RISK MANAGEMENT AND PATIENT SATISFACTION
| RISK, ERRORS, AND PATIENT SATISFACTION —Kevin M. Klauer, DO, Clinical Assistant Professor, Department
of Internal Medicine and Osteopathic Medicine, Michigan State College of Osteopathic Medicine, Director,
Quality and Clinical Education, Emergency Physicians, Ltd, and Director, Center for Emergency Medicine Education,
Canton, OH
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| Introduction: different providers need to be on same team; article from 2005 Journal of Patient Safety states most
errors identified before they affect patient; identified most often by nurses; emergency department (ED)—high-risk
environment; unpredictable; multiple parallel processes ongoing; multiple interruptions cause problems; patients
there for “snapshot in time” (something else may be developing, and further testing may be needed); no control
over outside departments (eg, laboratory, radiology); overcrowding and long waits; handwritten charts and orders
give opportunity for misinterpretation; patients expect more and better service for large ED expense
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| Locations of risk: prehospital providers—eg, emergency medical services (EMS) requests that ED physician declare
patient code 1 (nonemergency); bring patient into ED unless compelling reason to declare code 1; triage
process—must be rapid and accurate; question of where patient triaged; waiting room used only for family members
and visitors and when every possible treatment space in ED filled; invoked when ED physician not immediately
available to see patient; wait time—longer patient waits, more risk of not identifying serious medical
condition in waiting room; nursing evaluation— process independent of physician evaluation; nurse’s notes must
be read for each patient; address and document any discrepancies; ED course—adequate sign-out at shift change;
perform problem-focused brief examination for each patient; make own assessment of each patient, so no error in
assessment carried forward; medication errors—include drug-drug interactions and allergies; in United States, people
more likely to die in hospital from medical error than from motor vehicle crash; admitting orders—means accepting
responsibility for in-patient care until other physician arrives; discharge—adequate discharge instructions
at appropriate educational level and language; should be timed and specific; transfer of patient—discuss risk-benefit
assessment with patient
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| Red flags: time of care— physician not at peak at end of shift or when starting new shift early in morning; return visits
for same problem—opportunity to determine whether anything missed; language barriers—provide medical interpretive
services; try not to use family members; if patient declines, document; house staff—well-defined
protocols and guidelines about what house staff able to do; attending ED physician should be aware of consulting
house staff physician’s written orders; part-time physicians least likely to follow policies and procedures
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| High-risk phrases: nonspecific ST changes—does not mean normal; 23% of these patients have underlying coronary
artery disease; stable angina—should not be written as diagnosis on chart; if patient in ED, something has
changed; reproducible chest pain present in 14% of patients with acute myocardial infarction (MI); document but
do not use as basis of decision as to whether patient has acute coronary syndrome; transient ischemic attacks—must
admit patient; Bell’s palsy—distinguish from central cranial nerve VII event; also distinguish between new-onset
Bell’s palsy and meningoencephalitis secondary to Lyme disease (need lumbar puncture); children—in neonates
particularly, difficult to determine whether problem present based on appearance; vomiting subtle sign of increased
intracranial pressure (ICP); due to open fontanelles, infants with head injury or increased ICP have no signs of neurologic
deficit until they decompensate or herniate; change in feeding patterns may be only sign of meningitis; obstetric
issues—must rule out ectopic pregnancy; bleeding during pregnancy common in ED; slight elevation in
blood pressure (BP) possibly only indication of early pre-eclampsia; kidney stones—make sure not abdominal aortic
aneurysm; hypertensive emergency—not necessary to emergently treat asymptomatic patient with diastolic BP
≥110 mm Hg; chronically hypertensive patients have reset autoregulatory set point; rapid reduction of BP in these
patients has negative effect, causing end organ hypoperfusion (eg, MI, stroke, renal failure); however, necessary to
address elevated BP; may put patient on long-acting agent and refer for follow-up; pleurisy—diagnosis of exclusion;
in medical record, indicates pleural reaction from some source; must document negative study for pulmonary
embolism (PE), unless definitive diagnosis made in past; anxiety—seen in PE, acute MI, and acute coronary syndrome;
important sign to look for; foreign body in wound—do not tell patient all foreign body removed (always
chance that some foreign body still present); gastroenteritis—do not write as diagnosis; write symptomatically
based diagnosis or impression instead, eg, nausea, vomiting, diarrhea; ED procedures—need to “sell” to patient; if
subarachnoid hemorrhage suspected, must sell patient on lumbar puncture; if subdural or epidural hematoma supected,
obtain computed tomography (CT) immediately
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| Strategies for improving patient satisfaction: discharge instructions—never tell patient no need to return to
ED; communication with patient—important; patient much less likely to sue when adverse outcome occurs if patient
thinks physician did his or her best; attitude towards patient—“horizontal” patient really sick and wants competent
physician; “vertical” patient requires less medical care but expects more from physician; physician burnout— take
