3rd Annual Emergency Medicine Symposium, SJRMC

QA Reviews: Lessons from the Sharp End

David J. Adinaro MD, MAEd, FACEPChief, Adult Emergency Department, EM Residency Research Director

Disclosures

Disclosures

I have nothing to report in terms of financial disclosures.

However…. My biases

Biases

I have been both a Practitioner and Consumer of emergency medicine

Biases

I believe That I have the best job in the

world That I work with the best

people in the best profession That we do noble work

Biases

I believe That I have the best job in the

world That I work with the best

people in the best profession That we do noble work That we can do better

Those who do not learn from history….

“No plan survives contact with the enemy.”

Moltke the Elder (1800-1891)

No captain can do wrong placing his ship besides that of the enemy.

Admiral Lord Nelson (1758-1805)

» Understand ways to improve patient safety

» Understand the concepts of the sharp end, the blunt end, and HROs

» Review the working of EDQA committee

Objectives

» The Sharp End» The Blunt End» High Reliability

Organizations» EDQA

Definitions

The Sharp End

» Where the work is done and errors are made\discovered

» Real time decisions based on available information

» Last line of defense in error prevention

» In healthcare made up of doctors, nurses, techs

The Sharp End

» Distal to the sharp (work end)

» Often remote from real time decisions but contribute to the care given and errors made

» ED Exec, Hospital Administration, State regulations, National Policies

The Blunt End

Sharp and Blunt Ends in Errors

A High Reliability Organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity

HRO

» Hypercomplexity - HROs exist in complex environments that depend on multi-team systems that must coordinate for safety

» Tight coupling - HROs consist of tightly coupled teams in which the members depend on tasks performed across their team

» Extreme hierarchical differentiation - In HROs, roles are clearly differentiated and defined. Intensive coordination efforts are needed to keep members of the teams working cohesively

» Multiple decision makers in a complex communication network - HROs consist of many decision makers working to make important, interconnected decisions

» High degree of accountability - HROs have a high degree of accountability when an error occurs that has severe consequences

» Need for frequent, immediate feedback - HROs exist in industries where team members must receive frequent feedback at all times

» Compressed time constraints - Time constraints are common to many industries, including health care

HRO

» Aircraft carrier flight deck operations» Nuclear Power Plants» Fireground Operations (especially wildfire)

HRO

» Preoccupation with failure» Reluctance to simplify

interpretations» Sensitivity to operations

HRO» Commitment to

resilience» Deference to

expertise

Flight Deck Operations

So you want to understand an aircraft carrier? Well, just imagine that it's a busy day, and you shrink San Francisco Airport to only one short runway and one ramp and gate.

Flight Deck Operations

Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side, and require that everyone who leaves in the morning returns that same day.

Flight Deck Operations

Then turn off the radar to avoid detection, impose strict controls on radios, fuel the aircraft in place with their engines running, put an enemy in the air, and scatter live bombs and rockets around.

Flight Deck Operations

Now wet the whole thing down with salt water and oil, and man it with 20-year-olds, half of whom have never seen an airplane close up.

Flight Deck Operations

Oh, and by the way, try not to kill anyone.

2727

» Aircraft carrier flight deck operations» Nuclear Power Plants» Fireground Operations (especially wildfire)» Emergency Departments!

HRO

ED Operations

ED Operations

PICTURE

ED Operations

PICTURE

» Hypercomplexity

» Tight coupling

» Extreme hierarchical differentiation

» Multiple decision makers in a complex communication network

» High degree of accountability

» Need for frequent, immediate feedback

» Compressed time constraints

HRO

» Embraces many aspects of HRO» 2009 Survey of Staff

• Feedback related to validated, national Patient Safety Survey

• Don’t Drop the Ball Program– Residents, Medical

Students, Staff» Yellow Cards

» Operations and safety issues

» Anonymous

SJRMC ED Operations

» Emergency Department Quality Assurance Committee» Physician and Nursing Leaders

» ED Exec» Case management, nursing educator» Physician\nursing representatives» Quality Assurance representative

» Review of identified cases and evaluates them for concerns\problems related to certain aspects of care

» Grade care given and also identify SHARP and BLUNT END issues to be resolved.

SJRMC ED Operations

Everyone raise their Hands!

