Study claims EDs fall short on pneumonia and MI care
Numbers disputed — Documentation poor?
According to a new study by Johns Hopkins researchers, ED managers and their staffs are doing a poor job of treating pneumonia and heart attack patients. In fact, the authors of the Academic Emergency Medicine article say that as many as 22,000 preventable deaths occur each year in the United States because EDs across the country aren't meeting national goals.1
The researchers looked at the records of 1,492 heart attack and 3,955 pneumonia patients treated at 544 EDs between 1998 and 2004. They found:
- Only 40% of eligible heart attack patients received recommended aspirin therapy, and only 17% received recommended beta-blocker treatment;
- Among pneumonia patients, only 69% received recommended antibiotics, and 46% had blood oxygen levels assessed, as recommended by the American Thoracic Society.
However, ED observers assert that these numbers paint an inaccurate picture of care given in EDs, and that by and large it is poor documentation — not poor care — that caused the statistics to appear so disappointing.
"Once core measures started to be introduced, CMS [Centers for Medicare & Medicaid Services] would come to us an ask why we were not giving aspirin [to heart attack victims]," recalls Kevin Klauer, DO, FACEP, director of quality and clinical education and the Center for Emergency Medical Education with Emergency Medicine Physicians (EMP), a Canton, OH-based provider of emergency medical services. "We discovered that in every hospital, there was some component of sampling that was to blame. For example, EMS might have already given the patient aspirin, or they had taken it before arrival and the chart abstractor either didn't know to check that or just didn't do it."
Can't just blame documentation
Certainly, some areas are documented better than others, says the study's principal investigator, Julius Cuong Pham, MD, an assistant professor in the Department of Emergency Medicine at Johns Hopkins University School of Medicine, Baltimore, and a practicing emergency physician. "But if a patient gets an aspirin, the medical record is a legal document, so if you give someone aspirin you had better be sure you document it — the same thing with beta-blockers."
For other variables, such as pulse oximetry, Pham concedes that the physician may just measure it, determine it is normal, and not write that down. "What percentage [of reported errors] is due to documentation? We don't know," he says.
Klauer's own documentation, he says, shows good compliance when it comes to aspirin. "Two years ago we went to physicians checking charts and came up with different numbers than the hospital [was reporting]," he says. "We have physician reviewers review their peers' charts. They know to look in a specific part of the chart."
The numbers for all of his practice have been about 99%, with beta-blockers at 96%-97%, Klauer says. "We have a quality director at every site. These statistics are measured quarterly and annually and compared to the other facilities, and the doctors are partially compensated on that basis," he says. This incentive-based compensation plan puts a certain portion of the physician pay at risk, and of that portion, 5%-10% is assigned to quality, Klauer says.
Pham and Klauer agree the most controversial measure involves antibiotics. Pham says, "There's a lot of controversy in the ED as the whether four hours [from admission] is appropriate, vs. six or eight hours."
There isn't a single piece of controlled literature that assigns a specific time, says Klauer. "So, we may appear to not be in compliance because of flawed parameters, but we certainly won't let our doctors practice bad medicine," he says.
Pham and his colleagues recommend the creation of systems in the ED to minimize whatever lapses in care are occurring.
"Standardized protocols are shown in the literature to be effective," he says. "For example, every patient with acute MI or chest pain gets aspirin and beta-blockers as part of their care unless it is contraindicated." The nurse should serve as a check and balance by ensuring the doctors are following the protocol. There may even be a role for IT, Pham says. "If you have a diagnosis of heart attack and you are about to log off without giving aspirin a red flag may pop up. This takes the individual caregiver out of the equation," he says. "The ED is very hectic, and it is not unreasonable to forget something. We need some warning feedback."
Any performance feedback should be easily visualized, Pham adds. "It could be a blinking light on the computer screen, a red flag on a chart," he says. "The bottom line is, these errors are likely lead to patient harm and death, and whatever we can do to improve on that will affect the health of patients."
Klauer says, "If patients are getting aspirin 44% of the time, we are doing them a huge disservice, but I don't believe that is happening."
- Pham JC, Kelen GD, Pronovost, PJ. National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia. Acad Emerg Med 2007; 14:856-863.
For more information on the treatment of pneumonia and heart attack, contact:
- Kevin Klauer, DO, FACEP, Director of Quality and Clinical Education, Emergency Medicine Physicians, 4535 Dressler Road, Canton, OH 44718. Phone: (330) 705-9500. E-mail: email@example.com.
- Julius Cuong Pham, MD, Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore. Phone: (410) 570-8125.