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Top Five in 35!

Top Five in 35!. Stroke Sepsis Boarding Emergency Medical Records Health Insurance Portability and Accountability Act Health Information Technology for Economic and Clinical Health ( HITECH) Act Unintended Disclosure Photo/Video. Standard of Care Argument Is Informed Consent Required?

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Top Five in 35!

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  1. Top Five in 35! • Stroke • Sepsis • Boarding • Emergency Medical Records • Health Insurance Portability and Accountability Act Health Information Technology for Economic and Clinical Health (HITECH) Act • Unintended Disclosure • Photo/Video

  2. Standard of Care Argument • Is Informed Consent Required? • Incapacitated Patients Lack of Informed Consent

  3. Liang, B.A., et al, Review of Tissue Plasminogen Activator, Ischemic Stroke, and Potential Legal Issues Arch Neurol65(11):1429, November 2008 • “Standard of care”; and • “If informed refusal, the patient wasn’t appropriately informed.”

  4. Likelihood of Litigation • 95%: Lawsuits from not giving tissue plasminogen activator (tPa) or not diagnosing stroke • 5%: From complications • Just as likely to get sued for giving it as you are for not giving it: • Many more are not given the drug • Much larger pool • % tPA = % no tPA will result in lawsuits

  5. Jagoda: • Guideline is evidence-based • “Not intended to represent the only diagnostic and management options” • Klauer: • Eight years to draft the policy • Panel consensus by content experts with industry relationships • Many reasonable physicians may disagree on the interpretation • Panel stacking • Studies discounted, but meta-analysis using the same = Level A recommendations

  6. Community Hospital/EP/Hospital

  7. Sepsis

  8. 750,000 hospitalizations • 570,000 ED visits • 200,000 deaths • $16.7 billion • 975 with Sepsis • Mortality Rates • Hospital: 8.9% • One year: 23% vs. 1% • Two years: 28.8% vs. 2.6% • Five years: 43.8% vs. 8.3%

  9. Limitations and Liability • Death • Acute respiratory distress syndrome • Multiple organ dysfunction syndrome • Renal Failure • Hepatic failure • Encephalopathy • Disseminated intravascular coagulation • PurpuraFulminans • Septic Emboli • Endocarditis • Cavernous sinus thrombosis • Limb/digital amputations

  10. 1. Lack of Patient Education 2. Informed Consent for Vasopressors

  11. Outrage

  12. Case #5 • Three-year-old female presented at 13:00 • CC: Cough, earache, bruising and fever: • Ill for 2 days • Rash started today • Initial Eval (PA) in FT: 16:10 • Transferred to emergency department (ED) and eligible provider: 18:02

  13. Case #5 • Exam; • Physician findings: • “Slight Jaundice”; • “Purpura cheeks, earlobes, buttocks, thorax and lower extremities”; and • “Crying but easily consolable.”

  14. Case #5 • Diagnostics: • WBC: 3.1; PLT 50K; INR: 4.8; LFTs; • IVF; • Acetaminophen; • Ceftriaxone 1 gm: 18:52; • DDX: ITP, HSP, EB . . . ; and • Disposition: Transfer to Tertiary Referral Center: 2102 report; 2238 OTD.

  15. Case #5 • Outcome • Streptococcus A sepsis • Four-limb amputation • Multimillion-dollar settlement

  16. Boarding and Crowding

  17. Definitions • Crowding: Insufficient space to meet the immediate needs of emergency department patients. • Boarding: Holding admitted patients in the emergency department awaiting transfer to an inpatient unit.

  18. Non Emergency Cases? THE EFFECT OF LOW-COMPLEXITY PATIENTS ON EMERGENCY DEPARTMENT WAITING TIMES Schull, M.J., et al, Ann Emerg Med 49(3):257, March 2007. • 4.1 million visits/110 EDs (1,095) consecutive 8-hour intervals) • Evaluating: Relationship between acuity and mean ED LOS and time to physician contact for medium and high complexity patients. • Low complexity: 50.9% of all visits; mean LOS: 1.6 hrs; Physician: 1.1 • Medium: 2.8 hrs; 1.3 • High: 4.7 hrs; 1.1 • For every 10 new low complexity: Mean increase in LOS of 5.4 min.; 2.1 min time to Physician contact

  19. Ackroyd-Stolarz. BMJ Qual Saf2011: 14.3% adverse event rate For each hour in ED, odds of an adverse event increased 3% (OR 1.03, 95% CI 1.004 to 1.05) Patient with an adverse event had two times the length of stay Overall Adverse Events

  20. Patients Who Left Without Being Seen? Weiss, et al. Relationship between the National ED overcrowding scale and the number of patients who leave without being seen (LWBS) in an academic ED. Am J EM 2005; 23:288-294. Richardson, D.B. and Bryant, M. Confirmation of association between overcrowding and adverse events in patients who do not wait to be seen. Acad EM 2004; 11(5):462. • The longer the wait …….. > Elopements • Percentage of serious illness is no different than less serious

  21. Economic Impact One more ED admission per day? • $800,000 net annually • $600-$800 for every ED patient who left without being seen THE OPPORTUNITY LOSS OF BOARDING ADMITTED PATIENTS IN THE EMERGENCY DEPARTMENT Falvo, T., et al, Acad Emerg Med 14(4):332, April 2007 • York Hospital and Johns Hopkins (Fiscal Year 2005) • Two-hour time from decision to admit was exceeded in 30% • 10,397 extra ED hours: • Additional 3,175 could have been seen (8.7 pts per day) • $4 million (3/1 admissions v. discharges) $5,432 v. $384 • 13% increase in ED revenue (net)

  22. Mortality Rates? THE ASSOCIATION BETWEEN EMERGENCY DEPARTMENT CROWDING AND ADVERSE CARDIOVASCULAR OUTCOMES IN PATIENTS WITH CHEST PAIN Pines, J.M., et al, Acad Emerg Med 16(7):617, July 2009 • 4,424 Adults possible ACS • ACS: 18% • Death, Cardiac Arrest, Delayed AMI, CHF, Dysrhythmias, HYN: • 12% in ACS and 4% of others • ED Crowding ACS Group: lowest quartile to highest: or (adverse event) • Occupancy: 3.1; WR #: 3.7; Pt Care Hrs: 5.2.

