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Daniel Cabrera, M.D. @cabreraerdr

Editor-in-Chief Mayo Clinic EMBlog 

Activity by Daniel Cabrera, M.D. @cabreraerdr

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Wed, Mar 15 at 6:28am CDT by @cabreraerdr · View  

Mayo Clinic EM at SAEM 17


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Dec 13, 2016 by @cabreraerdr · View  

An overview of Healthcare Quality

Author: Venk Bellamkonda (@venkbellamkonda)

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Easa Shamih | flickr | no modification | CC BY 2.0
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Dec 7, 2016 by @cabreraerdr · View  

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

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.

 

venkbellamkonda

Venk Bellamkonda, MD responded Dec 7, 2016 · View

I am away from email. I will attend to your message when I return.   Thank you for your understanding,venk

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cabreraerdr

Nov 29, 2016 by @cabreraerdr · View  

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

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

Author Shawna Bellew, MD (@SBellzMD)

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Jul 20, 2016 by @cabreraerdr · View  

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

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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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cabreraerdr

Jul 4, 2016 by @cabreraerdr · View  

How to succeed as a Teacher - New Skills (Episode 7)

 

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Damian Baalmann, M.D. responded Sep 14, 2016 · View

Great posts. Keep the knowledge coming!

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Jun 29, 2016 by @cabreraerdr · View  

OnPar: a gamified didactic decision making learning tool

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Author:  Abhi Bikkani on behalf of the Mayo Education Innovation Lab

Click here for the OnPar app

A new online game from Mayo Clinic's Education Innovation Lab is setting out to help clinicians improve their critical-thinking and decision-making skill. OnPar, a clinical decision-making game, challenges clinicians to diagnose real life patient cases in an innovative and engaging new format that’s much like the game of golf.

This game was developed by a new product development team called Mayo Education Innovation.  This team has been given the charge to  shake up and lead the field in terms of how continuing professional education is accomplished.

For several months, the Mayo Education Innovation product development  team has been testing out how an innovation lab would work using the same methods that create successful startup companies. This lean startup methodology focuses on rapid learning, building, testing, succeeding and, when necessary, failing.

OnPar, one of the prototypes developed using the methodology, presents clinicians with their choice of patient cases and asks them to solve each case in as few “strokes” as possible. Once a case is selected, each clinician is shown a deck of cards that have a series of case-related questions. The high-level elements of the case -- the patient's original complaint, their vitals, etc. -- can also be seen on-screen along with the predetermined par for that case -- or the number of cards that an expert clinician would typically need to play before diagnosing the patient.

Keep up with the  Mayo Education Innovation Lab through their blog found at http://mc-edu-io.healthcareinnovators.com/

 

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May 25, 2016 by @cabreraerdr · View  

How to Succeed as a Teacher - Goal Setting (episode 3)

This is the third short video from a eight episodes series about prime concepts and recommendations to succeed as a teacher by Dustin Leigh, MD (@DLeigh0029)

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amanyalmmlka responded Dec 20, 2016 · View

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May 16, 2016 by @cabreraerdr · View  

Real-World Coronary CT Angiography Use is Associated with Increased Healthcare Utilization

Author: Jake Morris MD

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This is a summary from Morris et al. Comparative Trends and Downstream Outcomes of Coronary CT Angiography and Cardiac Stress Testing in Emergency Department Patients with Chest Pain: An Administrative Claims Analysis. Academic Emergency Medicine.

Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the Emergency Department (ED).  Numerous large randomized trials (CT-STAT, ACRIN-PA, ROMICAT II, and CT-COMPARE) have demonstrated that CCTA is safe in the assessment of patients at low risk for ACS, and that it significantly speeds up their evaluation in already crowded ED’s.

But does this accelerated evaluation come at a cost?  It has been suggested that CCTA, while safe and fast, may lead to more downstream procedures and healthcare utilization.  Because CCTA is an anatomical study and not a functional one, what are providers supposed to do if they identify a coronary plaque in a patient with chest pain?  Is that plaque causing ACS?  Does more testing need to be performed because there are not clear guidelines on how to interpret CCTA results?

