Emergency Department Quality Improvement Activity:
An Inventory from the American Board of Emergency Medicine
Maintenance of Certification Program
Terry Kowalenko, M.D., Dept. of Emergency Medicine Beaumont Hospital, Royal Oak, MI; Michael L. Carius, M.D., Dept. of Emergency Medicine,
Norwalk Hospital, Norwalk, Connecticut; Robert C. Korte, Ph.D., American Board of Emergency Physicians; Michele C. Miller, B.S., American Board of Emergency Physicians;
Earl J. Reisdorff, M.D., American Board of Emergency Physicians
TABLE 1. Part IV Attestation Menu
INTRODUCTION
Figure 1. General Category Types for Top 90% of Attestations
Table 2. Most Frequent Attestations
TABLE 1. Part IV Attestation Menu
PQRS (expanded drop-down list below)
Background
The ABEM Maintenance of Certification (MOC) program requires certified physicians to attest to participating
in a practice-based quality improvement (QI) activity as a component of the Assessment of Practice
Performance (APP) Practice Improvement (PI) requirement. The APP PI requirement is a clinically-focused
QI activity. The four parts of MOC are: 1) professional standing; 2) lifelong learning and self-assessment; 3)
cognitive expertise examination (the ABEM ConCert exam); and 4) assessment of practice performance (QI).
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The ABEM certification cycle is 10 years, divided into two 5-year cycles. An APP QI activity must be
completed during each of the five-year cycles. With 31,154 diplomates, approximately 6,200 (20%) would
have an APP QI activity requirement.
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ABEM diplomates can apply for a financial incentive through the Physician Quality Reporting System (PQRS)
MOC enhanced reimbursement program. To be eligible, diplomates must complete an APP QI activity must
occur in every year. Therefore, the number of APP attestations could exceed the anticipated 20 percent
annual reporting.
The APP QI activity attestations provide a snapshot of the various types of QI activities in which emergency
physicians (EPs) are involved. This reflects the degree to which EPs are measuring certain quality measures
and could provide guidance in the development of future quality measures.
Goals
ABEM sought to understand the type and frequency of these QI activities. This could inform the EM
community of the efforts targeted to improving patient care, refining ED operations, and enhancing patient
safety.
MATERIALS & METHODS
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12-lead electrocardiogram (ECG) performed for non-traumatic chest pain
12-lead electrocardiogram (ECG) performed for syncope
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate
Use
Acute Otitis Externa (AOE): Topical Therapy
Acute Pulmonary Embolus Anticoagulation
Aspirin at arrival for acute myocardial infarction
Community-acquired pneumonia (CAP): empiric antibiotic.
Community-acquired pneumonia (CAP): vital signs
Heart Failure (HF): Left Ventricular Function (LVF) Testing
Prevention of catheter-related bloodstream infections (CRBSI): CVC insertion protocol
Preventive Care and Screening: Screening for High Blood Pressure
Rh Immunoglobulin for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
Stroke & Stroke Rehab: Screening for Dysphagia
Stroke & Stroke Rehabilitation: Thrombolytic Therapy
Stroke and stroke rehabilitation: deep vein thrombosis prophylaxis (DVT) for stroke or
intracranial hemorrhage
Ultrasound Determination of Pregnancy Location - Pregnant Patients with Abdominal
Pain
Rank
Core Measures (expanded drop down list below)
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Acute Myocardial Infarction: aspirin on arrival
Acute Myocardial Infarction: ACE inhibitor or ARB given for LVSD
Acute Myocardial Infarction: Beta-blocker within 24 hours of arrival
Acute Myocardial Infarction: Fibrinolytic within 30 minutes of arrival
Acute Myocardial Infarction: PCI within 90 minutes of arrival
Pneumonia: Oxygenation assessment
Pneumonia: Blood cultures for ICU
Pneumonia: Blood culture before first antibiotic
Pneumonia: Antibiotic timing (within 4 hours; within 8 hours)
Sepsis Pathways
Asthma Pathways
Throughput Time Measures
Door to Balloon Time
Stroke Protocol/Pathways Activation
Door to Doctor Times
Left without Being Seen
Unscheduled Return Visits
Patient Call Back Program: Assessment of Clinical Care Given (not a satisfaction survey)
Other (free text option)
Key: Clinical = clinical protocols; Time = time-centered activities; Patient = patient-centered activities.
