Providing high-quality ED care is always a health care
system priority, especially in times of uncertainty and change.
The Emergency Department (ED) Return Visit Quality Program
launched in 2016 with the goal to foster and continuously improve the culture
of quality in Ontario’s EDs (learn more on our
In this program, participating EDs are provided with data reports that identify
return visits resulting in admission that involved 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
Although participants were not required to conduct audits in
2020 due to the COVID-19 pandemic, they still described an incredible amount of
work to improve the quality of care in their EDs. The team at Halton Healthcare
reported many interesting initiatives in their submission this year – some to
address the COVID-19 pandemic, and some to address the root causes of return visits.
Read on for a few examples.
Improving communication with patients waiting for care:
One of Halton Healthcare’s initiatives focused on the communication of wait times. This was inspired by a case involving an adolescent who presented to the ED with abdominal pain. Although the young patient, accompanied by his mother, had not been triaged, a hospital staff member, hearing the reason for presentation, conveyed to the patient and mother that he was likely to have a lengthy wait time. Upon hearing that information, the patient and mother decided to leave prior to the triage assessment. The patient returned many hours later and was diagnosed with a ruptured appendix. Although the patient recovered successfully, the team identified this as a safety issue to be addressed.
In collaboration with the patient and family, the team
drafted a policy related to the communication of wait times, known now as ‘Michael’s
Rule’, whereby any staff member would resist communication of patient-specific
wait times until the patient had been triaged and a more accurate determination
of wait time could be made.
Halton Healthcare has adopted this standard across their
three hospital sites. It requires that, for all pediatric patients, a chart
will be prepared and a fulsome and documented conversation regarding departure
will take place for any patient who states an intent to depart prior to seeing
consistent leadership during the pandemic
Halton Healthcare established an ED Pandemic
Leadership Team consisting of 6 charge nurses to allow for consistency in
leadership 24/7. This was an important tactic in keeping a core group up to
speed on the rapid communications from the Emergency Operations Centre. A series
of workshops were provided to this group, focusing on
evidencebased tools and training for advanced communications, conflict
management, peer feedback, crisis standards of care, and pivoting from usual
operations to surge/overcapacity protocols.
Education to support models of
In preparation for the potential influx of critically ill patients requiring
prolonged care in the ED, a novel ICU education program was developed and
implemented over a period of a few weeks. ICU educators, in partnership with ED
educator, hosted the educational event for 36 ED nurses. The sessions involved
both a didactic and experiential component that provided foundational critical
care skills that would be implemented in a team-based model of care scenario.
The educational resources developed remain in the ED setting and are reviewed
at regular intervals to ensure the sustainability of these competencies and
To connect with the team at
Halton Healthcare that worked on these initiatives, email EDQuality@ontariohealth.ca.