To assess how these questions are being answered in the real-world, we performed an administrative claims analysis utilizing a large national claims database (OptumLabs Data Warehouse).  We identified over two million ED patients from January 2006 to December 2013 who presented with a primary diagnosis of chest pain.  We established patients into cohorts based on whether they received CCTA, myocardial perfusion scan (MPS), stress echocardiography (SE), or treadmill exercise electrocardiogram (TMET) within 72 hours of their ED visit.  We assessed whether patients in each group subsequently underwent invasive coronary angiography (ICA), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG).  We further evaluated if they were hospitalized, had repeat imaging, or returned to the ED within 30 days.

 

Trends in Non-invasive Cardiac Testing:

  • During the study period, CCTA use increased from 0.8% to 4.5% of all cardiac testing within 72-hours, a change of 434% (P for trend < .001). At the same time, rates of other testing decreased (Figure 1).
  • Of all chest pain patients, 21.5% went on to have some form of non-invasive cardiac testing.
  • Of those receiving cardiac testing, 66% had MPS, 20% had SE, 11% had TMET, and 3% had CCTA.

Use of Downstream Resources

  • To compare cohorts, we used propensity-matching to control for coronary artery disease (CAD) risk factors, Charlson-Deyo comorbidity index, and baseline differences in age and sex.
  • After matching, there was no difference in the 30-day rate of AMI between testing modalities.
  • 8.3% of patients evaluated with CCTA subsequently had repeat cardiac testing.
  • Compared to MPS, CCTA was associated with higher rates of PCI (odds ratio [OR]=1.25, 95% confidence interval [CI] 1.04-1.51), and CABG (OR=1.47; 95% CI, 1.03-2.13) (Table 5).
  • Compared to stress echocardiography and treadmill stress testing, CCTA was associated with more invasive procedures, hospitalizations, return ED visits, and repeat noninvasive testing.

What’s the Bottom Line?

CCTA use increased four-fold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits.  This suggests that real-world CCTA use comes at the cost of increased healthcare utilization, and highlights the need for clear guidelines on the use and interpretation of CCTA.

  

Figure 1. CCTA and functional cardiac stress testing use in Emergency Department patients with chest pain.

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Table 5. Associations between CCTA, downstream utilization and acute myocardial infarction after propensity-score matching.

  Propensity model 1 Propensity model 2 Propensity model 3
Outcome CCTA vs MPS CCTA vs SE CCTA vs TMET
  OR* 95% CI P-value OR* 95% CI P-value OR* 95% CI P-value
Procedures 0.80 0.72-0.88 <.0001 1.23 1.10-1.37 0.00 1.12 1.00-1.25 0.04
Cardiac Catheterization 0.79 0.72-0.87 <.0001 1.21 1.08-1.35 0.00 1.11 0.99-1.24 0.07
PCI 1.25 1.05-1.51 0.02 1.49 1.22-1.81 <.0001 1.27 1.05-1.53 0.01
CABG 1.47 1.03-2.13 0.04 1.36 0.96-1.95 0.09 1.31 0.92-1.87 0.13
Healthcare Utilization
Repeat ED Visit 0.95 0.85-1.07 0.43 1.20 1.06-1.36 0.00 1.09 0.97-1.24 0.15
Hospitalization 1.10 0.99-1.22 0.07 1.59 1.42-1.78 <.0001 1.26 1.13-1.40 <.0001
    Repeat Cardiac Testing 1.68 1.48-1.90 <.0001 3.16 2.72-3.68 <.0001 1.32 1.17-1.48 <.0001
Acute Myocardial infarction within 30 days 1.00 0.47-2.12 1.00 1.00 0.47-2.12 1.00 0.82 0.40-1.67 0.59

 

Image by Shutterstock used under permission

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May 9, 2016 by @cabreraerdr · View  

How to Succeed as a Teacher - Asking Questions (episode 2)

This is the second short video from a eight episodes series about prime concepts and recommendations to succeed as a teacher by Dustin Leigh, MD (@DLeigh0029)

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