time off; do not place value on whether patient’s presence in ED necessary; predictors of satisfaction—need to convey
comfort and caring ability; demonstrate competence; documented that patients would rather have ED physician
refer them to specialist (as opposed to their family doctor); encourage patient to ask questions; effective pain management
important; inform patient about wait times to set up reasonable expectation up front; take time to listen; be
courteous; dialogue (not monologue); give patient undivided attention; underpromise and overdeliver; help patient
with limited English-speaking skills and those who are hearing-impaired; discuss patient’s expectations; be “owner”
of department and have pride in it; minimize delays; individual strategies—personalize meeting with patient; 3-
visit rule (every patient should get 3 visits from physician while in ED); consensus management—family members
should agree with plan; if family does not agree with plan, provide option; humility; let patient speak for at least 1
min; explain your impression (not final diagnosis) to patient; make sure patient’s family comfortable with plan;
make sure follow-up interval well defined and patients understand what is expected of them; use good discharge instructions
(preprinted or computerized)
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| WHAT IS THE BEST EVIDENCE FOR THE MANAGEMENT OF ACUTE BACK PAIN ?—Ann P. Nguyen,
MD, Assistant Professor, Department of Emergency Medicine, New York University School of Medicine and Bellevue
Hospital, New York, NY
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| Nonsteroidal anti-inflammatory drugs (NSAIDs): most commonly prescribed drugs for low back pain; plethora
of literature (3 systematic meta-analyses and 51 randomized controlled trials [RCTs]) available; 3 studies found
piroxicam, phenylbutazone, and indomethacin more effective than placebo in relieving low back pain; no study on
efficacy of ibuprofen for low back pain; study (Cochrane systematic review)—comprised of 6 RCTs, with sample
size of 727 participants; found that with NSAIDs, statistically significant improved relative risk for decrease in
pain, and that NSAIDs did not produce greater adverse effects than placebo; which NSAID superior—24 studies
available (5 had appropriate scientific methodology, and, of these, 2 looked at drugs available in United States);
looked at diclofenac vs piroxicam and diflunisal vs indomethacin; no difference found; equally efficacious
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| Opioids: 15 RCTs and 1 systematic meta-analysis; 3 studies of opioids available in United States, and, in all 3, opioids
better than placebo in relieving back pain and improving function; meta-analysis—pooled 4 RCTs, for sample
size of 486 patients; found adequate dosage of opioid used (73 mg daily of morphine equivalent or ≈6 mg of morphine
every 2 hr); found no difference in pain relief achieved with opioid vs placebo; which opioid superior—6
studies found no difference between different opioids; study in 1997 found oxycodone better than acetaminophen
with codeine (Tylenol No. 3)
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| Other analgesics: no studies on acetaminophen vs placebo; 3 drug company–sponsored trials found tramadol better
than placebo
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| Muscle relaxants: 30 RCTs and 2 meta-analyses; 2 classes include benzodiazepines and nonbenzodiazepines;
benzodiazepines—4 studies (2 for drugs available in Europe); concluded that sitrazepam (not available in United
States) superior to placebo in relieving low back pain; 2 studies of diazepam in United States (one found diazepam
better than placebo; other did not); meta-analysis—pooled 2 studies, with sample size of 222 participants; found
that pain improved with benzodiazepine; nonbenzodiazepines—5 studies; 6 of 7 comparisons found that nonbenzodiazepine
muscle relaxant (eg, cyclobenzaprine) better than placebo, but found greater risk for adverse effects;
main adverse effects nausea, dizziness, and somnolence; studies found one muscle relaxant not better than another,
except one study which found carisoprodol better (but compared it to low dose of diazepam)
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| Steroids: paucity of data (no RCTs or meta-analyses); study (2006)—only one that used intramuscular (IM) steroids
for low back pain in ED; only handful of studies on low back pain in ED; 86 ED patients with acute nonspecific
low back pain randomized to IM methylprednisolone or IM saline (independent of other treatment received in ED);
found no difference in pain score at short-term follow-up (1 wk and 1 mo after visit); not “clean” study, so cannot
conclude that steroids do not have effect on low back pain; better research needed
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| Trigger point injections: only 1 study of 63 outpatients; found trigger point therapy not any better than sham injection
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| Comparison of modalities: 16 articles looking at various classes and comparing them found no difference; one
study looked at ibuprofen plus muscle relaxant, compared to ibuprofen alone or aspirin and found no difference; no
study compared NSAID to muscle relaxant; adding muscle relaxant to NSAID does not give additional benefit; no
head-to-head comparison between acetaminophen and muscle relaxant, but studies show that giving both leads to
improvement, compared to acetaminophen alone; studies found no difference between opioids and NSAIDs; 2001
study in ED setting found no difference between meperedine IM and ketorolac IM; also found no difference between
nonopioid analgesics (eg, tramadol) and acetaminophen plus caffeine; summary—literature shows that
NSAIDs, opioids, tramadol, and muscle relaxants all superior to placebo in relieving low back pain; no evidence
that one medication superior to another in same class; no evidence that one class of medications superior to another
class; no conclusion possible about parenteral steroids and trigger point injections because data insufficient
