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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.

St. Joseph’s Healthcare Hamilton has kindly shared their experience of how participating in the program is helping them improve care in the ED.

St. Joseph’s Healthcare Hamilton is a multisite regional tertiary care centre and an academic teaching centre affiliated with McMaster University. Its ED sees more than 50,000 patients a year.

The Data

When the St. Joseph’s ED team reviewed their 2022/23 ED return visit data, they found that 10% of the charts audited involved patients being called back to the ED because of a discrepancy between the preliminary and final readings of diagnostic imaging (DI) scans. In these cases, the final reading by the radiologist revealed a diagnosis requiring intervention, such as appendicitis or cholecystitis, and patients were subsequently admitted.

In addition to this being a patient safety issue, the team noted that managing DI discrepancies was also time-consuming: reducing discrepancies would allow the ED team to focus more of its resources on active ED encounters rather than following up on completed visits.

The Initiative

To address this issue, the ED and DI teams leveraged an existing collaborative ED/DI working group to develop a discrepancy policy and processes to manage emergent, urgent, and incidental findings on DI scans. The goal of the new policy is to improve and standardize the hospital’s processes for addressing discrepancies in as timely a manner as possible.

Because St. Joseph’s is an academic teaching centre supporting education in all clinical capacities, overnight DI scans are read by a radiology resident, and final readings are done by the staff radiologist in the morning. Any discrepancies noted by the radiologist are documented and routed to a discrepancy folder for review by an on-call ED physician, and patients are notified to return to the ED as needed.

To minimize discrepancies, the team is engaging in ongoing collaborations with postgraduate medicine programs to ensure that residents are fully supported to interpret DI scans, particularly after hours.

Enablers and Barriers

A key strength of this initiative is the close collaboration of the ED and DI teams, particularly the team’s leveraging of the existing ED/DI working group. The group meets monthly, allowing members to continually monitor and track progress and to respond to challenges or opportunities in a timely manner.

Importantly, the initiative is supported by leadership, including the chief, director, and manager of the ED, as well as the chief of Radiology and the director and managers of Diagnostic Imaging.

As is common across Ontario hospitals, significant barriers have been limited financial resources and limited available staffing to manage daily discrepancy reports.

Quality Improvement Processes

The team began its work in March 2024. This involves collecting and analyzing data on the existing discrepancy reporting process, including what the discrepancies are, how often they are occurring, and how they are addressed.

In April, the team conducted a Gemba walk, a quality improvement activity that involves a workplace walkthrough to better understand how work is done on the ground. For St. Joseph’s, this involved observing how discrepancies were currently being managed and identifying key gaps and challenges. Following the Gemba walk, the team created a process map highlighting issues to be addressed that was then verified by the chief of Emergency.

Progress So Far

Though the initiative is still underway, the team feels they are building success and are happy to have the support of both leadership and ED and DI staff, who believe the initiative has great potential to improve patient safety and help allocate ED resources as effectively as possible.

To learn more about the St. Joseph’s Healthcare Hamilton initiative to improve the management of DI discrepancies, please contact Dr. Erich Hanel, Chief, ED, at ehanel@stjosham.on.ca; Donna Johnson, Senior Director, Acute Operations, at djohnson@stjoes.ca; or Kyle Davies, Clinical Manager, ED, at kdavies@stjoes.ca.