» Started in the Fall of 2009» Initially met once

a month, then twice a month, now weekly for two hours

» In 2010 SJRMC saw 126,000 patients

» EDQA reviewed 115

EDQA

» Some acceleration in 2011• 56 reviewed to date • 25,000 ED visits

» Between 1 and 2 of every 1,000 charts submitted for review

EDQA

» Peds not well represented • 30% of patients, < 10%

of charts» Good mix of admitted

and discharged patients» Physicians average 4-8

charts a year reviewed

EDQA

» A major tool for physician review, early warning, and blunt end decision making

» Recently Wayne ED has joined process» Has become a model for other

departments in hospital

EDQA

EDQA

Where do the charts come from?» Most are identified\referred from our own

department• Leadership becomes aware of patient issue• Referrals by those on the sharp end

– Sharon Pineda (pinedas@sjhmc.org)• Automatic screens (Admit after RTC < 72

hours, mortality)» A significant number come from other

departments• Trauma, STEMI committee, Risk

management

Limitations» Specific to St. Joe’s» Small proportion

of Peds cases

To date approximately 200 charts have been reviewed during EDQAThe information collected on these sheets form the basis of the information that follows

EDQA Review

» Adverse Outcome?» Area of Concern» Who Referred» Documentaton Issue?» Care Issue?» System Issue?» Reccomendations» Outcome\EDQA Referral

» 70 year old female. Hypotensive, signs of sepsis, no IV access» Screen (Sepsis care)» Delay in ABX tx» NO adverse outcome» NO documentation issues» State Trooper• Design of car and malfunction

of handguns

Example #1

» YES Care Issue»Clinical judgment»Communication\responsiveness»Delay in Abx and IV access

» YES System Issue»Awareness of sepsis and tx

» SCORE»2 (physician)

» RECC:»Phys to ED Chair

Example #1

Adverse Outcomes

» Still not well defined» Generally taken to mean did an

unexpected event cause increase in the anticipated care of the patient.• Not found in most of the

reviewed charts• However, need for

unanticipated life sustaining tx found in about 10% of all charts reviewed.

Yes

37%

No63%

Yes

37%

No63%

Adverse Outcomes

Care not Affected11%

Incr. Monitoring36%Life Sustaining Tx

36%

In-creased

Tx16%

Adverse Outcomes Breakdown

Area of Concern

Appropriate Care53%

Ap-pro-pri-ate Dis-

posi-tion6%

Mortality9%

RTC12%

Delay in Tx14%

Other6%

Yes32%

No68%

Documentation Issues

Documentation Issues

» Vast majority are not found to have documentation issues

» Most of these concerns reflect weakness in documentation of communication, care plan, vital signs and reassessment

» Tended to weaken impression of care given, leaving more to interpretation

Documentation Issues

For Nursing documentation» Mostly involved paucity of vital signs documentation» Many involve lack of reassessment, communication during hand off,

and notification of change in patient conditionFor Physician documentation» Most fell in the MDM section

• Documentation of consults, conversation with pmd’s• Re-assessment of patients prior to discharge• Plan\events• HPI\PE to match seriousness of patient• Procedure documentation

» 80 year old male. » CC: abd pain and vomiting» Chest tightness documented in triage» Initial EKG nl. Triage level 3» Labs ordered. » Seen in Main East (1 hour into care)

» Positive troponin» Reviewed EKG

»Over-read by ED attending as STEMI» STEMI Activation

Example #2

» Med Staff» Appropriateness of care» YES Adverse (though care not affected)» YES Documentation Issue (Physician) » YES Care Issue (Physician)

» Judgment\Decision making» Failure to identify STEMI

Example #2

54

» YES System» Should have been Level 2» Issue with triage process» Benefit of MUSE on all ED Computers» Need for old EKGs

» SCORE: 3» Referred MDPR

Example #2

Yes42%

No58%

Care Issues

Physician Care Issues

Diagnosis5%

Tech-nique\Skills5% Knowl

edge1%Policy Com-

pliance4%Super-vision

1%Planning

6%

Clinical Judgment\Decision Making

50%

Communication19%

Follow-up9%

Care Issues

Physician Care» Lack of contact with pmd on discharge of patients

(especially, older or complex)» Under-resuscitation of shock» Trauma alert criteria not followed» EKG misinterpretation» Abnl Labs or vital signs not addressed» Protocol not followed STEMI, Stroke, Septic Shock» Delay\No consultant

Care Issues

No Physician can go wrong placing herself next to a critical patient and treating aggressively.

