QA Reviews: Lessons from the Sharp End
3rd Annual Emergency Medicine Symposium, SJRMC
David J. Adinaro MD, MAEd, FACEP
Chief, Adult Emergency Department, EM Residency Research Director
Disclosures
Disclosures
I have nothing to report in
terms of financial
disclosures.
However….
My biases
Biases
I have been both
a Practitioner and Consumer
of emergency medicine
Biases
I believe
 That I have the best job in the
world
 That I work with the best
people in the best profession
 That we do noble work
Biases
I believe
 That I have the best job in the
world
 That I work with the best
people in the best profession
 That we do noble work
 That we can do better
Those who do not learn
from history….
 “No plan survives contact with the
enemy.”
Moltke the Elder (1800-1891)
 No captain can do wrong placing his
ship besides that of the enemy.
Admiral Lord Nelson (1758-1805)
Objectives
» Understand ways to
improve patient safety
» Understand the concepts
of the sharp end, the blunt
end, and HROs
» Review the working of
EDQA committee
Definitions
» The Sharp End
» The Blunt End
» High Reliability
Organizations
» EDQA
The Sharp End
The Sharp End
» Where the work is done
and errors are
made\discovered
» Real time decisions based
on available information
» Last line of defense in
error prevention
» In healthcare made up
of doctors, nurses, techs
The Blunt End
» Distal to the sharp (work end)
» Often remote from real time
decisions but contribute to the care
given and errors made
» ED Exec, Hospital Administration,
State regulations, National Policies
Sharp and Blunt Ends in Errors
HRO
A High Reliability Organization (HRO) is an organization
that has succeeded in avoiding catastrophes in an
environment where normal accidents can be expected
due to risk factors and complexity
HRO
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Hypercomplexity - HROs exist in complex environments that depend on multiteam systems that must coordinate for safety
Tight coupling - HROs consist of tightly coupled teams in which the members
depend on tasks performed across their team
Extreme hierarchical differentiation - In HROs, roles are clearly differentiated
and defined. Intensive coordination efforts are needed to keep members of
the teams working cohesively
Multiple decision makers in a complex communication network - HROs
consist of many decision makers working to make important, interconnected
decisions
High degree of accountability - HROs have a high degree of accountability
when an error occurs that has severe consequences
Need for frequent, immediate feedback - HROs exist in industries where
team members must receive frequent feedback at all times
Compressed time constraints - Time constraints are common to many
industries, including health care
HRO
» Aircraft carrier flight deck operations
» Nuclear Power Plants
» Fireground Operations (especially wildfire)
HRO
» Preoccupation with failure
» Reluctance to simplify
interpretations
» Sensitivity to operations
» Commitment to
resilience
» Deference to
expertise
Flight Deck Operations
So you want to understand an
aircraft carrier? Well, just
imagine that it's a busy day, and
you shrink San Francisco Airport
to only one short runway and
one ramp and gate.
Flight Deck Operations
Make planes take off and land at
the same time, at half the present
time interval, rock the runway
from side to side, and require
that everyone who leaves in the
morning returns that same day.
Flight Deck Operations
Then turn off the radar to avoid
detection, impose strict controls
on radios, fuel the aircraft in place
with their engines running, put an
enemy in the air, and scatter live
bombs and rockets around.
Flight Deck Operations
Now wet the whole thing down
with salt water and oil, and man it
with 20-year-olds, half of whom
have never seen an airplane close
up.
Flight Deck Operations
Oh, and by the way, try not to kill
anyone.
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HRO
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Aircraft carrier flight deck operations
Nuclear Power Plants
Fireground Operations (especially wildfire)
Emergency Departments!
ED Operations
ED Operations
ED Operations
HRO
» Hypercomplexity
» Tight coupling
» Extreme hierarchical differentiation
» Multiple decision makers in a complex communication network
» High degree of accountability
» Need for frequent, immediate feedback
» Compressed time constraints
SJRMC ED Operations
» Embraces many aspects of HRO
» 2009 Survey of Staff
• Feedback related to
validated, national Patient
Safety Survey
• Don’t Drop the Ball Program
– Residents, Medical
Students, Staff
» Yellow Cards
» Operations and
safety issues
» Anonymous
SJRMC ED Operations
» Emergency Department Quality Assurance Committee
» Physician and Nursing Leaders
» ED Exec
» Case management, nursing educator
» Physician\nursing representatives
» Quality Assurance representative
» Review of identified cases and evaluates them for
concerns\problems related to certain aspects of care
» Grade care given and also identify SHARP and BLUNT END
issues to be resolved.
Everyone raise their
Hands!
