Emergency care and patient safety thought-leaders from across North America convened in Las Vegas in May 2011 to spend two days together to address the patient safety challenges and opportunities throughout the continuum of emergency care. The event was hosted by the Emergency Medicine Patient Safety Foundation (EMPSF), a national not-for-profit organization based in California whose mission is to improve patient safety in the practice of emergency medicine through education, research, collaboration, and training.
Challenges Facing Emergency Care
Long considered the safety net of our nation’s healthcare delivery system, emergency medicine provides care to the community through emergency medical services (EMS) and hospital-based emergency departments. These traditional sources of emergency care have been supplemented with urgent care clinics, freestanding emergency departments, and, more recently, telemedicine that help to address the demand for timely access to care. As our health system advances initiatives to better coordinate care between providers, either through patient-centered medical homes or accountable care organizations (ACOs), addressing the specific challenges and opportunities of emergency care brings focus to a segment of our healthcare system that operates between office-based physicians providing primary and specialty care and inpatient care providers.
The challenges facing emergency care are significant. Utilization of emergency departments has increased 43% since 1991, with over 127 million patient visits in 2009 (Hsia et al., 2011). Patient utilization of EDs increases significantly with age, and so as the baby boomer cohort ages, a sustained increase in demand for emergency care is expected. Adding further complexity will be preparing for the unique needs of the geriatric patient. Physicians need to treat the geriatric patient with sensitivity to that patient’s overall health much in the same way a pediatric patient is considered distinct from an adult. For example, elderly patients often take multiple medications inherently increasing the risk of an adverse drug event (ADE).
As demand continues to rise, the number of emergency departments available to provide care has been decreasing. Over the past 20 years, one in four emergency departments has closed, and the number of EDs in urban markets has decreased 27% (Hsia et al., 2011). Rising demand and fewer departments has led to overcrowded EDs resulting in prolonged length of stays and in some cases, increased patient walkouts. The demand for emergency department services brings with it a demand for inpatient care as the ED can be the source of more than half of a hospital’s overall volume of admissions. And when the hospital is unable to accept all patients ready to be admitted from the ED, the department ends up holding these patients for an extended stay. Commonly referred to as “patient boarding,” this is one of the most significant patient safety issues for emergency departments today. When boarding occurs, the ED’s ability to accept more patients is constrained because beds are used for patients waiting to be admitted. When ED beds are required, it is sometimes necessary to keep boarded patients on gurneys in hallways, further congesting the department. Moreover, the continuity of those patients’ care from ED to inpatient areas is delayed and potentially compromised. It is clear that overcrowding in today’s EDs contributes to increased morbidity and mortality and is a major patient safety concern.
Patient Safety in Emergency Care
In an effort to address the increasing and complex issues facing our nation’s patient care safety net, EMPSF hosted its first annual patient safety summit, Patient Safety in Emergency Care: Excellence in Outcomes, and invited all those directly involved or allied with emergency care: providers, nursing, administrators, EMS, pharmacy, risk management, patient safety officers, researchers, and vendors to engage in a forum with experts in the fields of emergency care and patient safety.
The Emergency Medicine Patient Safety Foundation itself has been an agent for change. With a vision of “Making the Safety Net…Safer,” the organization was founded in 2003 as a not-for-profit organization allied with EPIC Risk Retention Group, an insurance provider exclusively serving the needs of emergency physicians. Over the years, under the leadership of executive director, Dianne Vass, and chairman, Graham Billingham MD, FACEP, EMPSF developed a grant and fellowship program to fund patient safety fellows to conduct research in emergency medicine. During this time period, EMPSF’s membership grew to 1800, making it the largest patient safety organization exclusively dedicated to emergency medicine.
In 2009, EMPSF received its certification as a nationally recognized Patient Safety Organization (PSO). EMPSF is seeking partners and contracts to collect and analyze emergency medicine patient safety data and to develop ways and means to reduce risk.