RESULTS
Characteristics of Study Subjects
During 2013, ABEM received 9,380 attestations for APP QI activities.
Main Results
91 total categories were defined.[Table2] The three most commonly reported quality activities were: 1) acute myocardial infarction: percutaneous coronary
intervention (PCI) within 90 minutes of arrival; 2) door to doctor times; and 3) throughput time measures. These three activities comprised 36.4% of all attestations.
All three are time-sensitive metrics. More than half of the attestations were captured by the five most frequently attested activities; roughly two-thirds (67.1%) of all
attestations were captured by the seven most frequent categories and about 90% (89.9%) of all attestations were captured by the 21 most common categories. The
general category types for these 21 categories are shown in figure 1. Of the 91 total attestation categories, 39 (42.9%) had fewer than 10 reports.
There were 5,435 attestations (57.9%) that involved PQRS and core measures. Of the 9,380 total attestations, 8,097 (86.3%) reports were recorded using pre-set
and drop-down items, and 1,283 (13.7%) that were free-text entered.
Study Design and Setting
This study is a retrospective descriptive review of all ABEM MOC APP QI activity attestations reported during
2013. None were excluded. The study was approved as exempt research by the Beaumont Health System
Research Institute Human Investigation Committee.
There were 107 (1.1%) attestations in the “other” category.
Limitations
Data is self-reported by physicians; there was no attempt to confirm the accuracy of every attestation. 20% of all attestations made in 2013 were verified by
contacting a designated verifier. The verifications received by the ABEM offices for 2013 had revealed no discordant attestations.
Selection of Participants
All attestations were self-reported by ABEM-certified physicians. Participants were self-selected.
The number of attestations does not reflect the number of ED – based QI activities. There were instances when multiple physicians from the same ED attested to
the same activity.
When using the preset and dropdown menus, only a single QI activity can be entered. Thus, this report gives only a sample of activities in which physicians are
engaged, not the entire number or types of activities. This likely represents a significant underestimation of the QI activities.
Methods and Measurements
When reporting an APP QI activity, physicians were presented various options of reporting, [Table 1] Details of
the QI activity were not requested, nor were they part of the reporting requirements. The physician would need
to confirm four steps: 1) that an initial measurement occurred; 2) the sample was evaluated against a
benchmark or standard (including possibly an internal baseline measurement); 3) that there was an
improvement intervention; and 4) that a re-sampling had occurred. The activity had to be linked to a direct
patient care.
Data for this study consisted of attestations by individual ABEM-certified physicians about their APP QI
activities. Attestations were self-reported and self-entered. The number in each preset category was analyzed
and reported by a single member of the ABEM data management team (MCM). The data is stored in a central
ABEM MOC website data repository.
There was likely a response bias as a result of having pre-designated measures and drop-down menus. Because it is easier to register by clicking on an existing
field and measure, physicians might more readily attest to a drop-down or pre-set activity. Using the “other” option required more effort involving free-text typing.
This extra work could have created a tendency to attest to something that was mechanically easier. However, 1,283 (13.7%) physicians opted to use the free-text
option.
The attestation menu was developed in 2010 and not revised until March 2014. The gradual changes in PQRS and core measures over a 3-year span were not
reflected in the attestation menu. This could have modified the types and frequency of reported quality activities. ABEM now annually revises the menu.
This study only included ABEM-certified physicians. The American Osteopathic Board of Emergency Medicine (AOBEM) has a similar program—Osteopathic
Continuous Certification. This report also does not include any QI activities of physicians working in EDs who are not certified by ABEM or AOBEM, but who are
certified by a different ABMS medical specialty board.
Discussion
This review showed a broad diversity of QI by ABEM-certified EPs. The most common activities involved time-sensitive metrics. The majority of attestations were
included in the five most frequently attested activities. Data sets such as these can be used by specialty societies to help guide the development of new quality
measures.
