Downloaded from www.nejm.org on May 2, 2007 AA recentrecent PhysicianPhysician CensusCensus byby thethe PalmPalm BeachBeach CountyCounty MedicalMedical SocietySociety confirmsconfirms thatthat thethe patientpatient accessaccess toto carecare crisiscrisis inin FloridaFlorida willwill worsenworsen asas thethe shortageshortage ofof physiciansphysicians reachesreaches dangerousdangerous levels.levels. MedicalMedical lawsuitlawsuit abuseabuse isis forcingforcing goodgood doctorsdoctors toto fleeflee thethe state,state, cutcut backback onon vitalvital services,services, oror leaveleave medicinemedicine altogether.altogether. DiminishingDiminishing EmergencyEmergency CareCare

St.St. LouisLouis PostPost--DispatchDispatch (5/10),(5/10), ""MedStarMedStar,, aa privateprivate provider,provider, announcedannounced thatthat itit wouldwould cutcut backback toto basicbasic lifelife supportsupport unitsunits inin thethe EastEast St.St. LouisLouis area,area, basedbased onon economicseconomics (too(too manymany lowlow--paidpaid MedicaidMedicaid andand MedicareMedicare calls)calls) andand staffstaff reluctancereluctance (too(too manymany medicsmedics facingfacing violenceviolence onon thethe job).job). ThisThis isis aa bigbig dealdeal forfor tenstens ofof thousandsthousands ofof peoplepeople----somesome ofof whomwhom maymay notnot survivesurvive theirtheir heartheart attacks,attacks, carcar wreckswrecks andand shootingsshootings withoutwithout rapidrapid paramedicparamedic carecare CriminalizingCriminalizing aa SystemSystem ProblemProblem

EDED deathdeath aa homicidehomicide ThoughThough thethe immediateimmediate causecause ofof HERHER deathdeath waswas aa heartheart attack,attack, theythey reportedreported sheshe alsoalso dieddied "as"as aa resultresult ofof grossgross deviationsdeviations fromfrom thethe standardstandard ofof carecare thatthat aa reasonablereasonable personperson wouldwould havehave exercisedexercised inin thisthis situationsituation------ StressedStressed outout byby overcrowdingovercrowding NationalNational QualityQuality InitiativesInitiatives

Door to balloon in 90 minutes----expectation--- reimbursement, media/public, malpractice risk Facilitating transfers in from referral hospitals-STEMI regionalization EKG in field or triage “Code Heart Medication Kit”-heparin, aspirin, beta blockers and nitroglycerin --all stored together Lab tests drawn, paperwork expedited get the patient to the lab ED charge nurses and staff immediately go to the patient to facilitate transfer to the cath lab – thus establishing clear priorities for the most urgently needed patient care ED team takes ownership for transferring the patient to the cath lab rather than having cath lab staff call when ready Source George Washington University –Urgent Matters March 07 DiversionDiversion ProjectProject

CaliforniaCalifornia HealthcareHealthcare FoundationFoundation DiversionDiversion hourshours upup toto 22%22% SomeSome onlyonly divertdivert forfor equipmentequipment problemsproblems PhysicianPhysician PerspectivesPerspectives

““OverOver thethe pastpast 4040 yearsyears oror so,so, therethere hashas beenbeen aa concertedconcerted efforteffort toto reducereduce thethe valuevalue ofof physiciansphysicians inin society.society. TheThe publicpublic hashas stoppedstopped seeingseeing thethe doctordoctor asas aa caregivercaregiver andand anan assetasset toto thethe community.community. NowNow thethe physicianphysician isis aa providerprovider ofof servicesservices andand moremore andand moremore inin placesplaces aa commoditycommodity withwith varyingvarying degreesdegrees ofof availability.availability. BeforeBefore physiciansphysicians werewere inin controlcontrol ofof medicinemedicine nownow medicinemedicine isis controlledcontrolled byby thosethose whowho knowknow economicseconomics””.. Physician Practice Nov/Dec. 13-14, 2006 PhysicianPhysician WellnessWellness

ConsideredConsidered leavingleaving medicine?medicine?

6/106/10 physiciansphysicians have!have! (1200 physicians-The Physician Executive December 06) Low Reimbursement Loss of autonomy Bureaucratic red tape Patient overload Loss of respect Medical liability environment PhysicianPhysician WellnessWellness

PhysiciansPhysicians experienceexperience duedue toto workwork FatigueFatigue 77%77% EmotionalEmotional burnoutburnout 67%67% Marital/familyMarital/family discorddiscord 34%34% DepressionDepression 32%32% SuicidalSuicidal thoughtsthoughts 04%04% SubstanceSubstance abuseabuse 03%03% (Survey ACPE 2006 www.acpe.org/education/surveys/morale/morale.htm ) PhysicianPhysician WellnessWellness

MoraleMorale ofof PhysiciansPhysicians 00--1010 pointpoint scalescale –– 1010 highesthighest moralemorale 60% - 5/10 or less StepsSteps takentaken toto combatcombat lowlow moralemorale Talk to fellow physicians Searched for a job outside health care Lobbied government for change Sought personnel counseling