Fast forward to 2011, and EMPSF is going into its 6th year of co-sponsoring a $75,000 Fellowship Grant funded for a 12-month period to enhance the development of an emergency medicine patient safety researcher. The recipient also receives funding to participate in the American Hospital Association and National Patient Safety Foundation Patient Safety Leadership Program. EMPSF also co-sponsors a directed research grant with the American College of Emergency Physicians Emergency Medicine Foundation (EMF) and has launched its own micro-grants program to assist ED practitioners to cultivate innovations to improve emergency care quality and advance safety. In April, after six years of service, Dr. Billingham became emeritus chairman of EMPSF and turned over the reins of chairman to Ramon Johnson, MD, FACEP, a long-standing board member and nationally recognized pediatric emergency medicine physician and leader in ACEP.
The Patient Safety Summit brought together nearly 100 leaders and practitioners in the emergency medicine patient safety space from more than 20 states and Canada. Launching the general session was a panel discussion moderated by Robert Wears MD, MS, of the University of Florida, Jacksonville and featuring Sandra Schneider MD, FACEP, president of American College of Emergency Physicians; AnnMarie Papa, DNP, RN, CEN, president of the Emergency Nurses Association; Diane Pinakiewicz, MBA, president of the National Patient Safety Foundation; and Michelle Hoppes, RN, MS, president of the American Society for Healthcare Risk Management. Key safety issues that emerged from this leadership panel included risks associated with patient boarding, ED crowding, communication and hand-offs, technology and systems issues, access to specialist consultants (especially for rural EDs), a shortage of nurses, and violence in the ED. AnnMarie Papa discussed how triage nurses in particular are at risk of being verbally or physically assaulted in the emergency department due to their exposure to patients during their initial assessment. The panel was asked by Dr. Wears if they could be granted one wish to address patient safety in emergency medicine, what would it be; the answers included eliminating inpatient boarding in the ED, revising the payment system so patients could have alternate places for care and focusing on sentinel patient events of which 50% occur in the ED alone, according to the Joint Commission (2002).
Aging Patients, Aging Providers
Our aging population presents two challenges in particular for emergency medicine—an aging cohort of providers and an aging patient population. Dr. Sandra Schneider reflected on the coming retirement over the next two decades of a significant share of emergency physicians who entered the profession at relatively the same time. With approximately 140 residency programs, we risk facing a shrinking provider population in future decades unless we increase the number of physicians entering emergency medicine.
On the patient-side, EMPSF chairman emeritus, Dr. Graham Billingham, spoke of the need to decrease risk and improve patient safety for the geriatric patient in the ED. Diagnoses that may be straightforward for an adult patient are inherently more complex for an elderly patient. Dr. Billingham went on to comment how much emergency medicine needs to study this patient population further and prepare our EDs to care for these patients. Throughout the conference, participants and speakers addressed the risks inherent to the ED environment itself: noisy, chaotic, crowded, and fast-paced – an environment that is challenging for a patient of any age. Today, there are approximately one dozen geriatric EDs with physical spaces designed with the elderly patient in mind and with a deeper focus on the issues and complications of this patient population. These patients can require 50% more labs, and 27% will either re-visit, be hospitalized, or die within three months following an ED visit. Dr. Billingham explained that elderly patients frequently present with subtle and atypical findings that can be difficult to sort out such as the elderly patient with a history of hypertension who presents with a normal blood pressure.
The scope of the presentations on the first day of the Patient Safety Summit included:
- Assuring safety in transitions in care from EMS providers to the ED by optimizing patient hand-offs—Drs. Jack Kelly and David Jaslow of Albert Einstein Medical Center’s Department of Emergency Medicine,
- Development of a conceptual model for ED procedural safety—Dr. Jesse Pines, director of Health Care Quality at the George Washington University Medical Center
- Caring for the unique safety concerns of pediatric patients. This, a joint presentation by Susan McDaniel Hohenhaus, director of the Institute for Quality, Safety and Injury Prevention at ENA, and Michael Gerardi, MD, FACEP, president of Superior Insurance Company and a practicing pediatric emergency physician, addressed the increasing patient safety risk of childhood obesity, the need for greater definition of pediatric emergency medicine competencies and called for clinical practice guidelines and standards of care for pediatric emergency medicine.
Additional topics were addressed via roundtable discussions with participants meeting over lunch and reporting their group discussions at the end of the day. Recognizing the role of the ED in a hospital, several topics addressed ED advocacy with hospital administration such as gaining leadership support for ED safety, creating safety champions within the ED, and working with nursing leaders to influence change.
