CONFERENCE PRESENTATIONS

Keynote Address: Closing the Research-to-practice Gap in Emergency MedicineCarolyn M. Clancy, MD

AbstractEmergency medicine in the United States is facing tremendous challenges due to recent public health emer-gencies, continuing threats of bioterrorism, and an increasing and unprecedented demand for emergencydepartment services. These challenges include overcrowding; long waiting times; ‘‘boarding’’ of patients;ambulance diversion; a need for better, more reliable tools for triaging patients; and medical errors andother patient safety concerns. These challenges and concerns were brought to the forefront several yearsago by the Institute of Medicine in several landmark reports that call for closing the research-to-practicegap in emergency medicine. The Agency for Healthcare Research and Quality is funding a number of pro-jects that address many of the concerns raised in the reports, including the use of an advanced access ap-pointment scheduling system to improve access to care; the use of an electronic medical record system toreduce waiting times and errors and improve patient and provider satisfaction; and the refinement of theEmergency Severity Index, a five-level triage scale to get patients to the right resources at the right time.The agency’s Healthcare Cost and Utilization Project is gathering data that will allow researchers to exam-ine a broad range of issues affecting the use, quality, and cost of emergency services. Although progresshas been made over the past few years in closing the research-to-practice gap in emergency medicine,many challenges remain. The Agency for Healthcare Research and Quality has supported and will continueto support a broad portfolio of research to address the many challenges confronting emergency medicine,including ways to improve emergency care through the application of research findings.

ACADEMIC EMERGENCY MEDICINE 2007; 14:932–935 ª 2007 by the Society for Academic EmergencyMedicine

Keywords: emergency care, triage, crowding, evidence-based medicine, medical errors

The past several years have presented tremendouschallenges to the field of emergency medicine.Not only have U.S. emergency departments (EDs)

been confronted with numerous public health emergen-cies (e.g., the devastating floods in New Orleans andother areas of the Mississippi delta) and escalatingthreats of bioterrorism, but they also have faced unprec-edented strains on their capacity and resources due toincreasing demands for ED services.

Three landmark studies published by the Institute ofMedicine (IOM) in June 2006 detailed the daunting condi-

From the Agency for Healthcare Research and Quality (CMC),

Washington, DC.

Received June 25, 2007; accepted June 25, 2007.

Presented at the 2007 Academic Emergency Medicine Consensus

Conference, ‘‘Knowledge Translation in Emergency Medicine:

Establishing a Research Agenda and Guide Map for Evidence

Uptake,’’ Chicago, IL, May 15, 2007.

The views expressed herein are those of the author and do not

necessarily represent the views of the Agency for Healthcare Re-

search and Quality or the U.S. Department of Health and Human

Services.

Contact for correspondence and reprints: Carolyn M. Clancy,

MD; e-mail: carolyn.clancy@ahrq.hhs.gov.

ISSN 1069-6563

PII ISSN 1069-6563583932

tions facing EDs and the impact on patients, clinicians,and the larger health care system. Collectively referredto as the Future of Emergency Medicine reports, theyprovide a series of recommendations to address and im-prove the safety and quality of hospital-based emergencycare, emergency medical services, and emergency carefor children.1–3 Key recommendations include adoptingrobust information and communications systems, endingthe practices of boarding patients in the ED and ambu-lance diversion, and endorsing the role of the federalgovernment in setting a coordinated emergency andtrauma care research agenda.

The U.S. Agency for Healthcare Research and Quality(AHRQ) and other government agencies have been work-ing aggressively to address and close the research-to-practice gap identified in the IOM reports and by theemergency medicine community. This article describesthe agency’s new and ongoing work in this arena and pro-poses a framework for future research and implementa-tion activities.

To provide a context for assessing the scope of theresearch-to-practice gap in emergency medicine, it isuseful to review some of the key recommendations fromthe IOM reports. Those recommendations can thenbe measured against the research and dissemination

ª 2007 by the Society for Academic Emergency Medicine

doi: 10.1197/j.aem.2007.06.028

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activities that AHRQ has undertaken in the year since thereports were released. The agency’s specific areas ofemphasis include funding research on the causes andconsequences of ED overcrowding, supporting work toimplement health information technology (IT) that re-duces ED waiting time and improves emergency careservices, evaluating and refining indexes used to triageemergency services, and developing strong, linked data-bases that include use of ED services.

