Foley Elizabeth M, Wolfe Richard E, Burstein Jonathan L, Edlow Jonathan A, Grossman Shamai A
Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
J Emerg Med. 2016 May;50(5):711-4. doi: 10.1016/j.jemermed.2016.02.007. Epub 2016 Mar 12.
The Joint Commission requires health care organizations to monitor and evaluate procedural sedation. However, the utility of mandatory review of procedural sedation in evaluating health care quality is unknown.
To determine whether procedural sedation is a useful marker for evaluating error in the emergency department (ED).
We prospectively collected data for patients presenting to an urban, tertiary care, academic medical center ED between October 2013 and June 2015. We used an automated, electronic tracking system to identify patients who underwent procedural sedation. We randomly assigned cases to physician reviewers. Reviewers used a structured tool to determine the presence of error and adverse events. If a reviewer felt that the case had an error or adverse event, it was referred to a quality assurance (QA) committee, which made a final determination as to whether or not an error or adverse event occurred.
There were 166 cases of procedural sedation reviewed. Two errors were identified, for an error rate of 1.2% (95% confidence interval [CI] 0.003-0.043). Both errors occurred during the use of propofol to facilitate upper gastrointestinal endoscopy. Neither error resulted in an adverse event. One adverse event was identified that was unrelated to physician error (0.6%; 95% CI 0.001-0.033).
Routine review of procedural sedation performed in the ED offers little advantage over existing QA markers. Directed review of high-risk cases, such as those involving endoscopy or other longer-duration procedures, may be more useful. Future studies focusing quality review on projected high-risk sedation cases may establish more valuable markers for QA review.
联合委员会要求医疗保健机构对程序性镇静进行监测和评估。然而，对程序性镇静进行强制审查在评估医疗质量方面的效用尚不清楚。
确定程序性镇静是否是评估急诊科（ED）差错的有用指标。
我们前瞻性收集了2013年10月至2015年6月期间到一家城市三级学术医疗中心急诊科就诊患者的数据。我们使用自动化电子追踪系统识别接受程序性镇静的患者。我们将病例随机分配给医师评审员。评审员使用结构化工具确定是否存在差错和不良事件。如果评审员认为该病例存在差错或不良事件，将提交给质量保证（QA）委员会，由其最终确定是否发生了差错或不良事件。
共审查了166例程序性镇静病例。识别出2例差错，差错率为1.2%（95%置信区间[CI] 0.003 - 0.043）。两例差错均发生在使用丙泊酚辅助上消化道内镜检查过程中。两例差错均未导致不良事件。识别出1例与医师差错无关的不良事件（0.6%；95% CI 0.001 - 0.033）。
对急诊科进行的程序性镇静进行常规审查相比现有的质量保证指标优势不大。对高风险病例，如涉及内镜检查或其他较长时间操作的病例进行定向审查可能更有用。未来将质量审查聚焦于预计高风险镇静病例的研究可能会为质量保证审查建立更有价值的指标。