Data from preset-listed QI activities were reported in aggregate. The data from the “other” option were placed
into preset categories when possible. For QI activities not listed in preset categories, activities were grouped
together when possible. Any activity with two or more attestations would get assigned a QI activity category.
Any single attestation for which there was no similar activity was placed into the “other” category. [Table2]
As a consequence of the Affordable Care Act, there is a greater emphasis on physician quality reporting (i.e., PQRS) and adherence to quality measures. This
focus on adherence to quality measures will be greater with the implementation of the Value-based Modifier (VBM) and the changing implications of PQRS for
physician payment. It is important to have measures that are relevant to the clinical practice of EM. The clinical quality measure development process could be
informed by the projects reported to the ABEM MOC program. Frequently reported QI activities (e.g., safe sign-outs and hand-offs) could represent an area where a
relevant quality measure could be developed.
The 21 categories, comprising approximately 90% of attestations, were then grouped into three logical divisions
for further analysis. The divisions were time-centered activities, clinical protocols, and patient-centered
activities.
The types of activities that are performed tend to be commonly occurring QI activities for most, if not all, EDs and physicians to self-select an activity that will be
relevant to the physician or the department. Thus, the relevancy of an APP activity is solely determined by the reporting physician and his or her ED. All QI
programs that follow a process akin to the Plan-Do-Check-Act (PDCA) cycle would likely meet the ABEM APP requirements. Moreover, any Lean or Six-sigma
project would likely meet this requirement. ABEM’s philosophy is that EPs who are engaged in QI activities should receive credit for those activities without being
encumbered by additional work
CONCLUSION
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This report demonstrates that widespread and varied QI activities occurred in EDs across the United States. The majority of reported projects are nested in
a few categories, following recognized areas of emphasis in emergency care, particularly in areas that use a time-sensitive metric.
Activity
Attestations
Cumulative Percent
1,201
1,172
1,045
877
810
750
12.8
25.3
36.4
45.8
54.4
62.4
1
2
3
4
5
6
Acute myocardial infarction: percutaneous coronary intervention (PCI) within 90 minutes of arrival (includes door to balloon time
activities)
Door to doctor times
Throughput time measures
Acute Myocardial Infarction (AMI): Aspirin on arrival
Sepsis pathways (includes goal-directed care)
Stroke care: protocols for emergent assessment and care for stroke patients (excludes thrombolytic use)
7
8
Pneumonia: Blood culture before first antibiotic
Pneumonia: Antibiotic timing (administration within preset time)
439
344
67.1
70.8
9
10
11
12
13
14
15
299
281
248
218
159
88
85
74.0
77.0
79.6
81.9
83.6
84.6
85.5
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Left without being seen
Patient call back program: Assessment of quality of care (not satisfaction)
12-lead electrocardiogram (ECG) for non-traumatic chest pain
Review of unscheduled return visits
Pneumonia: Empiric antibiotic selection
Pneumonia: Oxygen saturation assessment
General quality improvement activities (including routine chart reviews, morbidity and mortality reviews, Lean projects, Six sigma
projects)
Safe sign-outs and hand-offs
Pneumonia: Blood cultures for intensive care unit patients
12-lead ECG for syncope
Risk management activities (includes chart reviews of high-risk conditions)
Asthma treatment pathways (including appropriate discharge medications)
Evaluation and risk stratification of chest pain (including TIMI risk assessment)
Chart and record completion (timeliness and thoroughness)
Pneumonia: Vital signs
Assessment of patients with abdominal pain (including approaches to imaging)
Assessment of suicidal risk
Patient experience of care quality improvement activities
ECG to interpretation times
CT of non-traumatic headache
CT for pulmonary embolus (including frequency of use, approach to decision-making, integration of d-dimer in decision-making).