The first day concluded with an evening reception featuring poster presentations that included work by EMPSF research fellows and small grant recipients. The content of the poster presentations expanded the breadth of topics addressed at the summit including patient safety and the disposition decision, the impact of teammate familiarity on perceptions of teamwork in the emergency department, and implementation of a quality improvement program to reduce blood culture contamination in an ED. Additional topics included validation of a simulated team experience and assessment methodology, teaching modules for pediatric ED patient safety, and a cognitive systems engineering analysis of ED patient boarding.
Improving Communication and Human Factors
On the second day of the Patient Safety Summit, Mary Patterson, medical director at Cincinnati Children’s Center for Simulation and Research, discussed the importance of communication and teamwork in emergency care, which she brought into focus showing videos of patient care simulations before and after communication and teamwork coaching. EMPSF Fellowship Grant recipient, Dr. Terry Fairbanks, director of National Center for Human Factors Engineering in Healthcare at MedStar Health in Washington, DC, discussed the importance of designing computer-based tracking, order entry, and documentation systems that are optimized for human use so as to reduce harm from unnecessary errors just as the aviation and nuclear engineering industries have employed with their technologies for years.
The understanding of human factors engineering is a growing field focused on applying scientific data to reduce human error by designing technologies to optimize the relationship between technology and the human user. Alarm fatigue with bedside devices is an example of a human factor issue with technology that can potentially lead to increased patient safety risks. As our nation advances towards further automation in the ED, clinicians and staff members working in inpatient clinical areas and physician offices need to be careful that, for all the promise of greater safety from legible, accessible, structured, and intelligent data, that the implementation of these systems does not create barriers within caregiver teams and between caregivers and their patients.
“Who should be in the ED?” was a topic addressed in the presentation, “Reducing Medication Errors in the ED—the Value of Adding a Pharmacist to the Team,” prepared by Joe Spillane, PharmD, DABAT of Shands Hospital at the University of Florida, Jacksonville. In his presentation, Dr. Spillane identified how medications in an ED environment present increased patient safety risks. These include the use of high-alert medications in which an error in dosing or administration can pose a significant health risk, decreasing the time period between when a medication order is given and when it is administered, and the reliance on verbal orders when working in a noisy, chaotic, crowded environment in which interruptions are frequent. Presenting for Dr. Spillane, who had a last-minute conflict, was Sue Dill Calloway RN, Esq., MSN, JD, of Patient Safety & Health Care Consulting. Sue shared Dr. Spillane’s recommendation to consider adding a pharmacist to the ED, which currently is the case in less than 14% of emergency departments nationally and found mostly in teaching and academic institutions. Having a pharmacist in the ED can help in the following ways: participating in high-risk situations such as stroke alerts and resuscitations, prospective order review prior to medications getting to the patients, procuring and prepping meds, helping with medication and toxicology information, monitoring how patients are responding to medications, and documenting adverse drug events and medication errors.
The Summit ended with our national discourse on patient safety in emergency medicine newly energized. The participants acknowledged that the work ahead lies as much in creating an ongoing dialogue between stakeholders with shared access to data and insights on what works and what doesn’t as in getting more resources to provide research and apply patient safety initiatives. EMPSF announced that they are developing a series of online forums to help facilitate information sharing, which will bridge future annual summits, with the next summit scheduled for March 22 to 23, 2012, in San Antonio, Texas. In addition, the conference renewed interest between patient safety organizations and clinical societies to seek opportunities to synergize their work together and stimulate future research and design of patient safety initiatives.
Counter Measures vs. Solutions
While the underlying goal of the summit was to champion patient safety ‘solutions’, Dr. Billingham reflected that in healthcare, a safer mindset to adopt may in fact be to continually seek counter-measures rather than solutions. In any industry or organization that adopts a solution mindset, it is possible to become complacent once initial goals are met. Given the complexities of healthcare, the healthcare community has seen health issues remerge and/or manifest in new ways. By adopting a counter-measure mindset, we recognize that solutions may need to evolve over time and therefore we need to be vigilant in continually monitoring and measuring the incidence, nature, and severity of issues so that we prevent them from re-emerging.
For more information on the Emergency Medicine Patient Safety Foundation, membership, and their fellows and grant opportunities, visit www.empsf.org. Those interested in speaking opportunities at the 2012 Patient Safety Summit should contact Dianne Vass, executive director of EMPSF at (916) 357-6723.