REDUCING HOSPITAL ED CROWDING

Today, many EDs and trauma centers are overcrowded,resulting in a strain on overall hospital capacity that hasbeen steadily building for more than a decade, accordingto the IOM’s Hospital-Based Emergency Care: At theBreaking Point.1 According to the report, ED visits grewby 26% between 1993 and 2003, the number of EDs de-clined by 425, and the number of hospital beds droppedby 198,000 during that same period. ED crowding is a hos-pital-wide problem, because patients who cannot get ad-mitted to inpatient beds are held in the ED. This practice,known as ‘‘boarding,’’ often results in patients being heldin the ED for up to 48 hours or more, and ambulancesbeing diverted from overcrowded EDs 501,000 times, oran average of once every minute between 1993 and 2003.

To address the problems of ED boarding and diversion,the IOM recommends that hospitals improve efficiencyand patient flow anduseoperational managementmethodsand ITs. One research study funded by AHRQ and nearingcompletion will help determine both the causes and conse-quences of ED overcrowding and how ED utilization couldbe reduced. Led by Brent Asplin, MD, MPH, at HealthPart-ners Research Foundation, Minneapolis, this study exam-ines the variables that contribute to ED crowding: input,throughput, and output.4 The project is based on a nationalsurvey of ambulatory clinics that estimated the availabilityand timing of outpatient appointments for medical andsurgical conditions that required urgent ED follow-upcare according to patients’ insurance status (i.e., patientswho have private insurance, Medicaid coverage, or noinsurance).

The ED access project, which is scheduled for comple-tion in 2007, will also determine if the ‘‘advanced access’’appointment system is associated with a reduction in EDutilization rates. Advanced access is an appointmentscheduling system that allows ambulatory clinics to offersame-day time slots to patients or appointments within24 hours. This system has been shown to improve accessto care in ambulatory care settings.5

A second AHRQ study, led by Marion Sills, MD, MPH, atthe University of Colorado, Denver, will examine ED over-crowding and its impact on pediatric emergency care.6

According to data from the National Center for Health Sta-tistics, children had 754,000 ED visits for asthma in 2004, arate of 103 per 10,000 children.7 Dr. Sills’ project will modelthe association between ED overcrowding and severalprocess and outcome measures of quality for acute asthmacare for patients aged 2–18 years.

The results of both studies will add to the growing ev-idence base that describes and analyzes the impact of EDovercrowding and will test the strength of ambulatorycare patient flow models and quality measures.

IMPLEMENTING HEALTH IT

Supporting research that seeks to implement innovativeapplications of health IT is another mechanism AHRQis using to improve the evidence base for efficient and ef-fective ED services. Two such health IT implementationprojects, described in the following text, were scheduledto be completed in September 2007.

The goal of the first project is to better identify the keytechnological needs for accessing and sharing health in-formation between providers in Kentucky and Indiana.The researchers will implement an electronic medicalrecord system in the EDs of two small community hospi-tals, one medium-sized community hospital, and threeprimary care physician practices.8 Led by Jewish Hospi-tal Health Care (Louisville, KY) chief information officerDavid Pecoraro, the project also involves training usersof the system and an evaluation of the reduction inmedical errors and waiting times, as well as patient andphysician satisfaction.

A second health IT implementation study funded byAHRQ will use a time-insensitive predictive instrument(TIPI) built into the computerized electrocardiograph inEDs and emergency medical service settings.9 The TIPIcan aid diagnostic and treatment decisions for patientswith acute cardiac ischemia and unstable angina pecto-ris. The project, headed by Harry Selker, MD, MPH, atNew England Medical Center, Boston, will also evaluatethe impact of TIPI on reducing errors and avoidabledelays in emergency care.

The results of these projects will better determine therole of health IT in improving ED patient flow and reduc-ing errors. At the same time, evidence suggests that hos-pitals are beginning to appreciate the role of process andstaff changes in the ED in order to gain the maximumbenefit from patient flow technologies.

A recent survey by the American College of Emer-gency Physicians found that more than three fourths(76%) of respondents said patient flow technology couldrelieve ED overcrowding, provided that it was accompa-nied by other process and staff changes.10 The survey,which included more than 200 hospital chief executive of-ficers, administrators, and managers, was conducted inJanuary 2007. Only 17% of respondents indicated thattechnology on its own could address ED patient flowand overcrowding.

