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 at our website or read our latest report). 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 issues.
Health Sciences North has made use of a variety of approaches to implementing this program, including:
- Providing data reports listing return visits to each physician
- Connecting with other hospitals in the North East LHIN to discuss the program
- Deriving educational opportunities from case studies
- Generating solution or practice changes as a result of rapid improvement events
We spoke with Dr. Louise Logan, Emergency Medicine Physician at Health Sciences North, to find out more.
How do you conduct the audits in your hospital?
Along with being an Emergency Physician at Health Sciences North, I am the continuous quality improvement medical lead. I receive the quarterly reports of return visits from our decision support. This includes the return visits to the ED relating to a sentinel diagnosis, randomly selected return visits and all return visits resulting in death within 48 hours of the index visit. To conduct the audits, I review the charts and provide an analysis using Health Quality Ontario’s template. Next I review the cases with our nursing continuous quality improvement manager, who provides a nursing perspective to the audits. Together, we identify themes and opportunities for improvement that direct quality improvement initiatives for our team and our patients.
I then review the cases in which quality issues or concerns have been identified with our Medical Director, who weighs in on findings and provides perspective for quality improvement initiatives and follow up. When required, he reaches out to other stakeholders and departments at Health Sciences North with feedback and opportunities. As for the emergency department group, learning opportunities are shared with the treating physician on a case by case basis. Some of the ways that this is done is through verbal feedback, presentation at Morbidity and Mortality rounds and, more recently, physicians are forwarded the template analysis for their particular case for further review.
We don’t currently have plans to create a committee to do these audits, although this would be an interesting collaborative approach. However, we do provide data reports listing return visits to our physicians so that they can review and learn from their own cases.
Could you tell us about your initiative to provide data reports containing lists of return visits to all of your ED physicians?
We got this idea from a webinar about the ED Return Visit Quality Program, where the Hospital for Sick Kids described providing physicians with personalized data reports listing return visits for which they were the treating physician.
I was looking for a way to utilise the data already gathered by decision support for the ED Return Visits. The return visit data for each of our physicians is extracted from the existing Excel spreadsheet and is sent to them. Physicians receive these reports twice yearly. Since each physician has only a small number of cases to review, it is not a huge time burden, and although the data reports may be received long after the case occurs, there are still opportunities to learn from in reviewing these charts. Several physicians have reported to me that they appreciate this process.
Distributing these reports has led to our physicians being more aware of and engaged in the ED Return Visit Quality Program. I also present the highlights of our learnings to our physician team yearly, and sharing the data reports has led to increased interest in this.
Can you tell us about how you have connected with other hospitals in the North East LHIN to discuss the ED Return Visit Quality Program?
One of our ED physicians is the LHIN Lead for Emergency Medicine in the North East LHIN. He, along with all our physicians, has a strong interest in quality improvement. He’s been able to mobilize the people who are involved in the ED Return Visit Quality Program within the LHIN. He organises a meeting of the participating hospitals within the LHIN to discuss the program findings over teleconference.
It is often the medical director, ED leadership, and front line nursing staff who are involved in the review and submission process at their respective hospitals who attend. We discuss challenges with the program, how we have implemented the program, our lessons learned, the quality improvement initiatives that have come out of it, and the impact of the change. Each site sends a brief outline summarizing their audit results and any highlights in advance of the meeting.
These meetings are very interesting and lead to discussions and networking within the LHIN. Sometimes, people move conversations offline to discuss initiatives they are interested in in more detail. We also find these calls useful to discuss shared challenges –which are sometimes unique to the North.
You identified some cases you have used as educational opportunities. Could you tell us a bit about that?
Sometimes we find interesting cases involving a diagnosis or presentation that is relatively rare. Some of these cases have been reviewed for continuing medical education (CME) credits. We had one case that was related to atrial fibrillation and the initiation of anticoagulation with direct oral anticoagulants. We utilised the case as a teaching opportunity/project for one of our postgraduate year 3 emergency medicine residents who prepared a case presentation and current management review to help physicians manage these cases better in the future.
What has been the initiative that you’re most proud of over the three years of the program?
One of the outcomes that I’m most proud of is that the new process where the physicians are reviewing their own list of return visits and are engaged in learning from the cases that they were involved in. This is just one of the ways that we are successful in fulfilling the purpose of the ED Return Visit Program, by establishing a culture of continuous quality improvement.
Another highlight was an initiative we worked on after auditing cases involving patients who were returning for psychiatric visits. We found that the follow-up disposition for some psychiatric patients was not always clear to our ED physicians. After discussing these cases with the medical director, we chose to collect more data to better understand this problem. We found that our admission rates for patients needing psychiatric care were quite high during hours that we did not have psychiatric coverage for ED consultations. This finding supported a need for longer on-call hours for psychiatry, and we were ultimately able to expand the on-call hours. As a result, we have better access to care for this population. Further data to measure this improvement is being gathered.
Our Medical Director engaged stakeholders and leadership to discuss this issue. With the information highlighted in the return visit audits which supported our concerns, as well as the additional data collected, it was evident to all involved that this was an issue that needed to be addressed. We have a high number of alternate level of care patients and a high number of inpatients in the ED. Our data highlighted that the opportunity to optimize psychiatric coverage may contribute to a systemic improvement for those large issues.