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.
Lakeridge Health has kindly shared their
experience of how participating in the program has helped them improve care in
Lakeridge Health comprises 5 hospital sites
in Durham Region, including 4 EDs, 3 critical care units, a long-term care
home, a full range of medical and surgical specialties, and more than 20
community health care locations.
Between April 2021 and March 2022, Lakeridge
had 198,056 ED visits, and their ED Return Visit Program data showed an
increase in patients who left without being seen (LWBS). Many of these patients
then returned to the ED in worse condition, resulting in poorer health outcomes
and longer hospital stays.
The Change Idea
In the fall of 2022, team members from each
Lakeridge site took part in a 3-day kaizen quality improvement (QI) event where
they dug into their data to understand their current state, examined their
workflow, completed a root-cause analysis, and developed a future-state
analysis. On the last day, the team trialed an initiative called Super Track: a
low-acuity assessment area with designated staff designed with the goals of
reducing the LWBS rate for all ED patients, reducing time to physician initial
assessment, and reducing length of stay for non-admitted patients.
Sending low-acuity patients through Super
Track keeps these patients out of the main ED, thus increasing the number of ED
beds available to patients with more complex needs and reducing time to
physician initial assessment for both high- and low-acuity patients.
During the kaizen trial, 29 patients went
through Super Track, and none left without being seen. Time to physician initial
assessment had a 90th percentile of 43 minutes (meaning that 90% of patients
were seen within this time frame), and length of stay had a 90th percentile of
190 minutes. After the event, the team used QI methodology to refine the model
before going live with it in January 2023.
As Dr. Michael Howlett, chief and medical
director, Emergency Services, explains, “The new process helps both the
patients with minor illness and those who are more seriously ill. CTAS [Canadian
Triage and Acuity Scale] vertical (able to stand or walk) 3, 4, and 5 patients
represent a significant part of our ED volume (it could be up to 40% at our
site). We can decrease overall time to physician initial assessment and create
more ED bed space for sicker patients by keeping those who don't need a bed
outside of the main department. Then, more acute people can go through the
normal process, while less sick patients are seen more quickly. This alleviates
some of the pressures on available beds to see the sicker patients.”
Keys to Success
Dr. Howlett acknowledges that the biggest
challenge to implementing Super Track was staffing, a universal issue at
Ontario hospitals. To secure dedicated resources for Super Track, the QI team first
had to convince front-line staff that the initiative was worth implementing. The
kaizen trial made this possible by allowing staff to test-drive the model and by
providing immediate results.
Also key to successful implementation was having
supportive hospital leadership, who immediately got on board and worked with
front-line staff to alleviate concerns and remove some of the perceived
barriers. Another enabler was having decision-support staff provide continuous data
updates so the ED team could see how things were progressing and make adjustments
in real time.
“If there is any work to be done to
standardize processes,” Dr. Howlett says, “the QI team handles it.”
The data do not lie. Since Super Track went
live, Ajax Pickering’s LWBS rate has decreased from 9.02% to 5.76%. The team
attributes this result to a decrease in overall time to physician initial assessment
and in ED length of stay. The Lakeridge team has shown that dedicating staff to
low-acuity patients can reduce wait times for everyone.
As Dr. Howlett emphasizes, “Everyone
deserves to be seen.”
If you have any questions about this initiative, please
contact Courtney Paxton, quality lead, Emergency and Critical Care Program,