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Mayo Clinic EM at SAEM 17

March 15th, 2017

Mayo Clinic EM at SAEM 17

By Daniel Cabrera, M.D. cabreraerdr


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An overview of  Healthcare Quality

December 13th, 2016

An overview of Healthcare Quality

By Daniel Cabrera, M.D. cabreraerdr

Author: Venk Bellamkonda (@VenkBellamkonda)

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Easa Shamih | flickr | no modification | CC BY 2.0

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Integrating patient preferences in the delivery of Emergency Care. Kano analysis predicts change in experience.

December 7th, 2016

Integrating patient preferences in the delivery of Emergency Care. Kano analysis predicts change in experience.

By Daniel Cabrera, M.D. cabreraerdr

Author: Venk Bellamkonda (@VenkBellamkonda)

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In our publication in Annals of Emergency Medicine, Pilot Study of Kano “Attractive Quality” Techniques to Identify Change in Emergency Department Patient Experience, we describe our efforts to improve our patient’s perception of receiving concern and sensitivity from their healthcare providers.

The project originated in 2012, when our patients reported lower than expected ratings of receiving compassion by their emergency department (ED) providers. We used point-of-service survey cards to reassess this measure. We distributed 200 cards and received 193 (97% response rate) returned that gave a median rating of 4 out of 5 (IQR 3,5) with a top box percentage of 33% for provider concern and sensitivity.

A team of us began meeting with patients, advisory groups, and reviewing the literature to identify possible strategies for improving the patient experience. Four interventions were considered to close the patient experience gap:

  1. Sending a follow-up letter from the healthcare provider to the patient after their departure from the ED
  2. Supplying patients and their families with background information on their healthcare providers
  3. Increasing shared decision making opportunities between patients and their providers
  4. Increasing protocol-based testing from triage with the intent of decreasing throughput time

The next phase of our project involved using Noriaki Kano’s Attractive and Must-Be Quality model to try to predict the impact that each of these interventions would have upon our patients. We again used point-of-service survey cards with both functional and dysfunctional Kano format questions on them; 180 survey cards were distributed and 158 were returned (88% response rate). The responses were  plotted on a bubble graph as well as analyzed with a novel scoring system whereby the shared-decision making intervention scored 120 out of possible 246 and was likely to improve the patient experience to the greatest degree.

To test the prediction, we surveyed the impact that shared decision making had upon our patients. Two research studies were being conducted on shared decision making with patients experiencing chest pain or minor closed head injuries were ongoing. Twenty-six of 30 people receiving standard care (87% response) returned surveys rating median concern and sensitivity as 4 (IQR 3,5) and 19 of 19 (100% response) people receiving the shared decision making intervention returned surveys rating concern and sensitivity as 5 (IQR 5,5) with a difference of medians of 1 (95% CI 0.1 – 1.9). The top box percentages in the intervention group was 79% compared with 35% in the control group with a difference of 44% (95% CI 12-66).

This data suggest that Kano’s model likely does predict patient preferences and may be useful in other healthcare decision making situations. Please let us know on twitter (@VenkBellamkonda) how you would use the Kano model and read our publication in the November Annals of Emergency Medicine for the complete story.

 

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Is too sick to go home also too sick for the floor?

November 29th, 2016

Is too sick to go home also too sick for the floor?

By Daniel Cabrera, M.D. cabreraerdr

What patients admitted from the Emergency Department to a general floor/ward will deteriorate?

Author Shawna Bellew, MD (@SBellzMD)

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Shared Decision Making in the ED: A tale of two studies

November 16th, 2016

Shared Decision Making in the ED: A tale of two studies

By Daniel Cabrera, M.D. cabreraerdr

Author: Fernanda Bellolio, MD (@mfbellolio)

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Is there method in the madness: observation vs. full admission

November 8th, 2016

Is there method in the madness: observation vs. full admission

By Daniel Cabrera, M.D. cabreraerdr

Author: M. Fernanda Bellolio, MD (@mfbellolio)

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Women in Leadership: a glimmer of hope from ABMS

October 24th, 2016

Women in Leadership: a glimmer of hope from ABMS

By Daniel Cabrera, M.D. cabreraerdr


Author: Laura Walker, MD  (@dortzus)

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Peritonsillar abscess management on the Emergency Department: conservative or surgical approach?

