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.
Michael Garron Hospital has kindly shared
their experience of how participating in the program has helped them improve
care in the ED.
Michael Garron Hospital is a large,
full-service community teaching hospital in east Toronto serving a diverse
population of 400,000 residents. In 2021, they launched a
Child and Youth Emergency Zone (CYEZ) to
provide dedicated urgent and acute pediatric care in a family-friendly
environment that is physically separate from the hospital’s main ED. The CYEZ
is open daily from 9 a.m. to 10:30 p.m.
Recognizing a Need
In the fall of 2021, Michael Garron’s ED
was expecting a large influx of pediatric patients in the upcoming flu season.
In addition to the usual respiratory illnesses, COVID-19 would mean many more
visits, as would other bugs that patients were naïve to because of isolating
for so long. The ED team had also noticed from their data that for ED visits, a
good proportion of east Toronto’s families were taking their kids not to
Michael Garron but to the Hospital for Sick Children (SickKids). Why?
As the team dug into the data, they
realized it had nothing to do with the quality of care they provided but rather
the uniquely pediatric environment and specialized pediatric care that SickKids
provides. The ED team thus recognized an opportunity to serve their pediatric
population in a new way, and the idea for the CYEZ was born.
The ED is a scary place for kids, so in
addition to increasing access to in-person pediatric care, a further goal of
the initiative was to destigmatize young children’s first experiences with the
health care system.
Establishing the CYEZ was a hospital-wide
endeavour. In addition to soliciting the expertise of their pediatric
colleagues and that of SickKids and Kids Health Alliance (a network of
community hospital partnerships), the ED team engaged with many areas across
the hospital, including the infection prevention and control (IPAC) team to
ensure the new space was appropriate for managing a high volume of respiratory
patients. Additional resources were needed, too, including dedicated nursing
staff, support services, and the new role of child life specialist.
The ED team also emphasize the importance
of gaining support and input from patients and the community, who provided
valuable information early on through community outreach activities and pre-
and post-visit surveys about what was needed, what was working well, and what
could be improved. Knowing what the community needed and valued was a key
enabler to establishing the CYEZ.
Another important enabler was the
commitment from the hospital’s executive team, who saw the need and were
willing to take a risk on the initiative without additional funding being
secured before opening. This commitment was also demonstrated by a number of
executives who willingly gave up their office space to be used for the CYEZ.
The Importance of Data
secure funding since then, data has played a big part:
- The CYEZ is drawing families back to Michael
Garron and relieving pressure on SickKids and other tertiary hospitals in
- Time to physician initial assessment for
pediatric patients has gone down by about 14% at the 90th percentile, from 2.89
hours before the CYEZ opened to 2.4 hours now (meaning that 90% of pediatric
patients are now seen within 2.4 hours)
- 88% of patients and families surveyed have rated
their CYEZ experiences as excellent
- Not only are pediatric patients being seen
more quickly than before, but so are patients in the main ED
- CYEZ nursing staff report feeling more
confident, competent, and comfortable with caring for pediatric patients
According to Dr. Dorothy Quon, interim
director of the ED, “I think the data is the key. Showing the impact you’re
having matters very much.” Dr. Quon also says that it’s important to have
ongoing conversations with those who can provide funding and to identify where an organization’s needs align with the province’s
priorities – as was the case for emergency care for children and youth during
the COVID-19 pandemic.
Dr. Kyle Vojdani, chief and medical
director of the ED, adds that it’s important to think big and cautiously take
calculated risks. Taking a chance on the CYEZ without having secured funding
was seen as a risk by some, but by taking that chance, the team proved that
there was a tremendous need for what they were doing and that their community
could be served better than it had been previously.
Both Dr. Quon and Dr. Vojdani believe that
the ED Return Visit Quality Program has encouraged a philosophy across Michael
Garron’s ED of working collaboratively, which is being picked up in work on other
projects. Dr. Vojdani notes that the practice of regularly reviewing ED return
visit data has led to a number of changes in the department, such as having
naloxone kits available in medical dispensaries and the implementation of new
mental health secure zone. He says that the ED Return Visit Quality Program has
“changed the way we think, the way we review cases. Beyond that, it’s actually
changed the way we review all of the work we do in the department. So, it’s
actually helped us evolve the way we think.”
For organizations looking to implement a
program similar to the CYEZ, Dr. Quon and Dr. Vojdani say that it’s important
to know your data, know where your gaps are, know what your community needs,
and to be bold.
For Michael Garron’s ED team, it’s clear
that their boldness has paid off. As one parent remarked, “This was the perfect
antidote to having to take our 8-year-old to the adult emergency last night. It
was scary and uncomfortable. This was like going to Disney World! It made a
world of difference to my daughter in regard to hospitals. We feel so lucky this
To learn more about the CYEZ, please
contact Dr. Dorothy Quon, interim director of the Michael Garron Hospital