The Emergency Department (ED) Return Visit Quality Program launched in 2016 with the goal to foster and continuously improve the culture of quality in Ontario’s EDs (learn more at our website or read our latest report). In this program, participating EDs are provided with data reports that identify return visits resulting in admission that involved 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.
Woodstock Hospital has worked on many initiatives related to their learnings from the ED Return Visit Quality Program, including:
- Expanding access to diagnostic ultrasonography after hours
- Improving turn-around times for C-reactive protein testing by moving the tests in-house
- Improving documentation of vital signs by implementing bedside medical device integration
We spoke with Heidi Dantes, Director of the Emergency Department, and Steve Baker, Quality Improvement Specialist, to find out more.
Members of the Front Line Improving Performance (FLIP) team at Woodstock Hospital in 2017. From left: Randall Walach, Cindy Smart, Heidi Dantes, and Steve Baker.
How did you go about increasing ultrasound availability after hours without increasing costs?
Access to ultrasound after hours has been a long-standing issue and we have been advocating for improvement for some time. We saw this issue reflected in numerous return visits to the ED for diagnostic imaging where patients were then admitted.
We worked closely with the diagnostic imaging (DI) staff to identify solutions. By looking at resource utilization, morning ultrasonography hours were reallocated to the evening to reduce the number of next-day return visit exams. Ultrasonography is now available until 8:00 pm Monday to Friday.
In addition to extending the hours, we also challenged the US staff to improve on prioritizing imaging for ED patients. We made changes such as installing dedicated monitors to view an icon that fires when an US order is placed. We also set targets for ultrasonography time from order to start of exam and reported their progress on a weekly basis; this is a way for them to get recognition for the significant improvements they’ve made.
The increased access to ultrasonography has been very positive for our ED patients as we are able to make the decision to admit much earlier. It’s also improved our flow for the following day, since fewer people are returning for ultrasonography and results.
Did you need to address any cultural barriers to make these changes?
We’ve been collaborating closely with the DI department over the past few years as we worked on initiatives to improve the X-ray turnaround time. We’d hold working groups with DI and ED staff together to work out the solutions. So when we began the work on ultrasonography, we already had a strong relationship established.
Before this collaboration, the DI department viewed themselves predominantly as an outpatient department and viewed the ED as another source for walk-in patients. After working closely with the DI department to share data and show the impact on patient flow in the ED, the DI department committed to make ED patients more of a priority.
It was helpful to share how the workflows in DI affect ED workflows. In turn, we also recognized how ED flow affects DI – because when ED visits increase, DI test requests increase as well. They are feeling the same pressure we do related to increasing ED visits.
How were you able to bring your C-reactive protein (CRP) testing protocol in-house?
Previously, we were sending out CRP to a lab for testing, with the results being returned in about 24 hours. A case we audited through the ED Return Visit Quality Program (where a patient was discharged and returned with sepsis) spurred us to look into our CRP testing process.
We worked directly with the laboratory services team to bring this test in-house. After we raised the issue, the laboratory services team investigated and found that our instrumentation was capable of running this test. This required calibration and testing validation, additional quality control material, and external quality proficiency testing to ensure we were meeting all laboratory accreditation standards. We were able to bring the test in-house within 8 months of the initial request. Because of this, the time from ordering the test to verification of results dropped from a mean of >24 h to 38 min (see table).
Time from ordering CRP test to verification of results
Can you tell us about your bedside medical device integration (BMDI) initiative?
Vital sign documentation is one of the issues that has been identified numerous times in our audits. We have a busy department, and BMDI is a means to automatically record vital signs in the patient’s medical record. When this interface became available, it was a great solution to address this issue. Our post-anesthesia care unit was the first unit to incorporate BMDI as a pilot, and we adopted it in the ED afterward.
“If you want people to change their practice, you have to give them the tools to do it easily.”
We had to purchase interfaces, software and scanners. We then trained the nurses to scan, validate the vital signs and troubleshoot (there may be readings that aren’t accurate because, for example, the patient’s arm is positioned incorrectly). We use the BMDI to monitor the sickest patients in the acute zone.
Since we implemented this initiative, we have observed improvement, as demonstrated in an audit of vital signs documentation (see table). Another benefit is vital signs are now displayed on the electronic tracking board, highlighting abnormal measurements.
Vital sign documentation before and after incorporation of BDMI in the ED
(CTAS: Canadian Triage and Acuity Scale)
You are working on a lot of different quality initiatives. How do you keep all of this work aligned?
The ED Return Visit Quality Program dovetails nicely with the Pay-for-Results program overall. Sometimes, we are generally aware of quality issues that arise in the audits, but the ED Return Visit Quality Program highlights specific cases where patients are affected. This spurs us to investigate and improve and reminds us why we’re doing what we’re doing.
If we find a problem, we bring it to our front-line staff for awareness and to help find solutions. We have a small team dedicated to Quality called Front Line Improving Performance (FLIP). This is why our QI initiatives stick well. Involving the front-line staff in this way has been a big factor in our successes. Supportive leadership is also very important.