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.
Cambridge Memorial Hospital has made numerous improvements to care and culture in response to their learnings from the ED Return Visit Quality Program, including:
- Holding a seminar series on mindful medical practice
- Improving access to specialist consultation in the ED
- Improving triage accuracy in the ED
- Implementing a structured return-to-ED process to expedite care for patients returning for diagnostic imaging
We spoke with Rita Sharratt, Director, Emergency and Mental Health Programs, and Dr Arthur Eugenio, Chief of Emergency Medicine, to find out more.
Could you tell us about your seminar series on mindful medical practice?
We know that burnout among health care providers is a big problem in medicine. Better provider experience is part of the Quadruple Aim of medicine (along with better patient experience, better outcomes, and lower cost).
The mindful medical practice seminar series was part of our attempts to improve the culture within our department to improve clinician health, and along the way improve our care for and interaction with our patients. The technique of mindfulness has also been shown to address the issue of physician cognitive lapses, one of the themes identified in the ED Return Visit Quality Program audits.
We held a three-part seminar series on mindful medical practice that was led by a psychiatrist who is an expert in mindfulness strategies. Charge nurses, management, and most of our ED physicians attended. The seminars started good conversations about how we behave, think, and handle our emotions, and how this can lead to bias; they also touched on taking ownership and trying not to take things personally.
The seminars were very well received, and several attendees reported that they derived enormous benefit in terms of identifying their own perceptions during difficult encounters with patients. It was so successful that medical administrative wants to fund another round and have nurses attend the seminars as well.
Although the effects of these seminars is difficult to quantify with data, we did see an improvement in patient experience markers in the first few months after the seminars.
“We are doing a lot of work on culture and relationships. Good patient care comes from a well-functioning, mutually respectful team. This involves attending to one’s own personal and psychological health, but also attending to relationships – good communication, workplace habits, and teamwork will lead to better outcomes.”
How did you work to improve access to specialist consultation in the ED?
As a community hospital, we have specialists and surgeons on call at night, but they have clinics and ORs the next day. It is burdensome for them to come in late at night – which is a legitimate complaint. As such, ED physicians were having phone consultations with the specialists or surgeons instead of in person. We noticed that some of these patients would then return to the ED.
This observation was connected to a larger, hospital-wide issue related to consultation practices and admission to inpatient units. Addressing this issue involved a collaboration between the ED and medical administration to change practice and culture around specialist consultation. Progress has been made and policies have been revised throughout the hospital.
Although the ED Return Visit Quality Program is centred on the ED, the audit findings reflect the decisions physicians make within the context and culture of the hospital. Addressing the issues that arise in the audits often must extend beyond the ED, given that the issues are often related to availability of resources elsewhere in the hospital.
How did you work to improve triage accuracy in your ED?
When we were reviewing charts, we identified some cases where patients’ triage status didn’t appear to align with their acuity and associated treatment plan. After noticing this, we did a more extensive audit to investigate and saw a trend where nurses weren’t always using modifiers to determine Canadian Triage and Acuity Scale (CTAS) scores.
We worked with eCTAS to provide education to our triage nurses to address this, and we now do audits to monitor this on a weekly basis: patients in the minors category with a length of stay longer than 5 hours are audited to investigate why they were held and determine whether they should have been triaged differently.
This is important work because correctly identifying someone with a lower CTAS level will lead to tests being done more quickly and identifying problems sooner.
Could you tell us about your structured return-to-ED process for patients returning for diagnostic imaging?
We noted that patients who were coming back for scheduled return visits (for example, for diagnostic ultrasonography) often waited a long time and ended up with findings such as appendicitis. We developed a structured return-to-ED process for patients receiving diagnostic ultrasounds. This process included a fast-track back to the ED green zone area bypassing our regular triage process. The charge nurse would do their eCTAS and ensure they were seen quickly. This helps streamline these patients’ return visits and also helps free up resources for patients waiting to be seen. The return visit audits were used as evidence to support the need for change.
What are you working on for the upcoming year?
At this point, our quality plans are related to structure and process rather than a specific quality initiative. Our goal is to get a team together to review the charts (rather than having the Chief of Emergency Medicine do all the audits).
“Having a team conduct audits of return visits will feed into the overall culture of quality improvement. This speaks to what the spirit of what this program is about.”
It will be helpful to have multiple perspectives and multiple people involved in assessing care, and there are definitely opportunities for learning as well. When clinicians review someone else’s chart, the process is very instructional for the reviewer as well; they may identify learnings that they can apply to their own cases.