Quality Indicators and PostGraduate Competencies: Emergency Care for Older Patients

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Quality Indicators and Post-Graduate
Competencies Emergency Care for Older Patients

• Christopher R. Carpenter, MD, MSc
• Washington University in St. Louis
• March 6, 2009

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The Result Your ED Waiting Room Looks Like This
And It is Not Just Us...
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Projected Workforce Shortage Physicians
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
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Compared with younger populations in the ED,
older adults are more difficult for
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Compared with younger populations in the ED,
older adults consume more resources for
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Compared with younger populations in the ED,
older adults are more time-consuming for
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Geriatric EM What Problems?

• Krumholz, Ann IM 1999 131 648-654
• 51 over age 65 did not receive B-blocker
• Rathore, Am J Med 2003 114 307-315
• Acute reperfusion 54.4 versus 31.2, plt0.0001
• Nerney, Annals EM 2001 38 140-145
• Insufficient pain management reduces satisfaction
• Donaldson, Arch Gerontol Geriatr 2005 41
  311-317
• 68 of ED fallers do not receive guideline care
• Hustey, Annals EM 2002 39 248-253
• Dementia/delirium only identified in 28 ED cases

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Conceptual Framework of Quality of Care

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered
• Institute of Medicine

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Guidelines v. Quality Indicators v. Competencies

• Guidelines Tools to help set individualized
  goals by providers and patients should not be
  considered a maximum or minimum level of care.
• Quality Indicator Measurement tool that
  specifies patient eligibility and care (or
  outcome) that if not met nearly always indicates
  that the patient received inadequate quality
  care.
• Competency - A minimum standard for learners to
  demonstrate their ability to perform a specific
  defined behavior. If not performed nearly always
  indicates inadequate quality care.

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Characteristics of Quality Indicators

• Aim of the Quality Indicator
• Research
• Quality improvement
• Accountability
• Level of Measurement
• Healthcare system
• Health plan
• Emergency room / Hospital
• Medical / Physician group
• Physician
• Data source
• Administrative data
• Medical records
• Patient interview

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Characteristics of Competencies

• Aim of the Competencies
• At resident, residency program and patient care
  levels
• Research
• Quality improvement
• Accountability
• Level of Measurement
• Resident Knowledge
• Resident Skills
• Resident Performance in elder care delivery
• Residency Performance in resident teaching
• Residency Performance in resident
  assessment/evaluation
• Data source
• Didactic testing
• Medical records
• Patient interview
• Resident portfolios
• Resident evaluations

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How is quality of care assessed?

• Donabedian Quality Model

Structure Material Resources Operational
Characteristics Organizational Characteristics
Process Clinical Care Policy and
Procedure Adherence to standards
Outcome Health status of patients Clinical
measures
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How are geriatric competencies assessed?
Structure Material Resources Operational
Characteristics Organizational Characteristics
Process Curricular structure Definition of
performance standards Adherence to standards
Outcome Resident performance Residency program
performance
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Quality Indicators Span the Range of Care
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What is Performance Measurement?

• Health care performance measurement is the
  process of using a tool based on research
  (performance measure) to evaluate a health plan
  or program, hospital, or health care practitioner
• Performance implies that the responsible health
  care providing entity
• can be identified
• held accountable
• has control over the aspect of care being
  evaluated

-Understanding Performance Measurement
www/ahcpr.gov/chtoolbx
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Constructing Process of Care QIs

• Clinical evidence and clinical agreement that the
  process - outcome link is strong enough that not
  providing the care process is bad care
• This is the aim of Competencies the resident NOT
  meeting the competency provides INCOMPETENT care.
• Clearly specified eligible patient (If)
• Clearly specified care process (Then)
• Timing
• Responsible party / venue
• Specified exclusions
• Contraindications
• Refusals
• Inconsistent with level of aggressiveness / goals

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Quality Indicators and Resident Competencies

• Areas are almost interchangeable
• Competencies language avoids IF/THEN and
  substitutes a measurable verb
• IF a Vulnerable Elder is treated at an emergency
  department or admitted to a hospital, THEN there
  should be documentation of communication with a
  continuity physician,...
• Document attempts of notification of the PCP for
  all older adults discharged to the community

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Emergency Medicine Quality Indicators

• Cognitive Assessment (Fred Hustey)
• Medication Selection (Kennon Heard)
• Pain Assessment and Management (Ula Hwang)
• Functional Assessment (Scott Wilber)
• Nursing Home Transfer Communication (Kevin
  Terrell)
• Prevention and Screening (Chris Carpenter)

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Quality and CompetencyThey really do overlap!

• Kennon Heard
• SAEM Geriatric Task Force

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Taskforce

• Created by SAEM/ACEP
• Improve the care delivered to older patients
• Educational projects
• SAEM consensus conference
• Online case simulation
• Quality indicators for geriatric-related
  conditions

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Emergency Medicine Quality Indicators

• Cognitive Assessment (Fred Hustey)
• Medication Selection (Kennon Heard)
• Pain Assessment and Management (Ula Hwang)
• Functional Assessment (Scott Wilber)
• Nursing Home Transfer Communication (Kevin
  Terrell)
• Prevention and Screening (Chris Carpenter)

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Development

• Initial indicators from content experts based on
  literature review
• Circulated among the task force
• Modified
• Presented at SAEM and AGS
• Modified
• Accepted or rejected
• Ultimately published and used (hopefully)

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Format

• ACOVE project format
• IF statement to determine if a patient is
  eligible for the care process
• THEN statement describes the care process
• Because the care process causes
• Satisfied if the medical record indicates that a
  patient is offered the care process

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Example

• IF older adults are discharged from the ED
• THEN they should have a validated prognostic tool
  (TRST or ISAR) applied
• Because high-risk elderly patients can be
  identified.

