ED Peer Review Process IDs Trends Before Suits Occur

A new peer review and quality improvement process at the University of Michigan Hospital and Health Systems in Ann Arbor methodically samples patient safety indicators in the emergency department (ED) to spot trends that signal problems.

“We monitor cases for peer review monthly, based on a predetermined set of criteria,” says Steven Kronick, MD, MS, service chief of adult emergency medicine and associate professor in the Department of Emergency Medicine.

These criteria are deaths in the ED, deaths within 24 hours of admission, transfers of admitted patients to the intensive care unit from the floor within 24 hours, deaths within 24 hours of admission, and admissions to the hospital seen and discharged from the ED within the previous 72 hours.

“We also review all cases referred to us by other services, as well as any case referred from anyone in the department,” says Kronick. “Cases may also be self-referred.”

Cases are reviewed by a committee of emergency medicine faculty, and there is also an institutional safety monitoring reporting system. Cases referred through this system are reviewed if the care delivered by the provider is implicated in the report.

One particular area of concern is identifying risk in patients with gastrointestinal hemorrhage. Patients can seem to be relatively stable, and when there is deterioration, it is frequently sudden, explains Kronick.

Although hundreds of cases are reviewed every year, there have been remarkably few trends identified, says Kronick. “One specific trend is the identification of those patients who are at risk for deterioration within the first 24 hours of admission,” he reports. “Aggressive care in the first few hours can have a significant impact on outcome. It is extremely important to be able to identify these patients.”

Variations Identified

“If we identify a trend, we perform a root cause analysis to determine if we think there is some element of the trend on which we think we can have impact,” says Kronick.

For example, a review of suspected ectopic pregnancy cases revealed that there was a lack of standardization around the management of these cases. “We adopted the method used at another site that involved standard management and follow up. There have not been any further concerns to date,” says Kronick.

By comparing emergency physicians against their peers, it was discovered that there is great variation in individual practice. “In some cases, that has led us to consider standardization. But in many cases, there is not enough evidence to recommend one practice over another,” says Kronick.

Kronick says that it is difficult to demonstrate that the frequency of ED malpractice claims has decreased, since the number of claims is low to begin with.

“But there is a sense that practice is more safe,” he says. “Patients are getting better care when we standardize the care delivered around high-risk diagnoses.”


For more information, contact:

  • Steven Kronick, MD, MS, Service Chief, Adult Emergency Medicine/Associate Professor, Department of Emergency Medicine, University of Michigan Hospital and Health Systems, Ann Arbor. Phone: (734) 763-9849. E-mail: skronick@med.umich.edu.