Survey ACPE 2006 WeWe KnowKnow WhatWhat isis NotNot Right!Right! NursingNursing homeshomes thatthat willwill notnot acceptaccept patientspatients onon evening,evening, weekweek endsends oror holidaysholidays butbut reliablyreliably sendsend toto thethe EDED forfor constipation.constipation. CTsCTs cannotcannot bebe readread afterafter certaincertain hourshours oror MRIsMRIs areare notnot availableavailable onon certaincertain days.days. FunctionalFunctional assessmentassessment ofof cardiaccardiac patientspatients isis limitedlimited toto certaincertain specialtyspecialty hourshours oror equipmentequipment staffing.staffing. BedsBeds areare beingbeing ““heldheld”” forfor surgerysurgery asas EDED patientspatients areare ““boardedboarded””.. PatientsPatients remainremain inin thethe EDED duedue toto unacceptableunacceptable nursingnursing ratios,ratios, nursingnursing reportreport isis beingbeing given,given, oror bedsbeds cannotcannot bebe cleaned.cleaned. ConsultantConsultant refuserefuse toto taketake callcall oror eveneven acceptaccept referralsreferrals EMEM PatientPatient Satisfaction:Satisfaction: AA NationalNational ConcernConcern

PressPress GaneyGaney--1.41.4 millionmillion visits,visits, 14341434 hospitalshospitals ConcernsConcerns WaitWait timetime HowHow wellwell informedinformed aboutabout delaysdelays AgeAge 1818--3535 leastleast satisfiedsatisfied DegreeDegree toto whichwhich staffstaff caredcared HowHow wellwell painpain controlledcontrolled RegulatoryRegulatory

AHRQAHRQ patientpatient satisfactionsatisfaction NoNo longerlonger voluntaryvoluntary ifif wantwant fullfull reimbursementreimbursement Never/sometimes/alwaysNever/sometimes/always------onlyonly displayingdisplaying alwaysalways responsesresponses toto thethe publicpublic TreatTreat withwith courtesycourtesy andand respect?respect? ListenListen carefullycarefully toto you?you? ExplainExplain thingsthings inin aa wayway youyou cancan understand?understand? SatisfactionSatisfaction SolutionsSolutions

RoundingRounding forfor outcomesoutcomes EmployeeEmployee thankthank youyou notesnotes EmployeeEmployee selectionselection andand thethe firstfirst 9090 daysdays CallCall backsbacks KeyKey wordswords andand keykey timestimes——scriptingscripting MedicalMedical ErrorError inin thethe EDED

StudyStudy specificspecific toto EDED 19351935 patientspatients overover 7days7days------400400 errorerror reportsreports 5.55.5 errorserrors perper 100100 hourshours workedworked 1818 errorserrors perper 100100 patientspatients seenseen 100100 millionmillion EDED patientspatients perper year=18year=18 millionmillion errorserrors 2%2% causecause harm=360,000harm=360,000 patientspatients MedicalMedical ErrorError inin thethe EDED

22%22% diagnosticdiagnostic studiesstudies 16%16% administrativeadministrative proceduresprocedures 13%13% medicationmedication 12%12% documentationdocumentation 11%11% communicationcommunication ContributingContributing factorsfactors Diagnostic study areas Mislabeling specimens Wrong order Organizational failure Situational awareness LatentLatent ErrorsErrors ActiveActive ErrorsErrors LatentLatent ErrorError inin thethe EDED

StudyStudy ofof 55 EDsEDs:: NursesNurses andand DoctorsDoctors nevernever signedsigned outout togethertogether (Wears and Perry) CommunicationCommunication SituationalSituational awarenessawareness isis criticalcritical

Fairbanks RJ, Bisantz AM, Sumn M. Emergency Department Communication Links and Patterns. Annals of Emergency Medicine (in press).

EMEM -- MalpracticeMalpractice RiskRisk NationalNational datadata -- 1:17,0001:17,000 –– 20,00020,000 visitsvisits AverageAverage EDED MDMD aa lawsuitlawsuit everyevery 77 yearsyears FrequencyFrequency isis decreasingdecreasing -- severityseverity isis notnot MultimillionMultimillion dollardollar verdictsverdicts accountaccount forfor 11 outout ofof 44 juryjury verdictsverdicts TheThe costcost ofof defensedefense andand awardsawards havehave doubleddoubled inin thethe pastpast fivefive yearsyears EarlyEarly infoinfo------ifif aa patientpatient isis seenseen inin lessless thanthan 3030 minutes,minutes, therethere isis aa 11 inin 25,00025,000 claimsclaims frequency,frequency, ifif aa patientpatient waitswaits moremore thanthan 9090 miminutesnutes itit goesgoes upup toto 44 inin 25,0000.25,0000. EMEM MedicalMedical MalpracticeMalpractice TrendsTrends PIAA Report

