Objectives Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement. We hypothesized that decades-old approaches used in many academic EDs are inefficient and low yield for identifying patient harm. Methods We conducted a prospective observational study to evaluate the efficiency and yield of current quality review processes at five academic EDs for a 12-month period. Sites provided descriptions of their current practice and collected summary data on the number and severity of events identified in their reviews and the referral sources that led to their capture. Categories of common referral sources were established at the beginning of the study. Sites used the Institute for Healthcare Improvement's definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for grading severity of events. Results Participating sites had similar processes for quality review, including a two-level review process, monthly reviews and conferences, similar screening criteria, and a grading system for evaluating cases. In 60 months of data collection, we reviewed a total of 4735 cases and identified 381 events. This included 287 near-misses, errors/events (MERP A–I) and 94 adverse events (AEs) (MERP E–I). The overall AE rate (event rate with harm) was 1.99 (95% confidence interval = 1.62%–2.43%), ranging from 1.24% to 3.47% across sites. The overall rate of quality concerns (events without harm) was 6.06% (5.42%–6.78%), ranging from 2.96% to 10.95% across sites. Seventy-two–hour returns were the most frequent referral source used, accounting for 47% of the cases reviewed but with a yield of only 0.81% in identifying harm. Other referral sources similarly had very low yields. External referrals were the highest yield referral source, with 14.34% (10.64%–19.03%) identifying AEs. As a percentage of the 94 AEs identified, external referrals also accounted for 41.49% of cases. Conclusions With an overall adverse event rate of 1.99%, commonly used referral sources seem to be low yield and inefficient for detecting patient harm. Approximately 6% of the cases identified by these criteria yielded a near miss or quality concern. New approaches to quality and safety review in the ED are needed to optimize their yield and efficiency for identifying harm and areas for improvement.
Introduction: Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware's (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS). Hypothesis: This study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival. Methods: This was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar's and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was "improved," "unchanged," or "worsened." Results: Seventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO2 < 92%, RR > 24, and cyanosis (P < .01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD = 1.9) to 14.1 (SD = 1.9) after CPAP (mean difference [MD] = 0.17; 95% CI, -0.49 to 0.83; P = .59). The HR decreased from 115.7 (SD = 53) to 105.1 (SD = 37) after CPAP (MD = -10.9; 95% CI, -3.2 to -18.6; P < .01). The SpO2 increased from 80.8% (SD = 11.4) to 96.9% (SD = 4.2) after CPAP (MD = 17.8; 95% CI, 14.2-21.5; P < .01). Conclusion: The BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training.Sahu N, Matthews P, Groner K, Papas MA, Megargel R. Observational study on safety of prehospital BLS CPAP in dyspnea. Prehosp Disaster Med. 2017;32(6):610-614. IntroductionRespiratory distress often results from conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma exacerbation, and pneumonia.
A71OBJECTIVES: Diagnosis related groups (DRG) like financing method was introduced in Hungary in 1993 for acute care hospital reimbursement. Due to the increased activity of the hospitals, an upper ceiling, the so called performance volume limit (PVL) was introduced in acute care hospital financing in 2006. The aim of our study was to analyze the effect of performance volume limit on DRG based hospital financing on the example of a Hungarian tertiary teaching hospital, the Clinical Centre of the University of Pécs. METHODS: Data derived from the financial database of the National Health Insurance Fund Administration, the only health care financing agency in Hungary. We analyzed the annual DRG based health insurance revenues with and without performance volume limit ceiling. We calculated the proportion of hospital activity over that ceiling measured by DRG cost-weights. The period 2007-2013 was involved into the study. RESULTS: We found a significant loss in DRG reimbursement due to performance volume limit. The annual loss in DRG reimbursement varied between 2.4-10.5 million USD between 2007-2013. The highest revenue loss was observed in 2009, and after 2009 the financial loss decreased to 7.0 (2010), 5.2 (2011), 3.0 (2012) and 2.8 (2013) million USD. This annual revenue loss represented 3.0-14.9 % of the annual revenues of the Clinical Centre of the University of Pécs. CONCLUSIONS: The introduction of performance volume limit into the DRG based hospital financing resulted in a partial loss of hospitals' revenues. The Clinical Centre of the University of Pécs experienced significant loss its revenues due to this regulation.
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