scholarly journals MP36: Reducing utilization of unnecessary coagulation tests by emergency providers

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S55-S55
Author(s):  
R. Gupta ◽  
S. Mondoux ◽  
G. Rutledge
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Length Of Stay ◽  
Cost Reduction ◽  
Control Charts ◽  
Cost Savings ◽  
International Normalized Ratio ◽  
Provider Education ◽  
Statistical Process ◽  
Process Measures

Background: Curbing unnecessary laboratory testing represents a significant opportunity for cost reduction in the Canadian health care system. A Choosing Wisely report cited a 31% decline in the number of tests ordered in a Canadian emergency department (ED) after implementation of recommendations. The international normalized ratio (INR) remains frequently ordered in emergency departments without an appropriate indication. Aim Statement: We aimed to reduce the number of INR tests completed in the St. Joseph's Healthcare Hamilton Emergency Department by 50% by April 30, 2019. Measures & Design: We conducted the study in an urban, academic ED employing the Epic electronic health record (EHR). We tailored interventions according to the Hierarchy of Effectiveness to address root causes revealed by analysis of our baseline ordering behaviour. Interventions included provider education around evidence-based ordering indications and removal of the INR from our “chest pain” bloodwork panel. Our outcome measure was the weekly number of INR tests completed per ED visit. Process measures included the proportion of INR tests ordered for inappropriate indications on monthly audits of 20 charts where an INR was completed. Balancing measures included average ED length of stay for patients receiving INR testing. Evaluation/Results: We collected outcome, process, and balancing measures through the EHR and analyzed this data using statistical process control charts. Over the nine-month study period, we decreased weekly INR tests from 248.4 to 115.0, a reduction of 56% which met criteria for special cause variation. This amounts to a cost savings of $43,008 per year. ED length of stay for patients receiving INR testing did not change significantly. Discussion/Impact: Our interventions were successful in realising our 50% target reduction in INR tests without an increase in ED length of stay from repeat venipuncture. This result is in keeping with similar efforts in other Canadian EDs. Our interventions could likely be spread to other settings where an INR is included as part of a “chest pain” panel. This may represent a substantial cost reduction opportunity on a national scale. Further work is needed in order to assess long term sustainability, which can be supported by employing high effectiveness mechanisms such as automation of optimal behaviour.

scholarly journals Assessment of Fever Advisory Cards (FACs) as an Initiative to Improve Febrile Neutropenia Management in a Regional Cancer Center Emergency Department

2016 ◽  
Vol 12 (9) ◽  
pp. e858-e863 ◽  
Author(s):  
Priyanka Kapil ◽  
Meghan MacMillan ◽  
Maritza Carvalho ◽  
Patricia Lymburner ◽  
Ron Fung ◽  
...  
Keyword(s):  
Emergency Department ◽  
Febrile Neutropenia ◽  
Control Charts ◽  
Cancer Center ◽  
Statistical Control ◽  
Statistical Process ◽  
Meaningful Improvement ◽  
Process Measures ◽  
Physician Assessment ◽  
Scale Scores

Purpose: We aimed to improve the time to antibiotics (TTA) for patients treated with chemotherapy who present to the emergency department (ED) with febrile neutropenia (FN) by using standardized fever advisory cards (FACs). Methods: Patients treated with chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada, with suspected FN were identified, before (April 2012 to March 2013) and after (October 2013 to March 2014) FAC implementation. The primary outcome of interest was TTA. Additional process measures included Canadian Triage and Acuity Scale score, time to physician assessment, and FAC compliance. Outcomes were analyzed with descriptive statistics and control charts to determine whether the change in primary measures were within statistical control over time. Results: Between the pre-FAC cohort (n = 239) and post-FAC cohort (n = 69), TTA did not change significantly post-FACs (195 v 244 min, P = .09), with monthly averages demonstrating normal variation by statistical process control methodology. The introduction of FACs increased the percentage of patients with correctly assigned Canadian Triage and Acuity Scale scores (87% v 100%) but did not affect time to physician assessment. Compliance with FACs among patients was not ideal, with only 62.5% using them as intended. Conclusion: The distribution of FACs was associated with an improved incidence of correct FN triaging but did not demonstrate a meaningful improvement in the quality of FN management. This may be explained by FAC use among patients not being ideal. Next steps in the continued effort toward high-quality FN care include redesign of FACs, reinforcement of provider and patient education, and ED outreach.