AgeAge------61%61% underunder thethe ageage 4545 GenderGender------higherhigher percentagepercentage ofof femalesfemales namednamed thanthan malesmales asas comparedcompared toto otherother specialtiesspecialties ResolutionResolution------23%23% ofof claimsclaims resultresult inin indemnityindemnity paymentpayment AllegationsAllegations----TheThe mostmost prevalentprevalent medicalmedical misadventuremisadventure isis diagnosticdiagnostic errorserrors EMEM MedicalMedical MalpracticeMalpractice TrendsTrends FrequencyFrequency---- appendicitis,appendicitis, MI,MI, abdomenabdomen oror pelvis,pelvis, meningitismeningitis IndemnityIndemnity---- averageaverage indemnityindemnity paymentpayment isis $249,000$249,000 MeningitisMeningitis-- highesthighest indemnityindemnity paymentpayment—— averageaverage paymentpayment ofof $443,000$443,000 MissedMissed MIMI’’ss -- indemnityindemnity paymentspayments 55%55% ofof thethe timetime OtherOther claimsclaims ——improperimproper procedures,procedures, proceduresprocedures notnot performed,performed, failurefailure toto supervisesupervise oror monitormonitor PediatricPediatric MalpracticeMalpractice

ED IOM focus area 16 year period review--$150 million paid, 300% increase over past 13 year Common diagnostic areas Meningitis Appendicitis Fractures 60% boys 50% under age 2 Jury cases-80% in favor of defendant—most settled RM lessons Abd pain---?---appy until proven otherwise, fracturesfractures— ensure timely radiology over-read and follow up Top ED Diagnosis Causes

$1,200,000 50

45 $1,000,000 40

35 $800,000 30

$600,000 25 Claim Count Claim 20 $400,000 15

10 $200,000 5

$0 0 Fail/Delay Behavioral Lab/Test Foreign Diagnose Health Res ults Body

Paid Outstanding Count Top ED Treatment Causes

$250,000 12

10 $200,000

8 $150,000

$100,000 Count Claim 4

$50,000 2

$0 0 Improper Fail/Delay IV Related Blood Sharps Sexual Lab/Test Urinary Feeding Use of Treatment to Treat Admin Assault Res ults Cath Ex c es s Force Paid Outstanding Count ReasonsReasons ForFor EMEM MalpracticeMalpractice

InadequateInadequate historyhistory && physicalphysical FailureFailure toto orderorder teststests PoorPoor communicationcommunication PoorPoor documentationdocumentation BadBad outcomeoutcome OperationalOperational issuesissues emergingemerging MostMost areare duedue toto failurefailure toto dodo thethe basicsbasics p.196 Annals of Emergency Medicine Volume 49, No. 2: February 2007 Hospital/FacilitiesHospital/Facilities PerspectivePerspective

EmergingEmerging RisksRisks TerrorismTerrorism PandemicsPandemics CredentialingCredentialing allegationsallegations InformationInformation SystemsSystems RemoteRemote DXDX && TreatmentTreatment UnauthorizedUnauthorized access/dist.access/dist. ofof medicalmedical recordsrecords CyberCyber riskrisk NewNew medicalmedical devices/proceduresdevices/procedures Foreign/crossForeign/crossForeign/cross-border--borderborder risksrisks HighHigh RiskRisk Categories:Categories: ““RedRed FlagsFlags”” Time of carecare Change of shift

Unscheduled return visit Many claims with 3 visits or more Second visit = different evaluation approach and/or different physician Third visit = admit patient and/or consult specialist …

Language problems Uncooperative patient Chest pain complaint SpecificSpecific PracticePractice FailuresFailures

FailureFailure toto diagnosediagnose Lack proper exam Excluding family Errors in ordering/interpreting tests MI—two enzymes, serial EKGs, observation FailureFailure toto treattreat MI-treating with a GI cocktail FailureFailure toto consultconsult // refer/refer/ admitadmit SpecificSpecific PracticePractice FailuresFailures

FailureFailure toto monitormonitor Discharge vital signs Waiting room re-assessment ImproperImproper triagetriage InappropriateInappropriate transfertransfer InadequateInadequate followfollow--upup planplan LWBS/AMALWBS/AMA patientpatient SpecificSpecific HighHigh RiskRisk ClinicalClinical AreasAreas

ChestChest painpain--- discharged pt/missed MI, aortic aneurysm, PE HeadacheHeadache ––SAH, meningitis TraumaTrauma-- head and spine, radiology issues StrokeStroke-- TPA or not AbdominalAbdominal painpain-- appy, elderly-AAA, ectopic FeverFever inin childrenchildren-- meningitis CaudaCauda equinaequina TesticularTesticular torsiontorsion WoundsWounds andand FracturesFractures OBOB inin EDED-- fetal assessment, triage IntoxicationIntoxication ClaimsClaims ReviewReview

3535 yearyear oldold disabled,disabled, malemale patientpatient withwith pastpast medicalmedical history:history: LowLow gradegrade astrocytomaastrocytoma (tumor)(tumor) DiagnosedDiagnosed sevenseven yearsyears ago.ago. HeHe underwentunderwent surgerysurgery andand radiationradiation treatmenttreatment RecentRecent (CVA)(CVA) withwith leftleft hemiparesishemiparesis andand seizureseizure disorderdisorder HeHe waswas takingtaking CoumadinCoumadin andand ChemotherapyChemotherapy HighHigh riskrisk oror lowlow risk?risk?

