Prognostic value of a modified surprise question designed for use in the emergency department setting.

OBJECTIVE: Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, Would you be surprised if this patient died in the next 30 days could predict in-hospital mortality and resource utilization for hospitalized emergency department patients. METHODS: For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated. RESULTS: 6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of \u27comfort measures\u27 orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses. CONCLUSION: The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely

Prognostic value of a modified surprise question designed for use in the emergency department setting

Objective Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, “Would you be surprised if this patient died in the next 30 days” could predict in-hospital mortality and resource utilization for hospitalized emergency department patients. Methods For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated. Results 6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of ‘comfort measures’ orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses. Conclusion The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay.

OBJECTIVE: The objective was to evaluate the effect of an emergency clinician-initiated ED admission holding order set on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients. METHODS: We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a non-value-added activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior. RESULTS: The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician\u27s admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention. CONCLUSIONS: We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change

Psychometric Properties of the Short Form Patient Activation Measure When Used with Adult Emergency Department Patients

Background: Patient engagement with healthcare is important as engaged patients make more informed healthcare decisions, incur lower expenses, and have improved outcomes. Patient activation, defined as knowledge, skills, and confidence in managing health and healthcare, is closely linked and is measurable using the short form Patient Activation Measure (PAM-13). While evidence supporting the PAM-13s validity has been established in the general and hospitalized populations, its psychometric properties have not been evaluated when used in the emergency setting (ED). Thus, we sought to assess the PAM-13s psychometric properties when used in the ED setting. Methods: We administered the PAM-13 to a convenience sample of adult patients receiving care in our Level-I tertiary ED. Patients were excluded if they could not read English or if their medical or cognitive condition precluded participation. Analyses included: a) internal consistency reliability using Cronbach’s alpha coefficient and item analysis, b) principle components analysis (PCA) with Varimax rotation and Kaiser normalization and c) internal consistency reliability of the components identified through PCA. Results: 200 patients participated in the study, 98 (49%) were female, median age 64 (range 21-95). PAM-13 scores ranged from 39.7 to 100, mean 67.2 (SD 13.25, 95% CI: 65.3-69.0). The initial standardized Cronbach’s alpha coefficient for all 13 items was 0.88, indicating high internal consistency reliability. One item displayed a low corrected item-to-total correlation (0.247) but was retained due to limited influence on alpha if deleted. The items were subjected to PCA yielding a two-component solution explaining 51.9% of observed variance. Cronbach’s alpha coefficient for the individual components were 0.87 (Component 1, 7 items) and 0.73 (Component 2, 6 items), indicating that the subscales may be used independently to assess unique aspects of patient activation. Conclusions: Results suggest that the PAM-13 is psychometrically sound when used with adult ED patients. While the PAM-13 holds promise as a tool for evaluating activation in the ED, additional research in needed to assess the relationships between patient characteristics and scores on the PAM-13. In addition, evaluation using methods grounded in Item Response Theory (IRT) are warranted as the PAM-13 was developed using an IRT-model

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay.

Objective The objective was to evaluate the effect of an emergency clinician-initiated \u27 ED admission holding order set\u27 on emergency department ( ED) treatment times and length of stay ( LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act ( PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone ( DDTPG) time, for admitted patients. Methods We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a \u27non-value-added\u27 activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior. Results The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [ IQR] = 295 to 543) and 395 ( IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 ( IQR = 21 to 431) and 316 ( IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician\u27s admitting DDTPG times with median times of 219 ( IQR = 150 to 306) and 200 ( IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 ( IQR = 58 to 138) and 92 ( IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 ( IQR = 112 to 261) and 178 ( IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 ( IQR = 129 to 316) and 202 ( IQR = 127 to 305) minutes following the intervention. Conclusions We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change

Using the Surprise Question To Identify Those with Unmet Palliative Care Needs in Emergency and Inpatient Settings: What Do Clinicians Think?

Background: The surprise question (SQ), \u27 Would you be surprised if this patient died within the next year?\u27 is effective in identifying end-stage renal disease and cancer patients at high risk of death and therefore potentially unmet palliative care needs. Following implementation of the SQ in our acute care setting, we sought to explore hospital-based providers\u27 perceptions of the tool. Objectives: To evaluate (1) providers\u27 perceptions regarding the feasibility of SQ use in emergency and inpatient settings, (2) clinician perceptions regarding the utility of the SQ, and (3) barriers to SQ use. Design: A cross-sectional survey of medical providers following addition of the SQ to the electronic record for all patients admitted to a tertiary care hospital. Results: A total of 111/203 (55%) providers participated: 48/57 (84%) emergency physicians (EPs) and 63/146 (43%) inpatient providers (IPs). Most reported no difficulty using the SQ. Modest numbers in both groups reported that the SQ influenced care delivery (EPs 37%, IPs 42%) as well as goals of care (EPs 45%, IPs 52%). At least some advance care planning discussions were prompted by the SQ (EPs 45%, IPs 58%). Team discussions were influenced by SQ use for more than half of each group. Most respondents (55%) expressed some concern that their SQ responses could be inaccurate. Conclusions: In this setting, clinicians indicated that use of the SQ is feasible, acceptable, and useful in facilitating advance care planning discussions among teams, patients, and families. Many reported that SQ use influenced goals of care, but concern regarding accuracy was a barrier. Additional research examining SQ accuracy and predictive ability is warranted