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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.

Health Sciences North has kindly shared their experience of how participating in the program has helped them improve care in the ED.

The Data

When Health Sciences North, a regional hospital in Sudbury, reviewed their Emergency Department (ED) Return Visit Program data, they found that most return visits were from older people with mobility issues.

The Problem

Because of the high volume of patients waiting to be seen in the ED, older patients often wait 12 to 48 hours for care, spending most of that time immobile in a bed or chair, which leads to muscle deconditioning and increases the risk of falls and symptoms of delirium, sometimes necessitating the use of restraints.

The Change Ideas

To address this issue, the hospital implemented a quality improvement (QI) initiative that integrated the hospital’s mobility team within the ED.

First, they hired dedicated physiotherapists and physiotherapist assistants to work in the ED to ensure that geriatric patients were assessed and mobilized while waiting for care for their acute condition.

Second, the hospital hired a high-risk assessor to screen the patients most at risk for an extended length of stay in hospital (e.g., those with social barriers to returning home). The goal was to determine this risk on day 1 rather than day 10 of a hospital stay, thus allowing a measurement of each patient’s baseline condition and providing the time to coordinate community support and create individualized care plans.

The ED mobility team operates 7 days a week, 13 hours a day Monday to Friday and 8 hours a day on weekends.

The Results

Not only did the hospital observe a high admission-avoidance rate (15 to 25 admission avoidances per month), but they also found that the presence of the high-risk assessor led to a decrease in length of stay for admitted patients. They also achieved the following:

• A 23% decrease in patients presenting with symptoms of delirium and dementia
• A 34% decrease in patients presenting with frailty and weakness
• A 31% decrease in patients presenting with falls
• 49% of patients released who were assessed by a high-risk assessor and 45% of patients who were mobilized in the ED were released in less than 6 days

Addressing Barriers

An initial barrier was obtaining physician support for the program. However, after physicians began to observe the work the team was doing and the results achieved, the team was able to build partnerships that allowed them to flag patients of concern, assist with discharge planning, and create pathways for patients when stable for discharge.

Keys to Success

Keys to the program’s success include:

• Having a designated care coordinator assigned to the ED to assist with monitoring at-risk patients and flagging them for the mobility team
• Taking an interdisciplinary approach, with a physiotherapist and physiotherapist assistant to focus on mobilization and preventing deconditioning and a high-risk assessor to address any social concerns and set up supports for discharge
• Partnering with the ED geriatric emergency medicine (GEM) team, which serves two integral purposes. First, the partnership allows the mobility team to gain a better understanding of geriatric care. Second, GEM nurses are able to flag patients at risk of extended length of stay for the mobility team. Thorough GEM assessments allow the mobility team to prioritize patients, ensure they are followed through to inpatient units, and ensure that interdisciplinary teams on inpatient units are aware of any barriers to discharge. The mobility team also helps the GEM team prepare discharges
• Providing a continuous flow of services from the ED to inpatient units, which allows unit teams to prioritize patients’ individual needs
• Integrating the mobility team within the ED, which allowed ED physicians to see the benefits of the team’s work

For those looking to implement a similar program, the hospital emphasizes the importance of having a multidisciplinary team with clearly defined roles and responsibilities to ensure that goals and set directives are met.

The mobility team and ED staff at Health Sciences North have common goals: to reduce ED return visits and to reduce admissions. Working together in this effort has been instrumental to their success.

If you have any questions about this initiative, please contact Meghan Forestell, manager, Access and Flow, Ramsay Lake Health Centre, Health Sciences North: mforestell@hsnsudbury.ca.