OnOn 55--1919--0505 hehe hadhad beenbeen drinkingdrinking inin aa bar.bar. HeHe statesstates hehe fellfell offoff thethe barstoolbarstool strikingstriking hishis head.head. ThereThere waswas slightslight bleedingbleeding withwith aa 33 cmcm abrasionabrasion onon hishis head.head. HeHe claimedclaimed notnot toto havehave lostlost consciousness.consciousness. TheThe ambulanceambulance crewcrew reportreport states:states: ““WitnessWitness statesstates patientpatient walkedwalked outout ofof bar,bar, confirmsconfirms ETOH,ETOH, fellfell andand hithit headhead onon sidewalk.sidewalk.”” TheThe patientpatient reportedreported aa headache,headache, andand hadhad difficultydifficulty answeringanswering questions.questions. DecisionDecision MakingMaking ProcessProcess

TheThe EDED physicianphysician waswas concernedconcerned aboutabout possiblepossible sequelaesequelae ofof thethe fallfall secondarysecondary toto CoumadinCoumadin use.use. However,However, thethe reviewreview ofof hishis symptoms,symptoms, history,history, labs,labs, andand physicalphysical examexam diddid notnot seemseem toto showshow anyany changechange fromfrom hishis baseline.baseline. HisHis mentalmental statusstatus andand abilityability toto communicatecommunicate hadhad improved,improved, andand therethere appearedappeared toto bebe nono furtherfurther bleeding.bleeding. HeHe waswas dischargeddischarged homehome inin fairfair condition.condition. OutcomeOutcome OnOn 55--2020--0505 hehe waswas unableunable toto bebe awakenedawakened byby hishis wifewife atat home.home. HeHe waswas transportedtransported viavia ambuambulancelance toto anotheranother nearbynearby hospital.hospital. AA CTCT scanscan showedshowed aa veryvery largelarge leftleft temporaltemporal parietalparietal hematoma.hematoma. HeHe underwentunderwent surgerysurgery forfor evacuationevacuation ofof thethe hematomahematoma.. HisHis conditioncondition deteriorateddeteriorated further,further, andand hehe expiredexpired onon 55-- 2121--0505 ClaimClaim settledsettled LessonsLessons

IntoxicationIntoxication –– examexam isis unreliableunreliable CoumadinCoumadin –– allall betsbets areare offoff MinorMinor headhead traumatrauma -- highhigh riskrisk vs.vs. lowlow riskrisk LowLow thresholdthreshold forfor CTCT ScanScan DischargeDischarge instructionsinstructions leftleft blankblank BewareBeware ofof ““lucidlucid”” intervalsintervals RapidityRapidity ofof surgicalsurgical interventionintervention isis criticalcritical ClaimClaim ReviewReview EMS REPORT 5555 y/oy/o malemale patientpatient complainingcomplaining ofof chestchest pain.pain. StatesStates hehe waswas atat restrest workingworking onon aa checkcheck bookbook atat onsetonset ofof thethe pain.pain. DescribedDescribed itit asas sharpsharp painpain 10/1010/10 withoutwithout radiationradiation toto leftleft arm/jaw,arm/jaw, accompaniedaccompanied byby dizzinessdizziness && somesome mildmild SOB.SOB. Pt.Pt. statedstated ““painpain gotgot mymy attentionattention””,, ““feltfelt likelike aa punchpunch toto thethe chestchest””.. Pt.Pt. diddid appearappear inin increasedincreased discomfortdiscomfort withwith complaintcomplaint ofof increasedincreased dizzinessdizziness appox.appox. 22--33 minutesminutes outout fromfrom ER,ER, thenthen ptpt’’ss BPBP decreaseddecreased toto 80/80/ atat samesame time.time. 1212 leadlead ECGECG nono significantsignificant changes.changes. AspirinAspirin waswas administeredadministered. WhatWhat wentwent wrongwrong andand why?why? TriageTriage:: chestchest painpain sincesince 12:4512:45 atat rest,rest, sharpsharp midsternalmidsternal chestchest painpain withwith dizzinessdizziness andand decreaseddecreased shortnessshortness ofof breath.breath. AppearsAppears confusedconfused withwith aphasiaaphasia onon arrival.arrival. LabsLabs drawn.drawn. AllAll returnedreturned WNL.WNL. EDED MDMD writes:writes: ChestChest painpain beganbegan aboutabout noon,noon, nonnon--radiating,radiating, upperupper sternalsternal areaarea markedmarked asas painpain site,site, statesstates relievedrelieved byby breathing.breathing. WhatWhat wentwent wrongwrong andand why?why?

PMH: hypertension, cardiomyopathy, enlarged heart, heart disease. Stress echo negative in past 2 years. Long distance runner; marathon ran in past 2 years.

Exam: no eye contact, hyperventilating. EKG-sinus brady. Chest x-ray-mild cardiomyopathy. BP 121/47, P 53, R 18, Sats 99% on 3 liters O2.

