Acceptable Types of IMP Activities

Acceptable Types of Patient Care Practice Improvement Activities

• Time-related (Throughput Time, ED length of stay, and other process time measures)

  • Door-to-doctor times (door-to-provider, door-to-evaluation)  [includes OP-20]
  • ED length of stay for discharged psychiatric and transferred patients [includes OP-18, CEDR]
  • Throughput time improvement [includes ED1-a, ED 1-b, ED-1c]
  • Time to disposition decision (admit, discharge, etc.) [includes ED-2a, ED-2b, ED-2c]

• Infectious Disease-related

  • Sepsis guidelines, including use of DART toolkit 
  • Septic shock: repeat lactate level measurement      
  • Antibiotic stewardship (includes selection, administration time, local resistance pattern identification, etc.)     
  • Septic shock: lactate clearance rate of greater than or equal to 10%
  • Appropriate testing for children with pharyngitis
  • Appropriate treatment for children with upper respiratory infection  
  • Antibiotic treatment for adults with acute bronchitis: avoidance of inappropriate use           
  • Antibiotics within a specific time (CAP and all other infections)       
  • Blood culture before antibiotics         
  • Immunization status - Pneumococcal, Influenza, Pediatric  
  • COVID-19 Patient Management         

• Stroke-related

  • Head CT within 45 minutes of arrival of stroke patient [OP-23]
  • Thrombolytic consideration or use in eligible patients [STK-4, PQRS #187, CEDR]
  • Door-to-puncture time for endovascular stroke treatment [PQRS #413]
  • Stroke activations and care pathways

• Cardiac-related

  • Door-to-balloon times for acute myocardial infarction (AMI)
  • Transfer time to another facility for AMI intervention [OP-3]
  • Aspirin at arrival for AMI or chest pain [includes OP-4b, OP-4c]
  • Assessment for chest pain (including risk stratification, non-invasive testing and stress testing, diagnostic protocols for early rule-out, TIMI risk assessment) [PQRS #54]
  • Median time to electrocardiogram (ECG) for AMI or chest pain
  • Improving care for patients with chest pain
  • Cardiac resuscitation and post-resuscitation care
  • Screening for high blood pressure and follow-up documented

• Appropriate Imaging

  • Appropriate CT use in minor blunt head trauma – patients aged 18+ [including PQRS #415, CEDR]  
  • Appropriate CT use in minor blunt head trauma – patients 2-17 years [PQRS #416, CEDR]
  • Appropriate CT for evaluation of suspected pulmonary embolus
  • Appropriate CT use for abdominal pain in adults
  • Appropriate imaging for renal and ureteral colic
  • Appropriate imaging for trauma patients (includes Nexus criteria and Ottawa rules)
  • Use of imaging for low back pain [PQRS #312]
  • Use of ultrasound for diagnosis for abdominal pain, pediatric
  • Ultrasound determination of pregnancy location for pregnant patients with abdominal pain [PQRS #254]
  • Appropriate use of neuroimaging for patients with primary headache, a normal neurological examination, and no trauma
  • Avoid head CT for patients with uncomplicated syncope

• Communication – Patient Care

  • Patient call back system
  • Improving patient understanding of discharge instructions
  • Improvements in response to Patient Experience of Care Survey results
  • Safe sign-out between Emergency Physicians
  • Transfer of care to other care provider (consultant, admitting physician, etc.)
  • Reduction of Healthcare Disparities/Implicit Bias

• Pain Management and Sedation

  • Time to pain management for all pain, including long-bone fractures [OP-21]
  • Reassessment of pain after administration of analgesia
  • Procedural sedation safety (includes appropriate medication selection, checklists, etc.)
    

• Patient Safety, Error Reduction, and Complication Avoidance

  • Prevention of central venous catheter-related blood stream infections [PQRS #76]
  • Ultrasound use for central line insertion
  • Appropriate Foley catheter use in the ED [CEDR]
  • Medication error reduction, including ACEP module, “Preventing Medication Errors”
  • Appropriate use of restraints and seclusion
  • Management of the intoxicated or alcohol withdrawal patient           
  • Reassessment of vital signs at discharge
  • Planning safer and more effective aftercare, including ACEP Module
  • Reducing discrepancies between emergency physician and radiologist X-ray interpretation
  • Notification of Regional Poison Control Center for poisoned patient
  • Safe ventilator management
  • Adherence to indications for blood transfusions

   

• Additional Common Measures and Activities

  • Left without being seen
  • Unscheduled return visits to ED (Including 72 hour returns)
  • OPPE/FPPE
  • Improvement of difficult airway management
    
  • Asthma pathways
  • EMA Clinical Performance Improvement Program
  • Pregnancy test for female abdominal pain patients
  • Appropriate use of urine culture

• Substance Use Disorder and Mental Health

  • Initiate medication for opioid use disorder (MOUD) in the ED (e.g., buprenorphine)  
  • Assure outpatient follow-up for MOUD treatment
  • Evaluation for risk of opioid use disorder
  • Use of statewide electronic pain medication prescribing system
  • Opioid overdose management (e.g., treatment, referral, harm reduction)
  • Adherence to opioid prescribing recommendations for chronic pain (includes CDC recommendations) 
  • Implement an alcohol withdrawal management guideline
  • Screening for substance use disorder (e.g., alcohol, cannabinoid, opioid, stimulant, tobacco)
  • Referral to outpatient community mental health
  • Depression screening
  • Integration of behavioral health into ED         

• Palliative Care

  • Use of Palliative Care consultation    
  • Discuss end-of-life care goals           
  • Integration of hospice into emergency care  
  • Adherence to POLST registry according to state standards

• Advancing Health Equity

  • Increasing the collection and data integrity of race, ethnicity, language preference and health related social needs
  • Use data to identify a health equity focus (e.g., throughput, LWBS, patient experience, STEMI and stroke metrics, pain management) Example Health Equity
  • Access to linguistically and culturally appropriate care
  • Secure pregnancy-related care for Black and/or American Indian/Alaskan Native women
  • Consultation to case manager/social work to improve health insurance or prescription access  
  • Consultation to mental health and substance use disorder specialists for at-risk populations (e.g., low income, inner city, rural, racial and ethnic minorities, LGBTQ+, etc.)
  • Auxiliary aids for patients with communication disabilities (e.g., deaf, blind, hearing or vision loss)