Despite the persistence of ED patient flow challenges, amajority of respondents said that their institution wouldbe able to improve its performance, according to thesurvey. More than half (53%) of the respondents to theAmerican College of Emergency Physicians survey saidpatient flow challenges had become more serious in thepast year, while 35% said they have remained the same.However, 71% of respondents predicted that their hospi-tal would improve its ability to handle these challenges.

EXPANDING THE EMERGENCY SEVERITY INDEX

As part of the IOM’s recommendations on the need for acoordinated, regionalized emergency care system, theFuture of Emergency Medicine reports1–3 called on thefederal government to support protocols for the treat-ment, triage, and transport of out-of-hospital patients.

934 Clancy � EVIDENCE UPTAKE IN EMERGENCY MEDICINE

A 2001 survey involving 27% of U.S. EDs found themajority (68%) used a three-level triage system, which in-cludes emergent, urgent, and nonurgent acuity levels.11

More recent data reflect a growing trend toward theuse of four- and five-level triage systems.

Nonetheless, the historic lack of a standardized triagesystem presents barriers to the accurate exchange of ag-gregate public health information. To address this con-cern, emergency physicians Richard Wuerz and DavidEitel developed the Emergency Severity Index (ESI), afive-level triage scale that seeks to not only determinewhich patients should be seen first but also to getpatients to the right resources at the right time.12 Thealgorithm produces rapid, reproducible, and clinicallyrelevant stratification of ED patients from level 1, themost urgent, to level 5, the least urgent.

Further work on the initial development of the ESI wasundertaken with AHRQ funding, resulting in the 2005publication of an implementation handbook, EmergencySeverity Index, Version 4.13 The most recent version ofthe ESI expands the level 1 criteria to include patientswho require immediate life-saving interventions, suchas those in severe respiratory distress requiring intuba-tion. ESI version 4 also refines the pediatric fever criteriaso that patients younger than 3 years would be upgradedto acuity level 2 if any vital sign criteria are exceeded.

Three free copies of both the implementation handbookand a DVD that provides highlights of ESI version 4 areavailable to organizations through AHRQ (ahrqpubs@ahrq.gov).

DEVELOPING STRONG, LINKED DATABASES

As the IOM reports1–3 underscore, providing timely,high-quality emergency care is a systems issue, not aninstitutional issue, and therefore requires a systemssolution to address current shortcomings. High-quality,efficient systems depend on strong, linked databases toidentify ED trends ranging from utilization, waitingtimes, and admissions to payment, patient demograph-ics, and insurance status.

AHRQ’s Healthcare Cost and Utilization Project, orHCUP, is a family of databases from 37 state data organi-zations, hospital associations, private data organizations,and the federal government.14 HCUP includes the largestcollection of longitudinal hospital care data in the UnitedStates, with all-payer, encounter-level data beginning in1988. It is a powerful information resource of patient-level data on care provided in the inpatient, outpatient,and, most recently, ED settings.

In addition to providing data on inpatient and outpa-tient encounters, 23 HCUP partners also report ED databeginning in 2005. These expanded data will allow re-searchers to examine a broad range of policy, access,and outcomes questions, such as the following: 1) Whatpercent of hospitalizations begin in the ED, by age, gen-der, and payer? 2) What percent of hospitalizations beginin the ED, by condition? 3) What is the trend in admis-sions from the ED?

AHRQ is exploring ways to maximize the utility of itsHCUP and ED data. A feasibility study is in progress toexamine the creation of a national ED database. State-specific queries of ED data are expected to be available

soon on HCUPnet, a free, online query system. We atAHRQ are excited about the potential benefits that thisexpanded availability of ED data will bring to the emer-gency medicine community.

CONCLUSIONS

In the year since the publication of the Future of Emer-gency Medicine reports,1–3 AHRQ and the health servicesresearch community have made significant progresstoward closing the research-to-practice gap.

AHRQ has supported and will continue to support asignificant portfolio of research on ED capacity, includ-ing projects that address demand for emergency ser-vices in the context of the larger health care systemand for conditions that create exceptionally high utiliza-tion. The agency’s support of health IT implementationprojects is aggressive, and the anticipated results oftwo such projects will provide important informationon the role of technology in improving patient flow, re-ducing errors, and preventing avoidable delays in emer-gency care. Recent revisions made to the ESI reflect thetool’s usefulness and clinical precision for effectivelytriaging ED patients. Finally, the expansion of HCUPto include ED data will allow researchers to gain adeeper understanding of key policy, access, and out-comes questions and to inform the larger debate aboutthe contribution of emergency care to our health caresystem.