Substitution of Generic Warfarin for Coumadin in an HMO Setting

2002 ◽  
Vol 36 (5) ◽  
pp. 764-768 ◽  
Author(s):  
Paul E Milligan ◽  
Gerald A Banet ◽  
Amy D Waterman ◽  
Susan K Gatchel ◽  
Brian F Gage
Keyword(s):  
Adverse Events ◽  
Control Charts ◽  
Health Maintenance Organization ◽  
Therapeutic Index ◽  
International Normalized Ratio ◽  
Rank Test ◽  
Statistical Process ◽  
Health Maintenance ◽  
Statistical Process Control Charts ◽  
Signed Rank Test

BACKGROUND: Substitution of generic warfarin for Coumadin presents safety concerns due to warfarin's narrow therapeutic index and because a prior generic formulation was removed from the US market after it was associated with adverse events. OBJECTIVE: To determine whether a health maintenance organization (HMO) can add generic warfarin to its formulary without adversely affecting warfarin management or increasing adverse events. DESIGN: In a prospective, observational study, an HMO that formerly dispensed only Coumadin added a generic warfarin preparation (Barr Laboratories, Pomona, NY) to its formulary. SETTING: An anticoagulation service (ACS) affiliated with an HMO that was based in St. Louis, MO. PARTICIPANTS: The cohort consisted of 182 enrollees in the ACS as of May 1, 1999. At the start of the study, these participants were taking Coumadin; by October 31, 2000, all had switched to Barr warfarin. MEASUREMENTS AND MAIN RESULTS: We collected data 8 months prior to and 10 months after the introduction of generic warfarin for the following endpoints: international normalized ratio (INR) control, frequency of INR monitoring, number of dose changes, and rate of thrombotic and hemorrhagic events. Statistical process control charts were used to differentiate between random variation in the endpoints and changes due to different warfarin formulations, and we used the Wilcoxon signed-rank test to look for a change in any endpoint after patients changed to generic warfarin. No significant differences were found in any endpoint. CONCLUSIONS: Substitution of Barr warfarin for Coumadin did not significantly affect INR control, warfarin management, or adverse events. Our findings suggest that HMOs can safely substitute at least 1 generic formulation of warfarin without extra monitoring.

Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

CJEM ◽  
2020 ◽  
Vol 22 (5) ◽  
pp. 678-686
Author(s):  
Shawn K. Dowling ◽  
Inelda Gjata ◽  
Nathan M. Solbak ◽  
Colin G.W. Weaver ◽  
Katharine Smart ◽  
...  
Keyword(s):  
Emergency Department ◽  
Control Charts ◽  
Patient Characteristics ◽  
Pediatric Emergency ◽  
Therapeutic Interventions ◽  
Audit And Feedback ◽  
Absolute Difference ◽  
Emergency Physicians ◽  
Feedback Session ◽  
Statistical Process

ABSTRACTObjectiveDespite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.MethodsOur cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.ResultsSeventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.ConclusionThe combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

scholarly journals Diagnostic anticipation to reduce emergency department length of stay: a cohort study in Ferrara University Hospital, Italy

2020 ◽  
Author(s):  
Andrea Strada ◽  
Niccolò Bolognesi ◽  
Lamberto Manzoli ◽  
Giorgia Valpiani ◽  
Chiara Morotti ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Abdominal Pain ◽  
Chest Pain ◽  
Length Of Stay ◽  
Diagnostic Algorithm ◽  
University Hospital ◽  
Blood Tests ◽  
Traumatic Bleeding ◽  
Ed Crowding

Abstract Background : Emergency Department (ED) crowding reduces staff satisfaction and healthcare quality and safety, which in turn increase costs. Despite a number of proposed solutions, ED length of stay (LOS) - a main cause of overcrowding - remains a major issue worldwide. This cohort study was aimed at evaluating the effectiveness on ED LOS of a procedure called “diagnostic anticipation”, which consisted in anticipating the ordering of blood tests by nurses, at triage, following a diagnostic algorithm approved by physicians. Methods : In the second half of 2019, the ED of the University Hospital of Ferrara, Italy, adopted the diagnostic anticipation protocol on alternate weeks for all patients with chest pain, abdominal pain, and non-traumatic bleeding. Using ED electronic data, LOS independent predictors were evaluated through multiple regression. Results : During the weeks when diagnostic anticipation was adopted, as compared to control weeks, the mean LOS was shorter by 18.2 minutes for chest pain, but longer by 15.7 minutes for abdominal pain, and 33.3 for non-traumatic bleeding. At multivariate analysis, adjusting for age, gender, triage priority and ED crowding, the difference in visit time was significant for chest pain only (p<0.001). Conclusions : The effectiveness of the anticipation of blood testing by nurses varied by patients' condition, being significant for chest pain only. Further research is needed before the implementation, estimating the potential proportion of inappropriate blood tests and ED crowding status

scholarly journals Statistical Process Control and Related Methods for Improvement of the Treated-Wood Industries

2020 ◽  
Vol 70 (2) ◽  
pp. 165-177
Author(s):  
Timothy M. Young ◽  
Patricia K. Lebow ◽  
Stan Lebow ◽  
Adam Taylor
Keyword(s):  
Process Control ◽  
Statistical Process Control ◽  
Continuous Improvement ◽  
Control Charts ◽  
Treated Wood ◽  
Cost Savings ◽  
Ground Contact ◽  
Industry Data ◽  
Statistical Process ◽  
Wood Protection

