Improving the Quality of Emergency Medicine
- Emergency physicians are committed to providing the highest quality of care in the most cost-effective and efficient way for the 136 million emergency patients who visit each year.
- The greatest threats to patient safety and quality in the emergency department are overcrowding and the on-call specialist shortage.
- ACEP supports the use of technology to improve patient safety and is working with the federal government to develop quality improvement measures that advance patient care.
- As health care reform evolves, it is critical that neither the government nor insurance companies nor hospitals ration care that, in the emergency physician’s judgment, is in the best interest of patients.
Q. .How are Emergency Physicians Involved in the Nation’s Efforts to Promote Quality and Reduce Health Care Costs?
ACEP is working at the national level to develop quality measures for emergency medicine and is aggressively advocating elimination of the practice of “boarding” in hospital emergency departments. The nation’s emergency physicians are also advocating for adequate bed surge capacity and research to improve patient safety.
Emergency physicians support the goal to improve quality of care, but are concerned that patient care will be sacrificed in favor of cost reduction and efficiency.
Q: What has ACEP done to improve the quality of emergency care for patients?
ACEP establishes evidence-based clinical policies and patient standards in emergency medicine from which many quality and safety measures are derived. ACEP also helps develop emergency medicine quality measures to ensure high-quality care for emergency patients. ACEP supports the use of technology to improve patient safety, and promotes the highest standards of emergency care by providing continuing medical education for emergency physicians and supporting the life-long learning process for maintaining board certification.
ACEP released a report that recommends high-impact, low-cost solutions to address the problem of holding, or “boarding,” patients who have been admitted to the hospital in the emergency department, a controversial practice that is the primary cause of overcrowding and causes patients to undergo unnecessary suffering and indignity, while putting lives at risk.
The report recommends:
- Move admitted patients out of the emergency department to inpatient areas. With each unit taking a small number of patients, the burden of boarding is more evenly spread, thus enabling the emergency department to better care for emergencies – without unduly stressing inpatient units.
- Coordinate the discharge of hospital patients before noon. Research shows that timely departure from the hospital can significantly improve the flow of patients in emergency departments by making more inpatient beds available to emergency patients.
- Coordinate the scheduling of elective patients and surgical cases. Studies show that the uneven influx of elective patients (heaviest early in the week) is a prime contributor to exceeding capacity.
ACEP’s Patient Safety Task Force developed the following principles of patient safety in the emergency department:
- Adequate funding and resources must be available to support the emergency care structure.
- Improvements must include, but not be limited to: funding to support adequate staffing, integration of information systems, and implementation of educational efforts designed to improve patient safety.
- Efforts must include the evaluation of its impact on all aspects of emergency care.
- A uniform lexicon on patient safety should be developed and accepted by agencies and providers.
- Systems for reporting medical errors must focus on developing solutions to improving patient care.
- Efforts to collaborate with private and public agencies to promote patient safety are critical to improving the quality of emergency care.
ACEP’s Quality and Performance Committee reviews quality measures developed by internal and external entities, develops emergency medicine measures, and provides recommendations to the ACEP Board of Directors.
Members of ACEP’s Section on Quality Improvement and Patient Safety participate in quality improvement issues in local hospitals and at state and national levels.
ACEP is an active participant of the American Medical Association Physician Consortium for Performance Improvement, leading the Emergency Medicine work group and serving on workgroups developing measures that impact emergency medicine. As a result, ACEP has been instrumental in ensuring that several Emergency Medicine measures are included in the 2010 PQRI program:
—#28. Aspirin at Arrival for Acute Myocardial Infarction (AMI) †
—#31. Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage†
—#54. 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain†
—#55. 12-Lead Electrocardiogram (ECG) Performed for Syncope†
—#56. Community-Acquired Pneumonia (CAP): Vital Signs*
—#57. Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation*
—#58. Community-Acquired Pneumonia (CAP): Assessment of Mental Status*
—#59. Community-Acquired Pneumonia (CAP): Empiric Antibiotic*
—#76. Prevention of Catheter-Related Bloodstream Infections (CRBSI): CVC Insertion Protocol.
†The Part B claim form place of service field must indicate emergency department
* Clinicians utilizing the critical care code (99291) must indicate the emergency department place of service (23) on the Part B claim form in order to report this measure.
Note: Measure #34 “Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (tPA) Considered,” was retired for 2010.
Q. What is pay-for-performance?
Pay-for- performance is a system to pay health care providers based on the quality of their services, as determined by the achievement of certain measures. The federal Medicare program is developing the major initiatives, although Medicaid and private insurers are also implementing programs. The system generally includes a set of targets, or objectives, that define what will be evaluated, as well as measures, performance standards and financial incentives. The federal government anticipates these initiatives will save Medicare and hospitals $1.3 billion in health care costs.
Q. Does ACEP favor mandatory reporting of medical errors?
ACEP supports voluntary reporting of medical errors and creation of a nonpunitive environment that will increase patient safety and encourage use of any reporting system.
- Reporting systems should protect patient identity and abide by all relevant confidentiality laws and regulations.
- Reported information should be used to correct systems and promote safety.
- The identities of health care professionals and organizations involved in errors should not be disclosed outside a reporting system without consent.
- Emergency departments are uniquely positioned to gather data about medical errors.
- Ninety percent of medical errors “are the result of failed systems and procedures that are poorly designed to accommodate the complexity of health care delivery,” according to the Institute of Medicine.[i]
For more information, visit www.acep.org and see ACEP’s Policy Statements on “Disclosure of Medical Errors.”
[i] Joint Commission. 2005. “Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury.” http://www.jointcommission.org/assets/1/18/Medical_Liability.pdf