Nurse documents: he appears to be confused with difficulty in expressing himself, - anxious? IV started right forearm.EKG performed.

ED MD documents: Sinus brady, left ventricular hypertrophy. Given Ativan. DecisionDecision MakingMaking ProcessProcess !!stst--TroponinTroponin slightlyslightly elevatedelevated MyoglobinMyoglobin withinwithin normalnormal limitslimits VitalsVitals stablestable 22nd--TroponinTroponin backback toto normalnormal level.level. MyoglobinMyoglobin isis elevatedelevated atat 118.0118.0 CKMBCKMB ––normalnormal

AddendumAddendum toto EDED admitadmit sheetsheet byby EDED MD:MD: DiscussedDiscussed withwith cardiologistcardiologist whowho agreesagrees thatthat itit isis difficultdifficult toto understandunderstand howhow thethe troponintroponin couldcould bebe elevatedelevated atat 11 hourhour butbut notnot atat 22 hours,hours, givengiven thethe longlong halfhalf lifelife ofof thisthis substancesubstance DecisionDecision MakingMaking ProcessProcess

SecondSecond setset ofof vitalsvitals----BPBP 95/41,95/41, PP 68,68, RR 1818 SatsSats roomroom airair 98%.98%. CardiacCardiac enzymesenzymes withinwithin normalnormal limitslimits PlanningPlanning toto dischargedischarge------suddensudden changechange inin conditioncondition---- BPBP 81/3581/35 WifeWife atat bedside,bedside, patientpatient clutchedclutched chestchest andand becamebecame unresponsive.unresponsive. MDMD atat bedside,bedside, ptpt incontinentincontinent ofof urine.urine. PulsePulse 2828 FiveFive hourshours andand 3535 minutesminutes afterafter admissionadmission toto thethe ED,ED, thethe patientpatient codedcoded DespiteDespite prolongedprolonged effortsefforts toto resuscitateresuscitate himhim hehe expired.expired. CauseCause ofof deathdeath perper autopsyautopsy waswas rupturedruptured dissectingdissecting aorticaortic aneurysmaneurysm……………….... FamilyFamily PerceptionPerception

WifeWife reportedreported --onon twotwo differentdifferent occasionsoccasions duringduring herher husbandhusband’’ss treatmenttreatment inin thethe ED,ED, thethe treatingtreating emergencyemergency physicianphysician waswas readyready toto dischargedischarge herher husbandhusband,, butbut atat herher insistenceinsistence thatthat somethingsomething waswas wrongwrong && thatthat hehe shouldnshouldn’’tt gogo home,home, thethe doctordoctor agreedagreed toto dodo anotheranother setset ofof labslabs andand rere--evaluateevaluate herher husbandhusband AdditionallyAdditionally sheshe pointedpointed outout thatthat monitormonitor alarmsalarms werewere turnedturned offoff byby nursingnursing,, whichwhich wouldwould havehave soundedsounded whenwhen herher husbandhusband’’ss heartheart raterate hadhad acceleratedaccelerated beforebefore thethe codecode Mrs.Mrs. SimonSimon alsoalso maintainsmaintains thatthat sheshe triedtried toto impressimpress uponupon thethe nursingnursing staffstaff thethe significancesignificance ofof thethe darkdark colorcolor ofof herher husbandhusband’’ss urineurine atat oneone point,point, butbut thatthat factfact appearedappeared toto havehave nono impactimpact onon thethe nursenurse involvedinvolved ExpertExpert OpinionsOpinions StandardStandard ofof carecare waswas notnot metmet PatientPatient presentedpresented withwith ““classicclassic”” symptomssymptoms ofof anan aorticaortic aneurysmaneurysm HeHe waswas notnot appropriatelyappropriately evaluatedevaluated forfor thisthis condition.condition. TheThe chartingcharting checkcheck listlist andand dictationdictation werewere notnot completecomplete CTCT shouldshould havehave beenbeen performedperformed afterafter whichwhich thethe patientpatient wouldwould havehave beenbeen takentaken straightstraight toto thethe operatingoperating roomroom PatientPatient’’ss chanceschances ofof survivalsurvival werewere 80%80% hadhad thethe aorticaortic aneurysmaneurysm beenbeen recognizedrecognized AppearedAppeared thatthat thethe cardiaccardiac evaluationevaluation stoppedstopped afterafter itit waswas determineddetermined thatthat thethe patientpatient waswas notnot experiencingexperiencing aa myocardialmyocardial infarctioninfarction LessonsLessons

HighHigh riskrisk differentialdifferential diagnosisdiagnosis TunnelTunnel visionvision isis dangerousdangerous AssumeAssume thethe worstworst andand proveprove yourselfyourself wrongwrong AnxietyAnxiety isis aa diagnosisdiagnosis ofof exclusionexclusion BewareBeware ofof ““classicclassic”” signssigns andand symptomssymptoms AtypicalAtypical presentationspresentations areare commoncommon AnyAny patientpatient withwith chestchest oror abdominalabdominal painpain thatthat hashas neurologicalneurological oror vascularvascular complaints,complaints, signssigns oror symptomssymptoms isis anan aneurysmaneurysm untiluntil provenproven otherwiseotherwise EmergingEmerging IssuesIssues

