improving patient safety & quality of care in a community emergency department by incorporating...
DESCRIPTION
This presentation was delivered in session D3 of Quality Forum 2014 by: Peter Chan Health System Planning Advisor Vancouver Coastal Health Sherry Stackhouse Emergency Clinician, Lions Gate Hospital Vancouver Coastal HealthTRANSCRIPT
Improving Patient Safety and Quality of Care in a Community Emergency Department by Incorporating Evidence Into Practice:
Using a Pivot Nurse to Improve Access to the Appropriate Level
of Care
Quality Forum 2014 Rapid Fire Session D3
February 27, 2014
Peter Chan and Sherry Stackhouse
Presentation Content
The Beginning (Oct 2012 - May 2013)
1. Context 2. Problem 3. Intervention 4. Measurement 5. Challenges & Lessons
Learned
The Journey (Jun 2013 – Feb 2014)
2. Problem Background
• Access Block and ED Overcrowding lead to long wait times, and avoidable delays in the Emergency Department (ED)
• Patient and staff dissatisfaction with the care they receive and provide
3. Intervention Project Overview
• Union of two separate initiatives: – A Quality Advisor led stakeholder engagement and applied a
framework to guide improvement work – A Clinical Nurse Leader led evidence in practice initiatives and
provided clinical coordination and leadership
• Goals were aligned and priorities were established at the beginning
3. Intervention Quality Framework
• Model for Improvement – Aim Statements – Measurement – PDSA Cycles
• Clinical Education and Role Modeling
• Culture • Sustainability
4. Measurement Clinical Issues Tested
• PDSA Results: – Reduced time to analgesia from 81 to 32 minutes during analgesia
protocol use – Reduced ALOS from 121 to 108 minutes for returning IV antibiotic
patients – Registered Nurses (RNs) participating in a research project regarding
RN initiated extremity X-Ray ordering
4. Measurement Issue: Delays at Triage and Registration
• Arrival to Triage Wait Time exceeds CTAS Guidelines • Average wait time is over 30 minutes
– Outliers greater than 90 minutes – This time is currently not being measured
4. Measurement Test: Pivot Nurse at Triage
• Concept: streaming patients at first point of contact – Two defined care streams in
the ED (Acute and Fast Track)
– Improve patient experience – Reduced interruptions for
triage nurses and registration clerks
• Results: Reduced average arrival to triage wait time from 30 to 7 minutes
4. Measurement PDSA Cycles: Pivot Nurse at Triage
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Tim
e in
Min
utes
Date of Observation
Run Chart - Lions Gate Hospital - Emergency Department - PDSA Cycles: Arrival to Triage Wait Time (Observed Patients)
Median
Measure
PDSA Cycle #1:Lower Surge Protocol
PDSA Cycle #2:Pivot Nurse - Quick Admit
PDSA Cycle #3:Pivot Nurse - Clipboard
PDSA Cycle #4:Pivot Nurse - ClipboardClinical Nurse Leader - First Aid
5. Challenges & Lessons Learned Success and Limitations
• Success – Time – Organizational Support – Staff Engagement – Communication – Culture – Sustainability
• Limitations – Time – Resources – Staff Engagement – Communication – Culture
Time to triage/reg with Pivot pivot observations
0
5
10
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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
patient visit
time
in m
inut
es
time
Arrival to triage Feb 8 2014
arrival time to triage completion
0.00
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Arrival to Triage (Min)
min
ute
s
11:31 2 pm 6:20 pm 11:20 pm
Pivot survey Jan 2014 (n=33) • “Make the pivot role more versatile.” • “There can be a lot of standing around..” • “It depends on who is working.” • “The most helpful pivots take charge of the
WR.” • “It can be stressful….limit length of shift.” • “When its done well its incredibly helpful.”
Questions?
• [email protected] Health System Planning Advisor
• [email protected] Emergency Clinician
Appendix
• Evidence: – Martin, M. (2012) A Pivot Nurse at Triage, Journal of Emergency Nursing, 38 (1) – Mc Hugh, M., Van Dyke, K., Mc Clelland, M. & Moss, D. (2011) Improving Patient
Flow and Reducing emergency Department Crowding: A Guide for Hospitals, Agency for Healthcare Research and Quality – AHRQ, Accessed at http://www.ahrq.gov
– Victorian Government (2008) Discussion Paper, Streaming Care; Fast track services in hospital emergency departments, Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services, Melbourne, Victoria; Accessed at www.health.vic.gov.au/emergency