Elephants, Quality, and Doing the Right Thing

Having just finished a busy emergency department (ED) shift, I was struck by the article in this issue of Academic Emergency Medicine on quality indicators for elder patients by Terrell and the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force.1 The ED shift was typical of many busy medical centers. In the morning there were about 20 admitted patients boarded in the ED. Some had admission orders in their charts, while others were waiting all night for an admitting service to write orders because the medicine, pediatrics, and cardiology residents and services had “capped” last night. Patients were in limbo between emergency medicine (EM) and admitted services; they had their acute care managed but their inpatient continuing care orders were not in place, a situation ripe for medical errors. We had 6 patients in hallway gurneys beds that would grow to 12 hallway bed patients in the afternoon. Four patients were psych holds waiting for psychiatric inpatient beds; these patients spend up to 5 days in the ED hallway getting no psychiatric treatment while waiting for an inpatient bed to open up somewhere in the city. The waiting time for ambulatory patients coming to the ED was 2 hours in the morning, but lengthened to 8 hours as ambulance patients filled the few available beds. I looked at the specialty call list for the day and found that we did not have ear, nose and throat (ENT), hand surgery, or spine specialists available, even though we are the regional trauma and tertiary care center. Indeed, EM in 2009 faces major quality of care issues including overcrowding, lack of back-up and specialty care, lack of inpatient and critical care beds, boarding of patients with significant illness or injury in hallways, long waits, and a lack of accountability. It is in the context of these “Quality of Care Elephants in the ED” that some clinicians will approach the paper on quality indicators for geriatric emergency care.1 Many emergency physicians (EPs) find it difficult to understand why we are being pushed to measure and improve quality indicators while these administrative problems are setups for medical errors in the ED. Why do we not focus more efforts on the quality elephants? The emphasis on quality in medical care is not new, but has been a focus of stakeholders including the public, consumers, policymakers, and regulatory agencies since the Institute of Medicine reports on medical errors and the quality chasm.2, 3 Issues such as the overuse or underuse of health care services, as well as the misuse of services resulting in adverse outcome for patients, are of concern to all stakeholders. The variation in the use of services unexplained by patient or disease differences, and the fact that medical errors are common, undermine the confidence of the public that medicine is scientifically based. If medical decisions are not scientifically based, stakeholders question whether there should be more oversight.4, 5 One response to the quality concerns about the appropriate use of medical services and variations in care is to develop clinical guidelines based on the best available medical evidence. As a result, we now have hundreds of clinical guidelines ranging from the use of imaging for cervical spine injuries and rapid strep cultures for pharyngitis to the treatment of sepsis and cardiac arrest. However, many physicians do not follow clinical guidelines even when the evidence is not under question. For example, many physicians do not regularly follow the Ottawa Ankle Rules for ordering radiographs, induce therapeutic hypothermia for comatose patients following a cardiac arrest, or use beta-blockers for patients with acute coronary syndrome. This results in an overuse of some health care services and underuse of important treatment modalities for other patients. Changing physician behavior is very complicated. One of the most successful methods to influence physician behavior is to measure and provide feedback through quality improvement initiatives. Quality improvement mandates have come from the U.S. Department of Health and Human Services through the Centers for Medicare and Medicaid Services. The Joint Commission has required quality improvement initiatives in a variety of areas that directly affect EM. While we may disagree with some of the indicators, most of the science guidelines are reasonable, such as prompt reperfusion following an ST-elevation myocardial infarction. However, whether we agree or disagree, quality improvement is a reality for the practice of medicine in 2009, and institutions must comply or risk losing their accreditation. Regulatory organizations in EM, under pressure from parent bodies, the public, and governmental stakeholders, also mandate participation in quality improvement initiatives. The American Board of Medical Specialties mandates that its member boards, including the American Board of Emergency Medicine (ABEM), assess practice performance by diplomats in their specialties. Beginning in 2011, ABEM diplomats must attest twice in a 10-year cycle that they are participating in a practice improvement program that meets ABEM Assessment of Practice Performance requirements, which are “1) assess the quality of care they provide compared to peers or other acceptable benchmarks and then 2) applies the best evidence or consensus recommendations to improve that care using follow-up assessments.”6 Similarly, the Accreditation Council for Graduate Medical Education (ACGME) has mandated that its Residency Review Committees (RRC) incorporate competencies into residency training. The RRC-EM Program Requirements state in the section for competency of systems-based practice that residents are expected to “actively participate in emergency department continuous performance quality improvement (PI) programs.” (EM Program Requirements-Section IV 5f(8)c).7 The 2007 Model