UMEM Educational Pearls - Quality Assurance/Quality Improvement

Takeaways: Physicians who have symptoms of burnout as measured by standard burnout scales are more likely to be involved in patient safety incidents, more likely to be cited for poor professionalism, and more likely to have lower patient satisfaction scores. They are also more likely to leave their jobs, experience career regret, and experience job dissatisfaction/ The risk of burnout is highest among emergency physicians and intensivists. 

In this systematic review and meta analysis, the authors reviewed 170 qualitative and quantitative studies including 239,246 physicans to determine the impact of physician burnout on a variety of issues including, quality of care delivered, perception of professionalism, patient satisfaction, and career engagement.

As compared to physicians who did not report symptoms of burnout, burned-out physicians were about four times more likely to be unhappy in their jobs and three times more likely to regret their career decision and to express an intention to leave their jobs.Physician burnout doubled the likelihood of involvement in a patient safety incident and made it three times more likely that the physician would be cited for unprofessional behavior. Burned out physicians were also three times more likely to have low patient satisfaction scores.

Burned-out physicians in their 20's and 30's were particularly at risk for involvement in patient safety incidents and burned-out trainees were more often cited for poor professionalism than older physicians, especially those in their 50's and beyond.

The bottom line: Physican burnout is a serious and growing problem. It has numerous potentially serious consequences for both physicians and patients. Physicians working in high-pressure specialties like emergency medicine and critical care have the highest risk for burnout. 

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Takeaways

The authors of this study retrospectively compared the 10-day mortality rates of patients who were triaged to levels 3-5 on the Scandinavian Rapid Emergency Triage and Treatment System (RETTS) during times of ED crowding (as measured by length of stay and percentage bed occupancy) with those who came to the ED at other times.

 

Patients were divided into four quartiles, corresponding with 2-hour length of stay blocks with quartile one having a length of stay of 2 or fewer hours and quartile four having a length of greater than 8 hours

 

Results: 705,076 patients were seen in one of two EDs from 2009 to 2016. The 10-day mortality rate was 0.09% (n = 623). The authors found an increased 10-day mortality for patients in quartile four as compared to those in quartile one “(adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94)”  This was also true for times when the ED occupancy ratio was greater than one (more than one patient in the ED per available bed). “Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively”

 

Older patients and those with co-morbidities were at greatest risk but lower-acuity patients in all age and morbidity classes had an increased risk of death within 10 days if they came to the ED when it was crowded.

 

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Does IV contrast help to make the diagnosis in ED abdominal pain patients undergoing CT scan? The authors of this study tried to answer that question. This study was a retrospective diagnostic accuracy study looking at contrast enhanced vs. non-enhanced images in 201 consecutive ED patients. The study demographics were:

“There were 201 included patients (female, 108; male, 93) with a mean age of 50.1 (SD, 20.9) years and mean BMI of 25.5 (SD, 5.4).”

 

The study found: “Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED.”

 

This study is limited by the small size, the overwhelming female to male inclusion, the reliance on radiology reading as the gold standard of pathology, and the retrospective nature. It does, however, show that there is a need for further study and at this time giving IV contrast has limited down side and potentially improves diagnostic accuracy of abdominal CT scans.

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