The Emergency Department (ED) Return Visit Quality Program launched in 2016 with the goal to foster a culture of quality in Ontario’s EDs. In this program, participating EDs are provided with data reports that identify return visits resulting in admission for which the initial visit occurred at their site. They conduct audits to investigate the causes of these return visits, identify any quality issues or adverse events that may be present, and take steps to address these issues.
The results of the second year of the ED Return Visit Quality Program were submitted to Health Quality Ontario in January of this year (read the report here). In their submission, Collingwood General and Marine Hospital mentioned a few interesting approaches, including discussing program results with other organizations in their LHIN. Dr. Kylie Bosman is the Chief of Emergency Medicine at Collingwood General and Marine Hospital and the LHIN Lead for Emergency Medicine for the North Simcoe Muskoka LHIN. We spoke with Dr. Bosman to learn more about these collaborations and her experience with the ED Return Visit Quality Program.
In your narrative, you mention that you discuss this program with other organizations in your LHIN through groups such as the North Simcoe Muskoka Patient Safety Task Force. Could you tell us a bit about this?
The North Simcoe Muskoka Patient Safety Task Force is a regional quality group that meets quarterly in our LHIN. The agenda is focused on different elements of patient safety – for example, we recently reviewed the quality standard on diabetic ulcers. We have also discussed the ED Return Visit Quality Program at a high level in these meetings (noting that this group is not specific to EDs, but also includes other departments). We presented on the program and shared the provincial summaries released in 2016.
In addition to this task force, there is an ED steering committee in the North Simcoe Muskoka LHIN that meets monthly. We have discussed initiatives and interventions arising from the ED Return Visit Quality Program at these meetings.
You mentioned you have done cross-organizational case reviews for some return visits?
This initially arose when I received an email from someone at another organization alerting us that a patient we had seen at our site had a return visit to their site, in case we wanted to review the file. The treating physician was alerted of this return visit and was appreciative of the opportunity for learning (even though there may not have been issues there). The patient would likely have been identified in the data reports, but we wouldn’t necessarily investigate the case (as we select cases randomly). This was very useful for the parties involved, and we’ve been discussing how we could formalize this system with other organizations.
We are also working to create a way to provide physicians with a list of return visits they were involved in so that they can review and learn from their own cases. Our staff have been able to create these reports, but unfortunately they take almost 20 minutes to be generated, so we don’t really have time to do this. There is not a great IT solution for the problem right now, although we are still looking into it.
What are some of the initiatives you’ve worked on as a result of this program?
We held a meeting with emergency physicians within Collingwood General and Marine Hospital to go over the report on the 2016 results released by Health Quality Ontario, and used this as a jumping point to review specific cases within our organization as a group. We had about 70% of our emergency physicians at this meeting, and we used this opportunity to come up with a few initiatives to follow up on.
We’ve added a flag for patients with multiple coronary risk factors, as well as one related to sepsis criteria. We are also now flagging abnormal vital signs for repeat assessment or explanation as to why they were abnormal, and have been working on improving nursing/physician communications to address abnormal vital signs for paediatric patients.
Collingwood General and Marine Hospital does not have a paediatrics department on site – patients are transferred to Orillia Soldiers’ Memorial Hospital, which is more than an hour away. If we are not transferring patients to Orillia, we may give them instructions to return the next day for reassessment. Reassessing a patient in 24 hours is actually the right thing to do sometimes and we shouldn’t consider this a miss if it results in admission and is flagged in our data reports. We now leave a note in our binder that we have requested the patient to come back, and we follow the same procedure as we use for recalls for x-rays.
The reassessment could also be done by the family physician, as long as the patient can be seen within the appropriate time frame – the formalized follow-up is the important point, regardless of location. In our community, most of the physicians know each other and communication is strong; we also have connectivity with the electronic medical records from family physicians. The system we use for reassessments may not be replicable in a city without a connected system.
What advice would you give to others working on this program?
The first hurdle that had to be overcome was the additional workload, which may initially fall largely on the ED chiefs. But the audits are very instructive once you start doing them. Now, I have other physicians participate in conducting the audits, which helps with the workload – the continuing medical education (CME) credits that they can attain by doing the audits is an added incentive. The program and audits have been well received by physicians who are interested in quality and want to do the right thing and improve.
Overall, the timing of this program is good, and it is recognized as a nonpunitive review of practice – but the process is still labour-intensive.