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 is helping them improve care in the ED.
Health Sciences North (HSN) is a large, full-service
hospital in Sudbury. It provides services in English and French and is a
regional hub for acute care services, supporting 23 other hospitals in
northeastern Ontario. This year, the ED team is implementing a comprehensive
discharge checklist to reduce the occurrence of unsafe discharges.
The Issue
A review of HSN’s 2022/23 ED return visit data highlighted
several themes among patients who return to the ED, including vital signs not
being reassessed, older patients being discharged without needed supports in
place, and unclear communication between clinicians, as well as with families.
In addition, the current reality of EDs means that the HSN ED is often
overcrowded and understaffed, which increases pressure on clinicians to disposition
patients home.
To reduce the occurrence of unsafe discharges and help
clinicians make the correct discharge dispositions, the ED team decided to
develop a comprehensive discharge checklist to be used specifically with
patients at high risk of experiencing an unsafe discharge. These include
pediatric patients, older patients with complex needs, and patients from
vulnerable populations, such as those who are underhoused or have cognitive
impairments.
The Initiative
The comprehensive discharge checklist will provide a
standardized process to ensure high-risk patients are safely discharged. The ED
team also plans to integrate the checklist into electronic medical record (EMR)
workflows to standardize implementation and make it easy to use.
As appropriate, the checklist will:
- Alert clinicians to abnormal vital signs and critical lab
values
- Prompt clinicians to reassess vital signs, request lab work,
perform walk tests, and ensure patients have needed supports in place,
including transportation home
- Prompt clinicians to provide care plans to patients,
families, and care partners before discharge
Collaboration
To ensure a comprehensive understanding of the issue, the ED
team conducted its chart review using a team-based, multidisciplinary approach
involving ED physicians, nurses, nurse educators, and HSN’s geriatric emergency
medicine (GEM) nurse team. They also conducted cross-specialty interviews with
HSN’s consultant physician groups to better understand the potential impact of the
ED’s disposition practices on patients who subsequently see these physicians.
Planning for Success
To plan for the success of their initiative, the ED team is:
- Developing formal educational materials, including videos
and posters
- Providing training to front-line staff
- Using quality improvement methodology in the form of a
plan-do-study-act (PDSA) cycle to iteratively monitor their progress and make
changes as needed
- Incorporating the checklist into the hospital’s EMR to
standardize and streamline its use
- Limiting use of the checklist to high-risk patients to
minimize staff workload burden
- Conducting a chart review following implementation to (1)
identify opportunities to improve ease of use, refine components, and ensure
the appropriate education is being given to front-line ED staff, and (2) assess
whether the initiative has been successful in reducing the occurrence of unsafe
discharges
For those looking to implement a similar initiative, keys to
the team’s success so far have been their engagement with a wide variety of
stakeholders, including clinicians, administrators, patients, families, and
care partners, as well as their understanding of the demands on ED clinicians’
time.
This initiative builds on the success of a previous
initiative to
integrate a mobility team into the ED to improve care for older patients
who often wait many hours to be seen. We hope that the addition of the
comprehensive discharge checklist will continue to improve care for HSN’s
high-risk patients!
To learn more about HSN’s comprehensive discharge checklist
initiative, please contact Dr. Adam Bignucolo at
abignucolo@hsnsudbury.ca.