October 10th, 2016

Peritonsillar abscess management on the Emergency Department: conservative or surgical approach?

By Daniel Cabrera, M.D. cabreraerdr

Author: Dante LS Souza

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Scribes are the heroes of Emergency Physicians but what is the evidence behind their impact?

October 4th, 2016

Scribes are the heroes of Emergency Physicians but what is the evidence behind their impact?

By Daniel Cabrera, M.D. cabreraerdr

Author: Heather Heaton, MD

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July 20th, 2016

Caring for behavioral health patients in community Emergency Departments, an every day challenge

By Daniel Cabrera, M.D. cabreraerdr

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Author: Amy O'Neil, MD

A commentary on Behavioral Health Boarding in Community Emergency Departments by O'Neil et al. (open access)

 

The challenges of caring for behavioral health patients in the emergency department (ED) are great.  Clinical decision making is difficult with limited histories and underlying disease that places the patient at high risk for harmful behavior.  Aside from the clinical challenges, the limited resources for behavioral health patients contribute to even greater frustrations when trying to provide care.  In academic centers we are fortunate to have the expertise of behavioral health staff readily available to develop care plans and make recommendations on medication management.  Unfortunately, this is not the case in the community.  This article surveyed 21 community hospitals within the Mayo Clinic Health System to better identify what resources are in fact available to provide care to behavioral health patients.  We found that logistical, staffing and systems based resources are all limited.

Caring for behavioral health patients appropriately requires a team approach.  Psychiatrists, psychologists, social works and case workers who know the patient well provide invaluable information when trying to determine the potential risk of self-harm and develop a care plan for the patient.  Portions of the health system surveyed have developed a behavioral health team that is on-call and assists with assessing and developing the best plan of care.  Survey responders from these sites reported very positive experiences when using this team to care for patients.  Unfortunately, over 20% of the health care system does not have psychiatric consulting services available.  The potential for telemedicine or a more expansive multi-disciplinary psychiatric care team in these settings is great.

When it is determined that a patient does need inpatient psychiatric care and one-to-one observation for safety, the personnel to provide this level of observation is frequently not available.  As a consequence, 40% of EDs report that patients are transferred to a medical unit or ICU to await bed placement in an inpatient psychiatric unit in order to provide the level of observation needed to ensure patient safety.  The availability of this practice is declining in part due to inpatient beds frequently being at capacity.  Fortunately, the practice is also decreasing as EDs develop new systems to provide the closer observation needed for one to one care.

Patient and staff safety must always be at the forefront of providing care.  However, we have found that due to limited resources, safety may be at risk.  In half of community EDs, there are no rooms in the ED designed to care for high risk behavioral health patients who may be actively suicidal, homicidal or violent.  This places both the staff and the patient at substantial risk.  In addition, only five of the EDs have 24-hour security personnel available.  This is a significant resource for the hospital to provide and the utilization of local police departments or other hospital personnel has filled this need.  As the rate of behavioral health visits continues to rise in addition to the increased reports of violent and threatening behavior occurring in the workplace, this is a resource that hospitals may need to consider moving forward.

The resources to provide safe and timely care for behavioral health patients in the community are limited.  Community EDs have developed innovative strategies to care for behavioral health patients including on-call multi-disciplinary teams and enhanced technology to provide safe patient observation.  As the number of behavioral health patients continue to rise, innovations in care will be vital to meet the health care needs of this growing population.

 

 

Image by Ryan Melaugh via flickr under CC BY 2.0

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