Download Results of the Sullivan Group`s Emergency Medicine Risk Initiative

Title:
Quality Indicators of Headache Evaluation and Treatment in U.S. Emergency Department
Patients
Authors:
1. John W. Hafner, MD FACEP*^+
2. James R. Hubler, MD JD FACEP FAAEM*^+
3. Jennifer Roberts, DO*^
4. Daniel J. Sullivan, MD JD FACEP$+
Affiliations:
*Department of Surgery, University of Illinois College of Medicine at Peoria
^OSF Saint Francis Medical Center, Peoria IL
$
Department of Emergency Medicine, Cook County Hospital/Rush Medical College,
Chicago, Illinois
+
The Sullivan Group, Inc., Risk Management Consulting
Introduction:
Patients with a chief complaint of non-traumatic headache (HA) represented 2.7% of
emergency department (ED) visits in 2005 (3.1 million visits). Although the majority of
these patients represent benign etiologies, some have serious and life-threatening
conditions. Distinguishing patients that require urgent diagnostic studies and treatment
requires the application of accepted evidence-based strategies and measurable indicators
of quality care. These strategies and indicators are useful in understand patterns of care
delivered and improving patient outcomes. This study describes specific quality
identifiers of a 2 year national ED quality assessment for HA patients.
Methods:
An explicit review of the audit chart database from the Sullivan Group’s Emergency
Medicine Risk Initiative (EMRI) was conducted for ED visits occurring between
1/1/2006 and 03/19/2008 representing 52 separate EDs nationwide. The EMRI is a
national ED chart review and quality assessment product designed to review provider
compliance with EM quality indicators in core chief complaint categories. ED charts are
reviewed by trained individual hospital staff using a template web-based system and
collated into a central national data repository. Records were analyzed if patient, provider
and hospital abstracted information were complete for the ED visit. Quality scores were
derived from the ratio of documented-to-total quality indicators (21 possible indicators).
Pearson’s chi square and one-way ANOVA was used for bivariant analysis with p < 0.05
considered statistically significant. Binary logistic regression analysis was performed to
determine the associations between visit characteristics and quality scores above and
below the mean.
Results:
During the study period 2494 ED visits were included representing 52 individual EDs.
HA patients were mostly female (75.7%) and eventually discharged from the ED
(95.8%). Primary medical providers for the ED visits were medical physicians (MD)
(80.4% of visits), osteopathic physicians (DO) (13.8%), nurse practitioners (NP) (1.6%)
and physician assistants (PA) (4.3%). Patients rated their pain severity most often using a
10 point scale (87.9%), with most reporting initial scores of 8, 9, or 10 (60.8%). Most
providers performed a detailed neurological exam (76.8%) and administered pain
medication (83.9% overall; 67.6% parenteral medications). Forty-six percent of HA
patients had a head computed tomography (CT) performed, with 7 SAH (0.3%) and 3
intracranial hemorrhage (0.1%) diagnoses reported. Of patients with negative head CT
imaging, only 27% received a follow-up lumbar puncture (LP) or documented an
informed refusal of the LP. Factors associated with a higher than mean overall quality
score were non-university teaching hospitals, use of an ED discharge instructions
program, a lack of resident physicians, physician providers (MD and DO), and trauma
level 3 facilities.
Conclusions:
In a national sample of ED HA patients, the 21 quality indicators, such as LP following a
negative CT and others, varied widely with provider type and facility characteristics. The
majority of HA patients were discharged after receiving parenteral medication, but a
minority had serious pathology.