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, London Health Sciences Centre described a new part-time role they had developed to lead this program – an Emergency Medicine Sentinel Events Coordinator. This position is held by Dr. Allison Meiwald, an emergency medicine physician at London Health Sciences Centre. We spoke with Dr. Meiwald to learn more about their experience with the ED Return Visit Quality Program and the changes they’ve made as a result of participating in the program.
It was interesting to hear that you created a new role for an Emergency Medicine Sentinel Events Coordinator to lead this program, and it looks like you have nursing roles as well. Can you tell us a bit about these roles?
Dr. Adam Dukelow, our ED Chair/Chief, recognized that this is an exceptional program that would benefit from consistent attention over time. I have been in the role of Sentinel Events Coordinator for two years now. The first quarter of data that we reviewed, I did it all on my own – the entire audit process. Although this was very interesting work, it was time-consuming, and we felt we could involve others in the process – not only making it more productive, but also making it multidisciplinary.
London Health Sciences Centre has two ED sites. One nurse at each site, who is in an advanced nursing role, has the sentinel events in their portfolio. Each quarter, their role is to review the initial and return visits. I then review the events that meet criteria for review.
You mentioned that you spoke to the treating physicians in a few cases. Can you talk about how you approached that?
We have two avenues of providing education back to physicians and nurses. The first is on a case-by-case basis. If we identify an issue in the audits, it’s usually more related to gathering information rather than the physician having done something wrong. I approach the person involved to say – “I was reviewing this and have a few questions, I wonder if you could help me understand what happened.” People are very receptive, and the issue is typically related to documentation.
For example, we had a paediatric sepsis case where I didn’t understand why the patient was discharged in the initial visit based on the chart review. When I approached the consultant, I found that he had actually consulted extensively internally, and reached consensus that admission was not needed at the time – but this conversation was just not recorded.
The second way we provide education is through grand rounds. Three to four times per year, we present deidentified cases or themes identified where improvements could have been made. The nurses who participate in the program now participate in these rounds to present return visit cases. This process existed before the program, but the program has led to new material/cases to present during these rounds.
“The biggest thing I would want people to know is that this is not a fearful or punishment- based process. It’s a process of learning and improvement. Embracing this idea will be beneficial for all in the health system.”
You mentioned that your organization will be implementing ED process and quality improvement teams?
Yes, we are in the early stages of doing this. Our goal was to first become comfortable with the process to ensure we’re focusing on the correct things to change – not just nitpicky things.
An example of a change we have made was based on a case where a patient with chest pain left without being seen and returned later that night with a heart attack. When ECGs are performed at triage, nurses approach physicians with a printout of the ECG and ask what to do. Physicians will make notes on the ECGs – for example, the patient should be in a monitored bed, etc. But we no longer keep these printed ECGs because they are stored electronically now – so we may have no record of what notes were written on that ECG.
We have asked our physicians to record recommendations on the patient chart so that the recommendations aren’t lost. Patients who leave without being seen is unfortunately too common when wait times are long, so putting measures in place to protect our patients is really important.
One of the ways we share tidbits like this is through our weekly and monthly newsletters, and one of the places where these are posted is on the back of the bathroom stall doors. This type of change is something that could take up a corner of this newsletter that everyone reads (because there’s not much else to look at!). We will also send emails, etc, but this is another way to disseminate and change these system things that may be simple but make a big difference. The new ED process and quality improvement teams will ensure process and consistency to how we assess cases, develop opportunities for improvement and implement change.
Do you think collaborations among hospitals could be useful for this program?
I think collaboration would be an excellent idea. Statistically, when we do our review, we might identify something that could look like a one-off. But when these small numbers are combined, something we thought was a one-time thing may be revealed as a more common issue that we could address. Collaboration among hospitals is really important – London Health Sciences Centre is the largest hospital in southwestern ON, and our relationships with other hospitals are really important to us.
Can you talk about the quality improvement culture in your hospital?
We definitely have a mindset of “if something is not working, we have to try something different”. I really feel that people are willing to try to change and are willing to move on to try something else if a change doesn’t work.
How was the ED Return Visit Quality Program initially received when it was launched?
We have been doing death reviews and traditional M&M rounds for years, so people are used to reviewing these types of cases and even presenting their own cases where they may have made an error. So this program fits into this process, and was not worrisome to us.
You mentioned that your organization was already working on quality improvement initiatives related to the patient care issues you identified through the audits. What additional value (if any) does the program provide when this is the case?
Doing the audits provide us with local data, and the ability to approach management to say, “Here is what is actually happening – we know it’s happening, and we know we need to change.” As an example, we identified a risk that patients with sepsis are not getting their antibiotics on time. The cases identified through the program helped us to advocate for improvements in sepsis care, and we have now added pop-up reminders when patients meet sepsis criteria. This allows for initiation of IV fluids and the drawing of bloodwork. Patients are then flagged as meeting sepsis criteria, and we as physicians are then aware they are in the department, so we can get to them to ensure early administration of antibiotics. So the local data arising from these audits can influence change throughout the entire organization.
If other organizations were to add roles similar to yours, what would help the people in this role to be successful?
This was a learning experience for me. In this role, you definitely need to be self-motivated and willing to do the work. You have to be open to the process and accept the fact that treatment may be provided differently among different physicians, but that these differences don’t necessarily make one treatment incorrect. You also need to be a lifelong learner with a goal to always do something better.