  23. Mortality Rates? Effect of Emergency Department Crowding on Outcomes of Admitted Patients Benjamin C. Sun, Renee Y. Hsia, Robert E. Weiss, David Zingmond, Li-Jung Liang, Weijuan Han, Heather McCreath, Steven M. Asch. Annals of emergency medicine 10 December 2012 • 995,379 ED visits resulting in admission to 187 hospitals • 5% greater odds of inpatient death • 1% increased costs per admission • 300 inpatient deaths • 6,200 hospital days • $17 million

  24. Mortality Rates?

  25. Mortality Rates? INCREASE IN PATIENT MORTALITY AT 10 DAYS ASSOCIATED WITH EMERGENCY DEPARTMENT OVERCROWDING Richardson, D.B., Med J Australia 184(5):213, March 6, 2006 • 736 shifts with ED overcrowding v. non-crowded shifts • Poor performance of standard performance measures • Ten-Day mortality: 0.42% v. 0.31% THE ASSOCIATION BETWEEN HOSPITAL OVERCROWDING AND MORTALITY AMONG PATIENTS ADMITTED VIA WESTERN AUSTRALIAN EMERGENCY DEPARTMENTS Sprivulis, P.C., et al, Med J Australia 184(5):208, March 6, 2006 • 62,495 Pts: ED Admissions to three tertiary facilities • Adjustment for confounders • Seven-Day mortality: Occupancy 90-99%: Hazard Ratio: 1.2; Higher occupancy: 1.3 • Deaths at 30 days: Due to overcrowding: 2.3 per 1,000 hospital admissions

  26. Waiting room disasters • Who’s patient is this? • Worsened outcomes • Complications • LWBS

  27. Waiting Room Issues Beatrice Vance of Waukegan, IL arrived at the emergency room of Vista Medical Center East at 10:15 pm on July 28 complaining of chest pains. After sitting in the waiting room for more than two hours, she was found unconscious and without a pulse. At 2 am, she was pronounced dead of a heart attack because of a blocked artery. “The definition of homicide that I give to the jury is either a willful and wanton act, or recklessness on the part of someone, whether that's by their actions or by their inactions," Keller said. "Certainly, by that definition, this is a homicide.”

  28. More Waiting Room Issues Family Plans $25M Suit in Waiting Room Death Wednesday, July 9, 2008 The relatives of a woman who died on the floor of a New York hospital say they plan to file a $25 million lawsuit against the city and the facility where EsminGreen died.Green's family is also calling for criminal charges against hospital workers, who they say failed to help her and then attempted to cover up the circumstances of her death. "My sister was killed twice," said Brenda James, Green's sister. "First, by those who neglected to offer her the needed health care. Secondly, she was killed by those who tried to cover up this criminal action.”

  29. Effective Strategies: Summary Rabin E, Kocher K, McClelland M, et al. Solutions to emergency department “boarding” and crowding are underused and may need to be legislated. Health Aff (Millwood). 2012;31(8):1757-1766. • Move stable ED boarders to inpatient halls while waiting for their final inpatient bed; • Smoothing out the scheduled elective surgical and procedural admissions; • Active bed management (aka “bed czar”); • Having a discharge lounge for patients who no longer need care but are waiting for a way to get home; • Streamlining and expediting discharges; • Monitoring of inpatient bed cleaning turnaround times; • Simplified admission protocol to get patients upstairs; and • A “reverse triage” system to identify patients for discharge who have the least need for inpatient beds when the hospital is full. • Additional Solutions • Internal waiting rooms • Verticality!

  30. Technology

  31. Medical Malpractice Liability in the Age of ElectronicHealth Records. N Engl J Med 363;21. November 18, 2010 • Early: • Inadequate training • Documentation gaps • Electronic health record bugs and failures • Mid: • Metadata creates more discoverable events • Cut and paste histories • Information overload • Ignoring decision support • Long term: • Failure to use may = breach in SOC • Widespread decision support may result in false SOC.

  32. Fraud?

  33. CC: Passed out/fever. HPI:33 year-old male, no previous medical history, c/o sudden-onset headache today. He has been having fevers as high as 100. He had 2 episodes of syncope today. No nausea or vomiting. He has had some chest congestion with cough. MEDS: Percocet ALL:Cephalosporins; Levaquin SH: Smokes tobacco. Denies drugs. Occasional EtOH. Case #1

  34. GENERAL: Well-appearing male, appears to be in pain VS: T 98.1º, HR 81, BP 123/77, RR 14, SaO2 97% on RA HEENT: NC/AT. PERRL. EOMI. Mucous membranes moist. NECK: Supple. No meningismus or meningeal signs. No JVD, no LAN. HEART: RRR, no murmurs. LUNGS: Clear to auscultation bilaterally. ABD: Soft, nontender, nondistended. Normal active BS. EXT: Thin, good peripheral pulses. No edema. NEURO: Alert and oriented x3. No deficits on exam. Physical Exam

  35. 11:13 Arrives by private vehicle 13:28 Seen by EM resident 13:59 Attending EM physician signs up on computerized tracking system 14:49 Ketorolac 30mg IV administered 16:24 LP completed 18:26 Morphine 5mg IV; Vancomycin 1gm IV administered (after LP results) ED Timeline

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