of Clinical Practice of Emergency Medicine includes Performance Improvement and Practice Guidelines as part of the practice of EM.8 Thus, quality improvement is a part of medicine in 2009. It is required in our training programs and for maintenance of our board certification. It is required as part of our responsibility for medical staff privileges in hospitals. In the future, compliance with quality indicators may be tied to our reimbursement through the Medicare pay-for-performance program. Thus, we do not have a choice of whether to participate in quality improvement programs. Knowing this, we need to be involved in making choices as to what quality improvement programs are most valuable for our patients and our practice. What about solving the elephant in the room quality issues described above? The elephant quality issues involve major systemic problems that must be addressed with solutions involving our health care nonsystem. As individual physicians, it is important that we advocate for better systems that do not subject our patients to long waits, hallway beds, and lack of specialty care. However, these are not issues that are amenable to quality indicators and performance improvement. The argument that physicians should not participate in quality improvement projects because there are other important quality issues in EM does not stand up to scrutiny. A patient with a serious chronic disease such as congestive heart failure or cancer who presents to the ED with a broken leg is still treated for the leg injury even though there are other serious problems. In our flawed nonsystem without clear responsibility for health care, we do our best as physicians to treat patients and improve quality for those issues that are under our control. At the 2002 Academic Emergency Medicine Consensus Conference on quality in EM, Kizer4 advocated that EPs should work for a “culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.” This culture of quality needs to be implemented on an organizational level. However, it does require that we as individual physicians do our part and recognize that we are working toward a larger goal. Graff et al.9 defined quality as “the care health care professionals would want to receive if they were sick.” This remarkably simple definition is similar to the dictum we use to teach medical students to treat every patient as if he or she were a close relative—a mother, father, brother, sister, or child. In this context, we can better understand the paper by Terrell et al. and the SAEM Geriatric Task Force reporting the results of a multiyear, multidisciplinary project supported by the American Geriatrics Society (AGS) and the John A. Hartford Foundation to develop quality indicators for the care of vulnerable elder patients needing emergency medical care. Previous literature has identified significant quality of care issues in the emergency care of elder patients. One example that concerned the Task Force was the assessment of the cognitive status of older patients. Studies from several different medical centers showed that when elder patients with no history of dementia underwent mental status assessment in the ED, 10% met criteria for delirium and another 20%–25% had cognitive abnormalities. These abnormalities were unrecognized by the EPs and some patients with delirium or acute confusional states were discharged home.10-13 To develop quality indicators, the Task Force focused on three common geriatric EM conditions—cognitive assessment, pain management, and transitional care. The methodology used was modeled after the Assessing Care of Vulnerable Elders (ACOVE) project sponsored by RAND Health and Pfizer to develop a set of medical care quality indicators for geriatric care.14 The content experts for each target condition did systematic literature reviews and developed a preliminary list of quality indicators. This list was then presented, reviewed, and modified at SAEM, American College of Emergency Physicians (ACEP), and AGS meetings over a 2-year period. The Task Force presents 6 indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing facilities and EDs. The quality indicators are presented as a series of IF–THEN statements that can be readily assessed through a medical record review. The recommendations are reasonable and consistent with high-quality medical care. For example, if my mother or father had delirium or new cognitive impairment and came to the ED after a fall, I would certainly want my parent to have the impairment recognized. If my parent was in a skilled nursing facility and sent to an ED after a fall, I would want good communication about his or her condition both before and after ED treatment. Elder patients are more difficult to care for in the ED. They present with more complex and atypical clinical presentations; often have comorbid diseases, polypharmacy, and decreased functional reserve; and may need social support systems or caretakers. The 2006 Emergency Department Summary of the National Hospital Ambulatory Medical Care database showed that persons age 75 and older had 60.2 ED visits per 100 persons in the United States, or about 10.2 million visits in 2006. Nursing home residents made 139.5 ED visits per 100 residents.15 The SAEM Geriatric Task Force project on quality indicators has produced an important report that is relevant to our daily practice. It is an educational project with consensus recommendations about three important issues in the ED care of elder patients. The article also provides EPs with consensus guidelines to improve their practice and quality of care within the ED. Finally, it provides an opportunity for EPs to comply with regulatory requirements by adopting one or more of the quality indicators. Perhaps someday, the efforts of the task force will help improve the care of our parents or ourselves.

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