EDQA
» Started in the Fall of 2009
» Initially met once
a month, then twice
a month, now weekly for
two hours
» In 2010 SJRMC saw
126,000 patients
» EDQA reviewed 115
EDQA
» Some acceleration in 2011
• 56 reviewed to date
• 25,000 ED visits
» Between 1 and 2 of every
1,000 charts submitted for
review
EDQA
» Peds not well
represented
• 30% of patients, < 10%
of charts
» Good mix of admitted
and discharged patients
» Physicians average 4-8
charts a year reviewed
EDQA
» A major tool for physician review, early
warning, and blunt end decision making
» Recently Wayne ED has joined process
» Has become a model for other
departments in hospital
EDQA
Where do the charts come from?
» Most are identified\referred from our own
department
• Leadership becomes aware of patient issue
• Referrals by those on the sharp end
– Sharon Pineda (pinedas@sjhmc.org)
• Automatic screens (Admit after RTC < 72
hours, mortality)
» A significant number come from other
departments
• Trauma, STEMI committee, Risk
management
To date approximately
200 charts have been
reviewed during EDQA
The information
collected on these
sheets form the basis
of the information
that follows
Limitations
» Specific to St. Joe’s
» Small proportion
of Peds cases
EDQA Review
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Adverse Outcome?
Area of Concern
Who Referred
Documentaton Issue?
Care Issue?
System Issue?
Reccomendations
Outcome\EDQA Referral
Example #1
» 70 year old female. Hypotensive, signs of
sepsis, no IV access
» Screen (Sepsis care)
» Delay in ABX tx
» NO adverse outcome
» NO documentation issues
» State Trooper
• Design of car and malfunction
of handguns
Example #1
» YES Care Issue
»Clinical judgment
»Communication\responsiveness
»Delay in Abx and IV access
» YES System Issue
»Awareness of sepsis and tx
» SCORE
»2 (physician)
» RECC:
»Phys to ED Chair
Adverse Outcomes
» Still not well defined
» Generally taken to mean did an
unexpected event cause
increase in the anticipated
care of the patient.
• Not found in most of the
reviewed charts
• However, need for
unanticipated life sustaining
tx found in about 10% of all
charts reviewed.
Yes
37%
No
63%
Adverse Outcomes
Yes
37%
No
63%
Adverse Outcomes Breakdown
Increased Tx
16%
Life Sustaining
Tx
36%
Care not
Affected
12%
Incr.
Monitoring
36%
Area of Concern
Delay in Tx
14%
RTC
12%
Mortality
9%
Appropriate
Disposition
6%
Other
6%
Appropriate Care
53%
Documentation Issues
Yes
32%
No
68%
Documentation Issues
» Vast majority are not found to have
documentation issues
» Most of these concerns reflect weakness
in documentation of communication, care
plan, vital signs and reassessment
» Tended to weaken impression of care
given, leaving more to interpretation
Documentation Issues
For Nursing documentation
» Mostly involved paucity of vital signs documentation
» Many involve lack of reassessment, communication during hand off,
and notification of change in patient condition
For Physician documentation
» Most fell in the MDM section
• Documentation of consults, conversation with pmd’s
• Re-assessment of patients prior to discharge
• Plan\events
• HPI\PE to match seriousness of patient
• Procedure documentation
Example #2
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80 year old male.
CC: abd pain and vomiting
Chest tightness documented in triage
Initial EKG nl. Triage level 3
Labs ordered.
Seen in Main East (1 hour into care)
» Positive troponin
» Reviewed EKG
»Over-read by ED attending as STEMI
» STEMI Activation
Example #2
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Med Staff
Appropriateness of care
YES Adverse (though care not affected)
YES Documentation Issue (Physician)
YES Care Issue (Physician)
» Judgment\Decision making
» Failure to identify STEMI
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Example #2
» YES System
» Should have been Level 2
» Issue with triage process
» Benefit of MUSE on all ED Computers
» Need for old EKGs
» SCORE: 3
» Referred MDPR
Care Issues
Yes
42%
No
58%
Physician Care Issues
Diagnosis
5%
Technique\Skills
5% Knowledge
Follow-up
9%
Policy
Compliance
Supervision 4%
1%
1%
Communication
19%
Planning
6%
Clinical Judgment\
Decision Making
50%
Care Issues
Physician Care
» Lack of contact with pmd on discharge of patients
(especially, older or complex)
» Under-resuscitation of shock
» Trauma alert criteria not followed
» EKG misinterpretation
» Abnl Labs or vital signs not addressed
» Protocol not followed STEMI, Stroke, Septic Shock
» Delay\No consultant
Care Issues
No Physician can go wrong
placing herself next to a critical
patient and treating aggressively.