HumanHuman mindmind——capablecapable ofof incorporatingincorporating 55--77 factorsfactors ofof aa decisiondecision Typical number of factors to consider for ED 20, for intensivist-50-60 InformationInformation isis explodingexploding Predictive medicine, genomic and proteomic markers TechnologyTechnology Computer fail safe design for diagnosis Clinical decision making tool Reduce misdiagnosis AbdominalAbdominal PainPain----LessonsLessons LearnedLearned

AbdominalAbdominal Pain:Pain: DischargeDischarge andand followfollow upup “Return to the ED or see your doctor if you get worse” is unacceptable as stand alone discharge instructions. Need action specific and time specific instructions: ‘Return to the ED in 8-12 hours for recheck’ 48-72 hour follow-up for ABD pain is too long! TheThe secondsecond unscheduledunscheduled visitvisit andand especiallyespecially aa thirdthird visitvisit forfor abdominalabdominal painpain shouldshould leadlead toto aa moremore aggressiveaggressive diagnosticdiagnostic investigationinvestigation ofof thethe patientpatient’’ss symptomssymptoms –– i.e.,i.e., moremore CTCT scans.scans. ChestChest PainPain

StillStill thethe #1#1 EDED medicalmedical malpracticemalpractice lossloss leaderleader Who/whatWho/what shouldshould wewe fear??fear?? FemaleFemale ageage 3535--5050 yrsyrs Chief complaint of ‘chest pain’; majority were smokers with a history of hypertension GIGI cocktailscocktails RushRush toto dischargedischarge ClaimsClaims ReviewReview

ChestChest PainPain

ChestChest painpain isis cardiaccardiac ischemiaischemia unlessunless youyou cancan definitivelydefinitively proveprove anotheranother diagnosisdiagnosis ConsiderConsider UndiagnosedUndiagnosed chestchest painpain mandatesmandates aa cardiaccardiac workupworkup whichwhich includesincludes atat aa minimumminimum serialserial EKGs,EKGs, serialserial biomarkers,biomarkers, andand observationobservation StressStress testingtesting beforebefore dischargedischarge or,or, forfor certaincertain defineddefined ‘‘lowlow--riskrisk’’ patients,patients, scheduledscheduled atat anan appropriateappropriate timetime afterafter discharge.discharge. CPCP BundleBundle

ChestChest painpain patientpatient------bundlebundle serialserial enzymesenzymes serialserial EKGEKG arrangearrange outpatientoutpatient stressstress testingtesting ProtocolProtocol OrderOrder setset AlgorithmAlgorithm AuditAudit——inspectinspect whatwhat youyou expectexpect AMAAMA andand LWBSLWBS----LessonsLessons LearnedLearned WhichWhich isis greatergreater risk?risk? PatientsPatients whowho refuserefuse examinationexamination oror recommendedrecommended treatmenttreatment (AMA)(AMA)------Document:Document: risksrisks andand benefits,benefits, alternativealternative treatmentstreatments patientpatient’’ss capacitycapacity patientpatient’’ss acceptanceacceptance ofof thethe risksrisks SignSign anan AMAAMA formform CallCall themthem backback------allall ofof themthem andand documentdocument itit ED CALL BACK PROCESS

DISCHARGE DIAGNOSIS o CHEST PAIN o FEVER o ASTHMA o HEADACHE o EYE INJURY o UTI o ABD PAIN o LACERATION o FRACTURE o OTHER______

SPECIFIC ISSUES TO ADDRESS ON CALL BACK ______

MD/PA/NP SIGNATURE______

PATIENT CONTACT INFORMATION______

CALL BACK RESULTS

o NO ANSWER 1ST ATTEMPT o NO ANSWER 2ND ATTEMPT o LEFT MESSAGE IF PRIOR AUTHORIZATION TO DO SO o SPOKE WITH PATIENT/GUARDIAN

FOLLOW UP o NO ACTION REQUIRED o PROVIDER NOTIFIED______o ACTION TAKEN ______

NURSE/PHYSICIAN SIGNATURE______PedsPeds FeverFever----LessonsLessons LearnedLearned

InfantsInfants withwith feversfevers PhysicalPhysical examexam Lethargic High pitched cry ReRe--assessmentassessment DischargeDischarge vitalvital signssigns FollowFollow--upup withinwithin 2424 hours;hours; AvoidAvoid ““SeeSee PCPPCP inin 1week1week””,, oror ““ReturnReturn ifif worseworse””.. TypesTypes ofof DocumentationDocumentation -- TemplatesTemplates vs.vs. HandwritingHandwriting vs.vs. DictationDictation vs.vs. EMREMR

LegibilityLegibility PromptsPrompts CheckCheck boxbox ““creepcreep”” TheyThey allall looklook thethe samesame ContemporaneousContemporaneous documentationdocumentation MedicalMedical decisiondecision makingmaking AddendumsAddendums levellevel 11 andand 22----criticalcritical carecare HighHigh riskrisk casescases –– intoxication,intoxication, hostile,hostile, AMAAMA EMEM RiskRisk ProfileProfile ComponentsComponents