Significant challenges remain, however. The dauntingstatistics reported by the IOM in 20061–3 about thestrained capacity of EDs, including long waiting timesfor care and ambulance diversion patterns, are unlikelyto have improved in 2007. What has evolved, and willcontinue to evolve, is the development of the tools andknowledge base necessary to provide the best possibletreatment to patients who seek timely, quality, and effec-tive care from our nation’s EDs, in essence, tools thatmake the right thing the easy thing to do.

References

1. Institute of Medicine of the National Academies. Hos-pital-Based Emergency Care: At the Breaking Point.Washington, DC: National Academies Press, 2006.

2. Institute of Medicine. The Future of Emergency Carein the United States Health System. Washington, DC:National Academies Press, 2006.

3. Institute of Medicine. Emergency Care for Children:Growing Pains. Washington, DC: National Acade-mies Press, 2006.

4. Agency for Healthcare Research and Quality. Emer-gency department crowding: causes and consequences,Brent Asplin, principal investigator. Abstract avai-lable at AHRQ Grants On-Line Database at: http://www.gold.ahrq.gov/GrantDetails.cfm?GrantNumber=K08%20HS13007. Accessed Jun 14, 2007.

5. Kaiser Family Foundation. Kaiser Network.org. Inter-view with Dr. Brent Asplin. Sept 13 Available at:http://www.kaisernetwork.org/health_cast/uploaded_files/091405_kff_drasplin_transcript.pdf. Accessed Jun7, 2007.

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6. Agency for Healthcare Research and Quality. Centerfor Patient Safety and Quality Improvement. Commu-nication, Jun 12, 2007. See also emergency departmentovercrowding and quality of acute asthma care forchildren, Marion Sills, principal investigator. Abstractavailable at AHRQ Grants On-Line Database at: http://www.gold.ahrq.gov/GrantDetails.cfm?GrantNumber=R03%20HS16418. Accessed Jun 14, 2007.

7. Centers for Disease Control and Prevention, NationalCenter for Health Statistics. Health E-Stats, AsthmaPrevalence, Health Care Use and Mortality, 2003-2005.Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/ashtma03-05/asthma03-05.htm. AccessedJun 7, 2007.

8. Agency for Healthcare Research and Quality. NationalResource Center for Health Information Technology.ED Information Systems—Kentucky and IndianaHospitals. Available at: http://healthit.ahrq.gov/portal/server.pt?open=512&objID=654&PageID=5585&mode=2&cached=false&state=Kentucky. Accessed Jun 7,2007.

9. Agency for Healthcare Research and Quality. Na-tional Resource Center for Health Information Tech-nology. EMS Based TIPI-IS Cardiac Care QI/ErrorReduction System, Harry Selker, principal investiga-

tor Abstract available at: http://www.gold.ahrq.gov/GrantDetails.cfm?GrantNumber=UC1%20HS15124.Accessed Jun 14, 2007.

10. American College of Emergency Physicians. Sur-vey: Hospital Overcrowding Issues Increase OverLast Year, According to Health Care OrganizationExecutives. Press Release, Jan 15, 2007. Avail-able at http://www.acep.org/webportal/Newsroom/NR/general/2007/011507.htm. Accessed Jun 14, 2007.

11. McMahon M. ED Triage: is a five-level triage systembest? Am J Nurs. 2003; 103(3):61–3.

12. Wuerz R, Milne LW, Eitel DR, Travers D, Gilboy N.Reliability and validity of a new five-level triage in-strument. Acad Emerg Med. 2000; 7:236–42.

13. Gilboy N, Tanabe P, Travers DA, Rosenau AM, EitelDR. Emergency Severity Index, Version 4: Implemen-tation Handbook. AHRQ Publication No. 05-0046-2.Rockville, MD: Agency for Healthcare Research andQuality, May 2005. Available at: http://www.ahrq.gov/research/esi/esihandbk.pdf. Accessed Jun 14,2007.

14. Agency for Healthcare Research and Quality. Health-care Cost and Utilization Project. Overview of HCUP.Available at: http://www.hcup-us.ahrq.gov/overview.jsp. Accessed Jun 7, 2007.