Abstract An approach for implementing statistical process control and other statistical methods as a cost-savings measure in the treated-wood industries is outlined. The purpose of the study is to use industry data to improve understanding of the application of continuous improvement methods. Variation in wood treatment is a cost when higher-than-necessary chemical retention targets are required to meet specifications. The data for this study were obtained in confidence from the American Lumber Standard Committee and were paired, normalized assay retentions for charges inspected by both the treating facility and auditing agencies. Capability analyses were developed from this data for three use categories established by the American Wood Protection Association (AWPA), including UC3B (above ground, exterior), UC4A (ground contact, freshwater, general use), and UC4B (ground contact, freshwater, critical structures, or high decay hazard zones). Agency and industry data indicate that between 4.45 and 9.82 percent of the charges were below the lower confidence limit of the passing standard (LCLAWPA), depending on use category. A Taguchi loss function (TLF), which is quadratic based and decomposes the monetary loss into shift and variation components, was developed to estimate the additional cost due to process variation. For example, if a treatment input cost of $1.00/ft3 is assumed for UC3B, reducing the variation in total retention allows lowering treatment targets, e.g., 1.45 to 1.38, reducing costs to $0.76/ft3. The study provides some important continuous improvement tools for this industry such as control charts, Cpk, Cpm capability indices, and the one-sided TLF.

35 Implementation of a quality improvement initiative to reduce pain and anxiety associated with needle-related procedures in a Canadian paediatric emergency department

2021 ◽  
Vol 26 (Supplement_1) ◽  
pp. e26-e27
Author(s):  
Naveen Poonai ◽  
Karina Burke ◽  
Shaily Brahmbhatt ◽  
Leslie Boisvert ◽  
Sheena Belisle ◽  
...  
Keyword(s):  
Emergency Department ◽  
Adverse Drug Reactions ◽  
Steering Committee ◽  
Subject Area ◽  
Quality Improvement Initiative ◽  
Drug Reactions ◽  
Provider Education ◽  
Topical Anesthetic ◽  
Statistical Process ◽  
Support Unit

Abstract Primary Subject area Emergency Medicine - Paediatric Background Needle-related procedures such as intravenous (IV) insertion, venipuncture, and lumbar puncture (LP) are commonly performed in children, particularly in the emergency department (ED). Children consistently rate these needle-related procedures as very distressing. While topical anesthetics have been shown to be highly effective and are available, they are inconsistently used. The Children’s Comfort Promise was originally developed at the Minnesota Children’s Hospital. It requires nursing staff to use four strategies for children undergoing needle-related procedures: (1) topical anesthetic, (2) sucrose or breastfeeding if ≤ 12 months, (3) Comfort positioning (swaddling, skin-to-skin, or facilitated tucking if ≤ 12 months and sitting upright for children &gt; 12 months), and (4) age-appropriate distraction. Objectives We sought to evaluate compliance with all 4 Comfort Promise strategies for managing children’s pain and anxiety during needle-related procedures in a Canadian paediatric ED. Design/Methods Implementation of The Comfort Promise in March 2020 included a focus group to perform a root cause analysis, designation of nurse champions, monthly steering committee and ED working group meetings, and didactic education sessions. Our institution’s decision support unit identified all encounters of children 0-17 years who underwent at least one needle-related procedure at our paediatric ED from January 1 to November 30, 2020. The outcome was compliance with all 4 Comfort Promise strategies. Balancing measures included adverse drug reactions and vasoconstriction. We used statistical process control to analyze the outcome from 2 months preceding and 7 months following implementation. Results From January 1 to November 30, 2020, 21,600 encounters were identified, of which 10,294/21,600 (47.7%) were female. Age ranged from 0-17 years with a mean (SD) of 6.9 (5.5) years. Needle-related procedures were performed in 730/21,600 (3.4%) encounters, most commonly IV insertion (289/730, 39.6%) and venipuncture for blood sampling (232/730, 31.8%). Half of all encounters had no compliance strategies electronically recorded (363/730, 49.7%). Compliance with all Comfort Promise strategies increased over the study period (Figure 1). Topical anesthetic increased from 3/35 (8.6%) to 35/83 (42.2%). Sucrose or breastfeeding increased from 0/6 (0%) to 2/16 (12.5%). Comfort positioning increased from 0/35 (0%) to 26/83 (31.3%). Distraction increased from 0/35 (0%) to 22/83 (26.5%). There were no adverse drug reactions or vasoconstriction. Conclusion Implementation of The Comfort Promise in a Canadian paediatric ED resulted in greater use of strategies, particularly topical anesthetic, to reduce needle-related distress in children. Ongoing compliance will depend on consistent electronic recording and provider education.

scholarly journals Low-Risk Patients With Chest Pain in the Emergency Department: Negative 64-MDCT Coronary Angiography May Reduce Length of Stay and Hospital Charges

2009 ◽  
Vol 193 (1) ◽  
pp. 150-154 ◽  
Author(s):  
Janet M. May ◽  
William P. Shuman ◽  
Jared N. Strote ◽  
Kelley R. Branch ◽  
Lee M. Mitsumori ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Coronary Angiography ◽  
Length Of Stay ◽  
Low Risk ◽  
Hospital Charges ◽  
Risk Patients ◽  
Mdct Coronary Angiography
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