Systems/operationalSystems/operational effectivenesseffectiveness CustomerCustomer satisfactionsatisfaction BehavioralBehavioral Clinical/performanceClinical/performance outcomesoutcomes FinancialFinancial performanceperformance MarketMarket shareshare RiskRisk ProfileProfile--BetterBetter PerformersPerformers RegistrationRegistration atat bedsidebedside RadiologyRadiology turnaroundturnaround andand coveragecoverage--24/724/7 TransportTransport teamteam FastFast tracktrack RapidRapid triagetriage ObservationObservation units/CPCunits/CPC InitiateInitiate ordersorders byby protocolprotocol Phys/ptPhys/pt staffingstaffing LabLab specimensspecimens differentdifferent colorcolor forfor EDED PaperlessPaperless accessaccess toto testtest resultsresults PointPoint ofof carecare testingtesting UseUse ofof technologytechnology HandHand heldheld communicationcommunication devicesdevices IncreasedIncreased secretarialsecretarial andand techtech supportsupport RiskRisk ProfileProfile NurseNurse stability/turnoverstability/turnover EDED physphys BoardBoard certified/residencycertified/residency trainedtrained Leadership,Leadership, governancegovernance——onon--sitesite medicalmedical directorsdirectors andand effectiveeffective committeescommittees MedicalMedical recordrecord documentationdocumentation effectivenesseffectiveness UseUse ofof EMR/CPOEEMR/CPOE ComputerizedComputerized dischargedischarge instructionsinstructions ChestChest painpain center/accreditationcenter/accreditation StrokeStroke protocols/strokeprotocols/stroke centercenter AvailabilityAvailability ofof onon--callcall physphys andand transfertransfer agreementsagreements PIPI indicators,indicators, monitoringmonitoring andand outcomesoutcomes areare effectiveeffective ProactiveProactive andand dedicateddedicated resourcesresources forfor RMRM CaseCase manamanaggersers RiskRisk ProfileProfile CallCall backback systemsystem 24/724/7 radiologyradiology supportsupport EKGEKG overover--readread andand xx--rayray discrepancydiscrepancy isis timelytimely UseUse 22 enzymesenzymes onon chestchest painpain ptspts andand serialserial EKGsEKGs AuditAudit highhigh riskrisk clinicalclinical areasareas andand outcomeoutcome PtPt satisfactionsatisfaction resultsresults atat leastleast 80%80% ClaimsClaims preventionprevention andand activeactive riskrisk reductionreduction planplan OperationalOperational structurestructure inin placeplace PhysicianPhysician evaluationevaluation processprocess PeerPeer reviewreview systemsystem effectiveeffective FormalFormal systemsystem toto reviewreview adverseadverse eventsevents Acuity/ptAcuity/pt mixmix isis inin lineline withwith resourcesresources CMECME OperationsOperations----ThroughputThroughput andand PatientPatient FlowFlow OvercrowdingOvercrowding——studystudy ofof 250250 EDED’’ss Average 1.1 pts/tx space 4.2 pts/nurse Staffing guidelines? SAEM, ACEP, ENA, legislated 9.7 pts/physician 81% of beds full more thanthan 6hrs/day6hrs/day 84% time use hall for pt care Why??Why?? Boarded patients Waiting for on-call consultants In-patient bed capacity QuestionQuestion

WhatWhat isis thethe rootroot causecause ofof thethe throughputthroughput challengeschallenges youyou have?have? DisasterDisaster WaitingWaiting toto HappenHappen

OvercrowdingOvercrowding DelayDelay inin diagnosisdiagnosis DelayDelay inin treatmenttreatment DecreaseDecrease inin qualityquality (AHA(AHA andand AnnualsAnnuals EM)EM) JCAHOJCAHO 50%50% sentinelsentinel events=delaysevents=delays inin ED,ED, 30%30% duedue toto overcrowdingovercrowding OvercrowdingOvercrowding ThreatsThreats

BoardingBoarding——filledfilled beyondbeyond capacitycapacity withwith highhigh acuityacuity patientspatients IncreaseIncrease inin errorerror raterate IncreaseIncrease inin diversiondiversion ThreatThreat toto disasterdisaster preparednesspreparedness ErodingEroding reliabilityreliability PatientPatient SatisfactionSatisfaction——ptpt preferprefer toto boardboard inin EDED roomroom versusversus anyany hallhall andand ifif havehave toto bebe inin hallhall preferprefer inin--ptpt hallhall (University(University ofof PAPA--www.aemj.orgwww.aemj.org MayMay 07)07) OvercrowdingOvercrowding--UnderlyingUnderlying CausesCauses