Adinaro/Nelson Rule

Technique\Skills6% Knowl

edge3%

Policy Com-

pliance13%

Planning6%

Clinical Judgment\Decision Making

38%

Communication25%

Follow-up9%

Nursing Care Issues

Care Issues

Nursing issues found less oftenPsych patient care» Removal of clothing» Identification of suicidal patients» Prolonged restraints\lack of sedation medsCommunication of critical information» Lab results» Abnl Vitals» Change in patient condition» Lack of known plan

Other Provider Care Issues

Diagnosis4%

Policy Compliance4%

Super-vision

4%Planning

4%

Clinical Judgement\De-cision Making

41%

Communication33%

Follow-up11%

Care Issues

Other Department» Clothing not removed from patient» Delay in arrival» Delay in responsiveness to consult

» Poor communication between consultant and other services

SCORE: Level of Assignment0. No problem with care/documentation 1. Minor process/documentation problem, clinical

outcome not affected 2. Problem with process/documentation,

disease/symptoms unchanged, adverse consequences possible

3. Problem with process/documentation, disease/symptoms occurred, made worse

4. Problem with process/documentation, permanent impact/quality of life

5. Death attributable to care provided that is significantly controversial

6. Death attributable to care provided/not provided that should have been provided

SCORE: Level of Assignment

No problem; 77

Minor, no affect; 41

Minor, effect possible; 42

Condition made

worse; 18

Permanent Impact ; 5 Death Attributalbe ; 2

» 56 yo male CC: feet swelling» Triaged 1538, labs obtained on standing orders» 1945, 2024, 2054 called no answer» 2055 Placed as LWOT and chart removed

» Next day: 1021» Sent back to ED by clinic due to abnl labs» Pale and weak» Moved to bed immediately» Hypotensive, INR 6. Hb 7.1» Had been 7.9 day before

Example #3

» Med Staff» Triage issue» YES Adverse: Increased monitoring» No Documentation» YES Care Issue (other\system)

» Long WR time» Labs not checked prior to removal of chart

Example #3

» YES System (Human, Safety\culture)» SCORE 2» RECCOMENDATION:

» System to ED Exec» Labs\orders done must be reviewed prior to

closing LWOT chart

Example #3

System Issues

Yes52%

No48%

Human System20%

Compute

r Sys-tem 4%

Non ED System19%Safety\Culture

39%

No Info18%

System Issues

System Issues – Safety Culture

• Call CT surgery early with issues• Alternative to Ultram in elderly• Clothing removal on ETOH patients• Desire to send borderline patients home• Communicating directly with consultants

and not through residents in critical cases• Calling PMDs on discharged patients• Ordering MRI when needed• Communication of important EDQA info to

staff• Abnormal vital sign reporting and tx

System Issues – Human Systems

• Changes needed in Front End processes• Charge nurse endorsement of hallway pt.• Clarification of trauma criteria• Delays in Triage-Bed in Peds• Difficult airway procedures. Checklist?• Including anginal equivalents for STEMI

screening (EKG)• STEMI med kit in Main East• Location of waiting Level 2 patients• EP to EP turnover (especially psych pt)

System Issues – Non ED Systems

• Cooling capacity in Cath Lab• Improved coordination among consult

services• Delays in Rad study completion times• Improve Surgery – OR communication• Non-notification by non-system

paramedics• Unresponsiveness of consultants• Trauma attending presence

System Issues – Computer Systems

• Lack of previous clinical data in medhost• Lack of physician access\orientation to

permanent clinical record• Rapid identification of radiology over-

reads at log in• Changes in script for nursing “visited

patient”

Doc to ED

Chair

46%

Nurse to ED Director15%

System to ED Exec17%

MDPR6%

Other

De-partmen

t15%

Feedback\Referrals by EDQA

A rookie baseball player after a great first game jokes that he wants to retire

When asked why he said» I had three hits in three

at bats. Put my glove on the ball a half dozen times without error

» My stats are perfect» It can only go down from

here!

Summary

• EDQA is a proactive Blunt End activity designed to improve care at the sharp end.

• Requires the active participation of Sharp End care providers.• Attend if possible\invited• Refer charts

• Benefits individual providers and system as a whole• Fulfills at least one of the goals of a HRO.• More info on SJRMC ED efforts:

• http://www.stjosephshealth.org/index.php/emergencytrauma

Thank You!