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| Physical interventions: exercise— large number of studies about whether back exercises effective for low back
pain (50 RCTs and 3 meta-analyses); problem with studies that exercises varied from one study to another (difficult
to compare); only 5 studies where conclusions could be reasonably drawn; found that exercise not helpful in acute
low back pain; only 2 studies favored exercise (group and home stretching better than usual care); one meta-analysis
of 10 studies (1192 participants) found that for acute low back pain, no difference in pain severity between exercise
group and nonexercise group; however, modest improvement noted in chronic low back pain; bed rest—11
studies and 2 meta-analyses; 3 studies looked at bed rest vs normal activities; neither study found bed rest good
(bed rest defined as >16 hr/day for 4 days); 2 studies looked at bed rest vs exercise and found no difference; 2007
meta-analysis (11 studies; 1963 participants) found that resting in bed resulted in increased pain and decreased
functional ability; concluded that bed rest actually detrimental to recovery in low back pain; heat and cold—
studies randomized and controlled, but not blinded; 5 studies found that heat better than other nonthermal intervention;
4 of 5 studies sponsored by manufacturer of thermal product; 1 study not manufacturer-sponsored found that
electric blanket better than regular wool blanket; no good studies comparing heat with cold, but 2 observational cohort
studies found no difference; no studies comparing cold with placebo; summary—back exercises not helpful in
relieving acute low back pain but marginally helpful in chronic low back pain; bed rest detrimental to recovery;
good evidence that heat better than other interventions, but no data about cold compared to other interventions
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| Conclusions: good evidence for performing imaging when red flags present and for using NSAIDs, opioids, tramadol,
muscle relaxants, and heat; enough evidence to conclusively state that imaging not necessary when red flags
absent and recommend against special back exercises or bed rest; not enough evidence to form conclusion about efficacy
of acetaminophen, steroids, trigger point injections, and cold therapy; caveats— in natural course of low
back pain, pain levels fluctuate; final pain scores not necessarily result of treatment effect; even though result statistically
significant in study, not necessarily clinically significant; consider needs of individual patient when
choosing therapy; marginal improvement obtained from specific therapy may not outweigh risks for particular patient
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Suggested Reading
Arendt KW et al: The left-without-being-seen patients: what would keep them from leaving? Ann Emerg Med
42:317, 2003; Brown AD et al: Developing an efficient model to select emergency department patient satisfaction
improvement strategies. Ann Emerg Med 46:3, 2005; Chou R et al: Medications for acute and chronic low back
pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
Ann Intern Med 147:505, 2007; Chrubasik S et al: A randomized double-blind pilot study comparing Doloteffin
and Vioxx in the treatment of low back pain. Rheumatology (Oxford) 42:141, 2003; Damush TM et al:
Randomized trial of a self-management program for primary care patients with acute low back pain: short-term effects.
Arthritis Rheum 49:179, 2003; George SZ et al: Distinguishing patient satisfaction with treatment delivery
from treatment effect: a preliminary investigation of patient satisfaction with symptoms after physical therapy treatment
of low back pain. Arch Phys Med Rehabil 86:1338, 2005; Jellema P et al: Should treatment of (sub)acute low
back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice. BMJ
331:84, 2005; Epub 2005 Jun 20. Kinkade S: Evaluation and treatment of acute low back pain. Am Fam Physician
75:1181, 2007; Koes B et al: Acute low back pain. Am Fam Physician 74:803, 2006; Nadler SF et al: Continuous
low-level heatwrap therapy for treating acute nonspecific low back pain. Arch Phys Med Rehabil 84:329, 2003; Nadler
SF et al: Overnight use of continuous low-level heatwrap therapy for relief of low back pain. Arch Phys Med
Rehabil 84:335, 2003; Patel PB et al: Team assignment system: expediting emergency department care. Ann Emerg
Med 46:499, 2005; Sun BC et al: A patient education intervention does not improve satisfaction with emergency
care. Ann Emerg Med 44:378, 2004; Waseem M et al: Parental perception of waiting time and its influence on parental
satisfaction in an urban pediatric emergency department: are parents accurate in determining waiting time?
South Med J 96:880, 2003
Educational Objectives
The goal of this program is to maximize patient satisfaction in the emergency department (ED) and to improve the management
of acute back pain. After hearing and assimilating this program, the clinician will be better able to:
 | 1. Locate the foci of risk in the ED.
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| 2. Practice strategies for improving patient satisfaction in the ED.
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| 3. Utilize the main classes of drugs to treat acute back pain.
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| 4. Compare the physical intervention therapies for treatment of acute back pain.
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| 5. Recognize which modalities have no effect on acute back pain.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Klauer was recorded at 18th Annual High-Risk Emergency Medicine, held April 16-17, 2007, in Las Vegas, NV, and
sponsored by the Center for Emergency Medicine Education. Dr. Nguyen was recorded at Contemporary Concepts in
Clinical Emergency Medicine, held June 6-8, 2007, in New York, NY, and sponsored by the New York University
School of Medicine, Department of Emergency Medicine. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
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