CausesCauses InadequateInadequate patientpatient capacitycapacity HigherHigher severityseverity ofof illnessillness BottlenecksBottlenecks HospitalHospital systemsystem restructuringrestructuring DelayDelay inin dischargesdischarges LOSLOS InappropriateInappropriate admissionsadmissions SolutionsSolutions Virtual approach Express admission unit/express admission nurse Frequent flier management Enforced admission criteria Patient flow coordinator Daily bed meetings Instant bed status alerts Electronic bed board Priority discharge/difficult discharge team Nurse initiated protocols Rapid test turnaround Physician extenders Bedside registration Fast track No delay nurse report Simulation Modeling PatientPatient FlowFlow--SimSim ModelingModeling Patient Focused Flow Redesign

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC Reducing Time to Physician

Time to Physician •“Key” to satisfaction “It seems like an eternity” 50% over estimate the time

Rapid triage/assessment-did not reduce LOS, but did decrease door to doc time and better pt satisfaction-(Children’s Hosp of Mich) Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC Reducing Time to Physician

Time to Physician • Average times National – 50 min Best Practice – 10 min.

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC Reducing Time to Physician

1 3

•Upfront Delays “Rapid Triage”; straight to room The “three person barrier” •Registration Bedside; concurrent w/ triage •Room Availability Pre DC waiting room, Admit/DC RN

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC Reducing Time to Physician

•Increase MD Availability MD 1st to see Physician scribes Eliminate unnecessary RN assessments •Paperwork Chart template, Physician Scribes •Discharge Independent MD DC, Admit/DC RN

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC Reducing Time to Physician

•Eliminate upfront delays •Eliminate barriers to MD assessment •Eliminate duplicate RN assessments “MD 1st to see”

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC Leveraging Waiting Time

Concurrent waiting for labs and MD

•Protocol driven RN initiation of work-up

•Medical decision making occurs sooner

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC SimulationSimulation ModelingModeling

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC % Door to Doc >30 minutes

Simulation Outputs Simulation Outputs 88.31% Left without being seen rate of 4.78%

Patient Time Log

Average Cycle Times Minutes Hours

Time Until Triage Starts Walk In 44.36 0.74

Ambulance 0.72 0.01

Time Until ED Bed Walk In 206.19 3.44

Ambulance 17.27 0.29

Time Until Initial Physician Assessment Walk In 222.24 3.70

Ambulance 34.33 0.57

Time Until Dispo Decision Walk In 401.38 6.69

Ambulance 227.31 3.79

Time Until Admitted Walk In 514.47 8.57

Ambulance 317.22 5.29

Time Until Discharged Walk In 433.44 7.22

Ambulance 268.51 4.48

Time Until Telemetry Patient From ED 503.28 8.39

Patient Transfer from Another Floor 123.33 2.06

Average Time in Telemetry All Patients 9559.82 159.33 6.64 days

Average Time in ED 419.04 6.98

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC MonthlyMonthly GraphsGraphs

Main ED Length of Stay

8 7 6 5 4 Hours 3 2 1 0 Apr May Jun Jul Aug Sep Oct Nov Dec Month

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC MonthlyMonthly GraphsGraphs

ED Patients Who Left Without Being Seen

7 6 5 4

Patients 3 LWBS 2 1 5 5 5 -0 0 -0 p 4 e Nov-0 ay Jul-05 S an-05 M ov-0 J Mar-05 N Sep-04 Month

Copyright, Proprietary and Confidential Information of Emergency Care and Health Organization, LTD and Echo Management and Consulting Group, LLC MoreMore EDED BedsBeds oror IncreaseIncrease InIn--patientpatient ExitExit RateRate

MedMed--ModelModel--computercomputer simulationsimulation NorthwesternNorthwestern UniversityUniversity--DePaulDePaul StudyStudy------increasingincreasing EDED bedsbeds inin 70,00070,000 ptpt visitvisit EDED diddid notnot changechange LOS,LOS, butbut increasingincreasing inin-- patientpatient exitexit raterate significantlysignificantly decreaseddecreased LOSLOS SummarySummary

ModifyModify thethe perceptionperception ofof thethe patientpatient BewareBeware ofof ““classicclassic”” presentationspresentations ReduceReduce thethe numbernumber ofof handhand offsoffs BeBe awareaware ofof thethe ““redred--flagsflags”” RuleRule outout highhigh--riskrisk diagnosesdiagnoses ImproveImprove EDED systemsystem problemsproblems Document,Document, document,document, documentdocument ChangeChange youryour riskrisk profileprofile TheThe FutureFuture

TechnologyTechnology willwill changechange thethe standardstandard ofof carecare PatientPatient SafetySafety willwill bebe partpart ofof thethe curriculumcurriculum SimulationSimulation trainingtraining willwill bebe thethe normnorm RiskRisk preventionprevention willwill occuroccur atat pointpoint ofof carecare TeamTeam trainingtraining willwill bebe thethe normnorm ThereThere willwill bebe twotwo veryvery differentdifferent typestypes ofof physicianphysician andand nursenurse practicespractices –– inpatientinpatient andand outpatientoutpatient PatientPatient SafetySafety isis everyoneeveryone’’ss responsibilityresponsibility CONTACT INFORMATION: Michelle Hoppes [email protected] 5178818987 5303281371 Patient Safety Risk Solutions www.psrisk.com