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.
Health Sciences North has kindly shared their experience of
how participating in the program has helped them improve care in the ED.
The Data
When Health Sciences North, a regional hospital in Sudbury,
reviewed their Emergency Department (ED) Return Visit Program data, they found
that most return visits were from older people with mobility issues.
The Problem
Because of the high volume of patients waiting to be seen in
the ED, older patients often wait 12 to 48 hours for care, spending most of
that time immobile in a bed or chair, which leads to muscle deconditioning and
increases the risk of falls and symptoms of delirium, sometimes necessitating
the use of restraints.
The Change Ideas
To address this issue, the hospital implemented a quality
improvement (QI) initiative that integrated the hospital’s mobility team within
the ED.
First, they hired dedicated physiotherapists and physiotherapist
assistants to work in the ED to ensure that geriatric patients were assessed
and mobilized while waiting for care for their acute condition.
Second, the hospital hired a high-risk assessor to screen the
patients most at risk for an extended length of stay in hospital (e.g., those
with social barriers to returning home). The goal was to determine this risk on
day 1 rather than day 10 of a hospital stay, thus allowing a measurement of
each patient’s baseline condition and providing the time to coordinate community
support and create individualized care plans.
The ED mobility team operates 7 days a week, 13 hours a day
Monday to Friday and 8 hours a day on weekends.
The Results
Not only did the hospital observe a high admission-avoidance
rate (15 to 25 admission avoidances per month), but they also found that the
presence of the high-risk assessor led to a decrease in length of stay for
admitted patients. They also achieved the following:
- A 23% decrease in patients presenting with symptoms of delirium
and dementia
- A 34% decrease in patients presenting with frailty and
weakness
- A 31% decrease in patients presenting with falls
- 49% of patients released who were assessed by a high-risk
assessor and 45% of patients who were mobilized in the ED were released in less
than 6 days
Addressing Barriers
An initial barrier was obtaining physician support for the
program. However, after physicians began to observe the work the team was doing
and the results achieved, the team was able to build partnerships that allowed them
to flag patients of concern, assist with discharge planning, and create
pathways for patients when stable for discharge.
Keys to Success
Keys to the program’s success include:
- Having a designated care coordinator assigned to the ED to
assist with monitoring at-risk patients and flagging them for the mobility team
- Taking an interdisciplinary approach, with a physiotherapist
and physiotherapist assistant to focus on mobilization and preventing deconditioning
and a high-risk assessor to address any social concerns and set up supports for
discharge
- Partnering with the ED geriatric emergency medicine (GEM)
team, which serves two integral purposes. First, the partnership allows the
mobility team to gain a better understanding of geriatric care. Second, GEM nurses
are able to flag patients at risk of extended length of stay for the mobility team.
Thorough GEM assessments allow the mobility team to prioritize patients, ensure
they are followed through to inpatient units, and ensure that interdisciplinary
teams on inpatient units are aware of any barriers to discharge. The mobility team
also helps the GEM team prepare discharges
- Providing a continuous flow of services from the ED to
inpatient units, which allows unit teams to prioritize patients’ individual needs
- Integrating the mobility team within the ED, which allowed ED
physicians to see the benefits of the team’s work
For those looking to implement a similar program, the
hospital emphasizes the importance of having a multidisciplinary team with
clearly defined roles and responsibilities to ensure that goals and set
directives are met.
The mobility team and ED staff at Health Sciences North have
common goals: to reduce ED return visits and to reduce admissions. Working
together in this effort has been instrumental to their success.
If you have any questions about this initiative, please contact
Meghan Forestell, manager, Access and Flow, Ramsay Lake Health Centre, Health
Sciences North:
mforestell@hsnsudbury.ca.