84
73
70
70
61
60
49
40
39
31
30
29
28
26
86.4
87.1
87.9
88.6
89.3
89.9
90.4
90.0
91.3
91.6
91.9
92.2
92.5
92.8
30
Acute myocardial infarction emergency care including cath lab activation (approach to care excluding time-based goals)
25
93.1
31
32
Door to ECG time
Emergency department ultrasound use (including quality audits, accuracy of image interpretation, and credentialing)
25
25
93.3
93.6
33
34
Acute pain management (non-specified)
Electronic health record use (including improved documentation and use of computerized physician order entry
23
23
93.9
94.1
35
36
Accuracy of laboratory interpretation and radiology reports
EMS process improvement (including EMS communications, transfers of care, and ambulance diversions)
21
20
94.3
94.5
37
38
39
40
CT use (non-specified)
Wound care (including abscess care and diabetic foot ulcer care)
Chronic and challenging pain management
Cardiac resuscitation (including cardiac arrest alerts, pediatric resuscitation, and post-resuscitation care)
17
17
16
15
94.7
94.9
95.1
95.2
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
AMI: Fibrinolytic within 30 minutes
Trauma care
Stroke and stroke rehabilitation: screening for dysphagia
Approach to pediatric abdominal pain (including imaging)
Preventative care and screening: screening for high blood pressure
Time to analgesia (long bone fracture)
Admission processes and utilization criteria (including observation)
CT for mild (low-risk) head trauma
Foley catheter use (avoidance)
Triage process improvement
Ultrasound determination of pregnancy location – pregnant patients with abdominal pain
Antibiotic selection (nonspecific, use of local resistance information)
Approach to cystitis / UTI care (including urine culture use)
Aspirin for chest pain patients
Patient safety activities (non-specified)
Web-based investigation of a clinical question
ECG interpretation accuracy
Mental health evaluation (e.g., mental screening examination, psychiatric evaluation, mental health care, geriatric-psychiatric issues
14
14
13
12
12
12
11
11
10
10
10
9
9
9
9
9
8
8
95.4
95.5
95.7
95.8
95.9
96.1
96.2
96.3
96.4
96.5
96.6
96.7
96.8
96.9
97.0
97.1
97.2
97.3
59
60
Stroke and stroke rehabilitation: thrombolytic therapy
Stroke and stroke rehabilitation: deep vein thrombosis (DVT) prophylaxis for stroke to intracranial hemorrhage
8
8
97.3
97.4
61
62
63
64
65
67
68
69
70
71
Use of antibiotics in upper respiratory tract infections
Vital sign audits (completeness, rechecking)
High risk and invasive procedure complication reduction
Inter-institutional patient transfers
Readmissions
CT use for ureteral colic and ureteral stones
Hand washing
HIV testing
Vaccinations (including pertussis)
Acute otitis externa (AOE): Systemic antimicrobial therapy – avoidance of inappropriate use and topical therapy
8
8
7
7
7
6
6
6
6
6
97.5
97.6
97.7
97.8
97.8
98.0
98.0
98.1
98.1
98.2
72
73
74
75
76
77
78
79
80
81
82
83
Procedural and conscious sedation
Syncope of evaluation and admission
Use of hyperbaric oxygen (quality audit)
Approach to pharyngitis (including use off strep screen use)
Blood culture use
Concussion
Rh immunoglobulin for Rh-negative pregnant women at risk for fetal blood exposure
Treating sexually-transmitted diseases (including partner care)
Acute myocardial infarction: Beta-blocker within 24 hours of arrival
Palliative care improvement
Pediatric/infant fever
Prevention of catheter-related bloodstream infections (CRBSI): Central venous catheter insertion
5
5
5
4
4
4
4
4
3
3
3
3
98.2
98.3
98.4
98.4
98.4
98.5
98.5
98.6
98.6
98.6
98.7
98.7
84
85
86
87
88
89
90
91
Accurate estimation of body surface area burned
Acute myocardial infarction: ACE inhibitor or ARB given for LVSD
General stroke care
Heart failure: Left ventricular function (LVF) testing
Nasal administration of drugs
Time to antibiotic administration (non-specified)
Use of blood transfusion
Other
2
2
2
2
2
2
2
107
98.7
98.7
98.8
98.8
98.8
98.8
98.8
100.0
Disclosure: Conflicts of Interest: Drs. Kowalenko and Carius are Directors on the Board of Directors for the American Board of Emergency Medicine (no financial compensation is received for the reported activity). Drs. Korte and Reisdorff and Ms. Miller are employed by the American Board of Emergency Medicine