Adinaro/Nelson Rule
Nursing Care Issues
Diagnosis Technique\Skills
0%
6%
Follow-up
9%
Knowledge
3%
Policy
Compliance
13%
Supervision
0%
Planning
6%
Communication
25%
Clinical
Judgment\
Decision Making
38%
Care Issues
Nursing issues found less often
Psych patient care
» Removal of clothing
» Identification of suicidal patients
» Prolonged restraints\lack of sedation meds
Communication of critical information
» Lab results
» Abnl Vitals
» Change in patient condition
» Lack of known plan
Other Provider Care Issues
Diagnosis
3%
Technique\Skills
0%
Follow-up
11%
Communication
33%
Knowledge
0%
Policy
Compliance
4%
Supervision
4%
Planning
4%
Clinical
Judgement\Decis
ion Making
41%
Care Issues
Other Department
» Clothing not removed from patient
» Delay in arrival
» Delay in responsiveness to consult
» Poor communication between
consultant and other services
SCORE: Level of Assignment
0.
1.
2.
3.
4.
5.
6.
No problem with care/documentation
Minor process/documentation problem, clinical
outcome not affected
Problem with process/documentation,
disease/symptoms unchanged, adverse
consequences possible
Problem with process/documentation,
disease/symptoms occurred, made worse
Problem with process/documentation, permanent
impact/quality of life
Death attributable to care provided that is
significantly controversial
Death attributable to care provided/not provided
that should have been provided
SCORE: Level of Assignment
Permanent
Death
Condition made Impact , 5 Attributalbe , 2
worse, 18
,0
No problem, 77
Minor, effect
possible, 42
Minor, no affect,
41
Example #3
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56 yo male CC: feet swelling
Triaged 1538, labs obtained on standing orders
1945, 2024, 2054 called no answer
2055 Placed as LWOT and chart removed
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Next day: 1021
Sent back to ED by clinic due to abnl labs
Pale and weak
Moved to bed immediately
Hypotensive, INR 6. Hb 7.1
Had been 7.9 day before
Example #3
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Med Staff
Triage issue
YES Adverse: Increased monitoring
No Documentation
YES Care Issue (other\system)
» Long WR time
» Labs not checked prior to removal of chart
Example #3
» YES System (Human, Safety\culture)
» SCORE 2
» RECCOMENDATION:
» System to ED Exec
» Labs\orders done must be reviewed prior to
closing LWOT chart
System Issues
No
48%
Yes
52%
System Issues
No Info
18%
Safety\Culture
39%
Human System
20%
Computer
System 4%
Non ED System
19%
System Issues – Safety Culture
•Call CT surgery early with issues
•Alternative to Ultram in elderly
•Clothing removal on ETOH patients
•Desire to send borderline patients home
•Communicating directly with consultants
and not through residents in critical cases
•Calling PMDs on discharged patients
•Ordering MRI when needed
•Communication of important EDQA info to
staff
•Abnormal vital sign reporting and tx
System Issues – Human Systems
•Changes needed in Front End processes
•Charge nurse endorsement of hallway pt.
•Clarification of trauma criteria
•Delays in Triage-Bed in Peds
•Difficult airway procedures. Checklist?
•Including anginal equivalents for STEMI
screening (EKG)
•STEMI med kit in Main East
•Location of waiting Level 2 patients
•EP to EP turnover (especially psych pt)
System Issues – Non ED Systems
•Cooling capacity in Cath Lab
•Improved coordination among consult
services
•Delays in Rad study completion times
•Improve Surgery – OR communication
•Non-notification by non-system
paramedics
•Unresponsiveness of consultants
•Trauma attending presence
System Issues – Computer Systems
• Lack of previous clinical data in medhost
•Lack of physician access\orientation to
permanent clinical record
•Rapid identification of radiology over-reads
at log in
•Changes in script for nursing “visited
patient”
Feedback\Referrals by EDQA
MDPR
6%
System to ED
Exec
18%
Other
Department
15%
0%
Doc to ED
Chair
46%
Nurse to ED
Director
15%
A rookie baseball player
after a great first game jokes
that he wants to retire
When asked why he said
» I had three hits in three
at bats. Put my glove on
the ball a half dozen
times without error
» My stats are perfect
» It can only go down from
here!
Summary
• EDQA
is a proactive Blunt End activity designed to
improve care at the sharp end.
• Requires the active participation of Sharp End care
providers.
•Attend if possible\invited
•Refer charts
•Benefits individual providers and system as a whole
•Fulfills at least one of the goals of a HRO.
•More info on SJRMC ED efforts:
•http://www.stjosephshealth.org/index.ph
p/emergencytrauma
Thank You!