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Goals

• Target important conditions
• Common
• Contribute to excess morbidity in elderly
• Suggest practices that are evidence based
• Metrics that can be readily obtained

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There is substantial overlap between the Quality
Indicators and the Geriatric Competencies
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Quality- Cognitive function

• IF an older adult presents to an ED
• THEN the ED provider should carry out and
  document a cognitive assessment (such as an
  indication of level of alertness and orientation
  or an indication of abnormal or intact cognitive
  status or document why a cognitive assessment did
  not occur).

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Competency- Cognitive function

• Assess whether an older patient is able to give
  an accurate history, participate in determining
  the plan of care, and understands discharge
  instructions.

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Quality- Cognitive function

• IF an older adult presents to an ED and is found
  to have cognitive impairment
• THEN an ED care provider should document whether
  there has been an acute change in mental status
  from baseline (or document an attempt to do so).

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Competency- Cognitive

• Assess and document current mental status and any
  change from baseline in every older adult with
  special attention to determining if delirium has
  been superimposed on dementia.

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Quality- Pain

• IF an older adult presents to the ED and has
  moderate to severe pain (i.e., a numeric rating
  scale score of 4 or higher out of 10)
• THEN pain treatment should be initiated (or the
  provider should document why treatment was not
  initiated).

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Competency- Pain

• Assess and provide ED management for pain and key
  non pain symptoms based on the patient's goals of
  care

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Quality-Falls

• If an older patient has functional decline
  identified in the ED and the patient is
  considered for discharge,
• Then the patient should be assessed for the
  ability to transfer and ambulate prior to
  discharge
• Because these activities of daily living are
  necessary unless 24 care is available

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Competency- Falls

• Assess for gait instability in all ambulatory
  fallers if present, ensure appropriate
  disposition and follow up including attempt to
  reach primary care provider.

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Quality- Medications

• If a person taking warfarin is prescribed a new
  medication
• Then the ED record should document a review for
  interactions of that medication with warfarin.
• Because warfarin-medication interactions are a
  common source of serious adverse drug events

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Competency- Medications

• Search for interactions and document reasons for
  use when prescribing drugs which  present high
  risk either alone, or in drug-drug or
  drug-disease interactions (e.g. benzodiazapines,
  digoxin, insulin, NSAID's, opioids, and
  warfarin).

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Quality- Medications

• If a benzodiazepine is prescribed to a patient
  older than 65,
• The care provider should document the that the
  benefits outweigh the risks and explain the
  increased risk of falls to the patient and a care
  provider.
• Because benzodiazepines increase the risk of
  falls in older patients

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Competency- Medications

• Explain all newly prescribed drugs to elders and
  care givers at discharge assuring they understand
  how and why the drug should be taken, the
  possible side effects, and how and when the drug
  should be stopped.

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Medication managementHow we performWhy we need
to be better
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• There are approximately 180,000 ED visits related
  to medication use
• Approximately 30 of ADRs are preventable
• Including 42 of serious or life-threatening
• 50 of older ED patients get an Rx

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Medication mismanagement

• Chin 1999
• Prospective observational study, 1 ED
• 1997 Beers criteria
• 32/898 (3.6) received potentially inappropriate
  Rx in the ED
• 23/418 (5.6) discharged with potentially
  inappropriate Rx
• Inappropriate Rx assoc with decreased QOL

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Medication mismanagement

• Caterino 2004
• NHAMCS ED data (Whole US population)
• 1992-2000
• 2003 Beers criteria
• Inappropriate meds in 16.1 million visits
• (13 of all visits gt age 65)

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Medication mismanagement

• Hastings 2007
• Retrospective study of 1 VA ED/UCC
• 2003 Beers, drug-drug/disease interaction,
  quality indicators
• 134/421 (32) had 1 or more inappropriate Rx at
  discharge

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Medication mismanagement

• Hustey 2008
• Retrospective review single ED
• 2003 Beers criteria
• 352 consecutive ED patients
• 13/101 (13) had 1 or more inappropriate Rx at
  discharge

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Performance summary

• Between 5 and 40 of older ED patients receive a
  potentially inappropriate prescription when they
  are discharged from the ED
• Improving prescribing could help reduce the
  180,000 annual ED visits attributed to adverse
  drug reactions

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Other performance

• Cognitive impairment is recognized only 28-38 of
  the time by emergency physicians
• gt1/3 older patients with long bone Fx receive no
  analgesia only 57 receive opioid medication
• 90 of patients transferred from NH to the ED
  lack some critical information

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We can make a difference

• Rapid screening can identify cognitive impairment
• Increased awareness leads to better pain
  management
• Interventions can decrease the risk of recurrent
  falls by 50

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Summary

• The Geriatric Task force has developed quality
  indicators for six domains of geriatric care
• These indicators have been reviewed, revised and
  await publication and adoption
• Several of these indicators overlap with the
  proposed competencies