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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.

Ross Memorial Hospital has kindly shared their experience of how participating in the program is helping them improve care in the ED.

Ross Memorial Hospital is an acute-care community hospital in the City of Kawartha Lakes serving more than 100,000 residents and visitors.

The Data

In the spring of 2023, Ross Memorial’s ED was asked to create a unit goal addressing patient satisfaction. Knowing that leaving the ED without being seen (LWBS) is both a patient satisfaction issue and a quality issue, the team decided that an initiative to reduce LWBS volumes could have real impact. Over the summer, the ED’s LWBS rate climbed to a high of 15%, and the team dug into the data to understand why this was happening.

From a review of their ED return visit data, the ED team learned that patients were most likely to leave without being seen if they arrived between 4 and 10 p.m., were between the ages of 25 and 60 years, and were assigned a Canadian Triage and Acuity Scale (CTAS) rating of 3 to 5. Given these demographics, the team assumed that most of these people were ambulatory and would meet the criteria to be seen in the ED’s low-acuity “see and treat” program, which was then staffed only between 10 a.m. and 4 p.m.

The Change Idea

The team thus extended the “see and treat” program into the evening hours, adding dedicated physician hours until 11 p.m. and dedicated nursing hours until 10 p.m. In addition, the team made physical changes to the triage area to make it easier for nurses to perform medical directives there, with the hope of reducing patients’ wait times once they have seen a physician. They also worked with the diagnostic imaging (DI) team to increase the DI resources available to meet the increasing evening demand. Funding from Ontario’s Pay for Results program was used to support the initiative.

Addressing Barriers

The biggest challenges for the team have been ED physician staffing, ED boarding (i.e., holding admitted patients in the ED while awaiting inpatient beds), and funding restrictions. Lack of sufficient funding has unfortunately meant that the evening “see and treat” program has dropped from 4 to 5 days a week to just 3.

For the initiative to be as successful as possible, the team recognizes that it is key to have an organizational focus on throughput and output. Accordingly, the hospital is reviewing and updating its surge policy and taking steps to improve patient flow throughout the hospital.

Additional measures to support the project include:

• Adding a 90th percentile predictive wait time clock to the ED waiting room
• Making physical improvements to the ED waiting room to increase patient comfort
• Providing a list of all local clinic and virtual care options on the hospital’s website
• Working with the local Family Health Team to support patients without a primary care physician who require follow-up after an ED visit

The Results So Far

Despite the challenges, Ross Memorial’s ED team has made significant headway in reducing its LWBS volumes. From 8.2% in 2023 – and a high of 15% in August that year – the rate has fallen to 5.7% so far in 2024.

Keys to the ED team’s success have been their use of return visit data to identify a quality concern and monitor progress toward addressing it, thinking creatively to make improvements in various areas, and using limited funding where it can have the most impact.

To learn more about Ross Memorial’s evening “see and treat” program, please contact Jennifer Chipp-Smith, Director of Critical Care, Emergency, Medicine and Patient Flow: jcsmith@rmh.org.