ED management : the monthly update on emergency department management
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Both emergency and inpatient physicians agree that miscommunication during interunit handoffs can compromise patient care and that sequential handoffs are particularly problematic, according to a new study conducted at the University of Nebraska Medical Center (UNMC) in Omaha, NE. The study highlights physician survey data showing that there is mistrust between inpatient and emergency physicians, and that which provider is responsible for patient care can be unclear when a verbal handoff is made. To make improvements, UNMC has been piloting a tool aimed at standardizing verbal and written handoff communications. ⋯ Ninety-four percent of emergency physicians surveyed indicated that they had to defend their clinical decisions at least some of the time. The admitting physicians largely validated this concern, with more than 25% noting that they usually disagree with decisions made in the ED. Using the situation, background, assessment, recommendation (SBAR) form of communication as a starting point, an intervention tool aims to streamline handoff communications, both verbally and in the electronic medical record.
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The long-delayed transition to the International Classification of Diseases, Clinical Modification administrative codes (lCD-10-CM) is set to take place in October, presenting a host of challenges for EPs. A new analysis suggests roughly a quarter of the clinical encounters that take place in the ED will involve complexity in the transition to the new system. Further, experts anticipate workflow challenges as well as new considerations when making planning decisions and reporting to public health departments. ⋯ Investigators found that that 23% of the visits, or 27% of the codes, emergency medicine physicians use are complex. The new coding system requires much more specificity, but there are also instances in which definitions have been altered or blended together, essentially changing the concepts described. While all EPs will face some challenges with the new coding system, analysts are particularly concerned about smaller EDs and physician groups because these practices typically don't have the ICD-10-CM implementation teams that larger systems have.
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With the incidence of kidney stone disease on the rise, more of these patients are presenting to EDs for care. However, new data suggest that as many as one in nine of these patients will have to return for a second emergency visit. Researchers have linked a number of factors with these bounce-back visits, including issues impacting care access and quality. ⋯ Utilizing data from more than 128,000 visits to California EDs over a two-year period, researchers found that patients on Medicaid were at about a 50% higher risk of having a repeat ED visit than patients with commercial insurance. In areas where there were few urologists, patients were also more likely to return to the ED for care. Patients who had their blood counts checked during their initial ED visit were 12% less likely to require a return visit.
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A new study highlights how schedule changes among inpatient providers on the upper floors can impact crowding and boarding in the ED. Using Lean Six Sigma (LSS) management techniques, investigators at Penn State Hershey Children's Hospital in Hershey, PA, discovered that by adding an extra inpatient rounding team, discharge times could be accelerated, resulting in improved throughput without increasing length of stay or readmission rates. ⋯ To make the schedule changes, a core group of seven inpatient physicians needed to agree to work an extra two or three "on service" weeks per year. Investigators acknowledge that implementing this type of intervention requires culture change, which can be very difficult initially.
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A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes. Investigators suggest more training on these issues is needed, and recommend that clinicians take the time to clarify choices during periods of critical illness. ⋯ While a national organization establishes POLST recommendations and sample policies, the documents themselves are established and regulated at the state level, along with training procedures. Experts recommend that hospitals establish quality control procedures to ensure that end-of-life-care documents are prepared and interpreted accurately.