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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 the ED.

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.

The Data

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 Results

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, Lakeridge Health: cpaxton@lh.ca.