A blueprint for building an emergency department quality improvement and patient safety committee.
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ABSTRACT:
SUBMITTER: Chartier LB
PROVIDER: S-EPMC8808466 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:IntroductionPatient portal enrollment following pediatric emergency department (ED) visits allows access to critical results, physician documentation, and telehealth follow-up options. Despite these advantages, there are many challenges to portal invitation and enrollment. Our primary objective was to improve patient portal enrollment rates for discharged pediatric ED patients.MethodsA multidisciplinary team of staff from two ED sites developed successful portal enrollment interventions through sequential Plan-Do-Study-Act cycles from October 2020 to October 2021. Interventions included a new invitation process, changes to patient paperwork on ED arrival, staff portal education, and changes to discharge paperwork and the portal website. The team utilized statistical process control charts to track the percentage of eligible discharged patients who received a portal invitation (process measure) and enrolled in the patient portal.ResultsBefore the study's initiation, less than 1% of eligible patients received patient portal invites or enrolled in the patient portal. Statistical process control charts revealed significant changes in enrollment and baseline shift at both a large academic ED campus and a satellite ED site by May 2021. Improvements in invitation rates were also observed at both campuses. Changes were sustained for over 6 months at both locations.ConclusionsHigh-reliability interventions and a multidisciplinary approach allowed for significant and sustained improvement in patient portal invitation and enrollment rates in eligible pediatric ED patients. Future study will examine enrollment patterns across patient demographics and further high-reliability interventions.
| S-EPMC10990375 | biostudies-literature
Project description:IntroductionEmergency airway management of critically ill children in the Emergency Department (ED) is associated with the risk of intubation-related desaturation, which can be minimized by apneic oxygenation. We evaluated the use of apneic oxygenation in the pediatric ED and reported a quality improvement initiative to incorporate apneic oxygenation as a routine standard of care during rapid sequence intubations (RSIs).MethodsA baseline period from June 2016 to April 2017 highlighted the practice gaps. Quality improvement interventions were subsequently developed and implemented as a care bundle consisting of a pre-intubation checklist, placing reminders and additional oxygen source in resuscitation bays, incorporating into the responsibilities of the airway doctor and the airway nurse (copiloting), education during airway workshops and simulation training for doctors and nurses, as well as enhancing documentation of the intubation process. We monitored a post-intervention observation period from May 2017 to April 2018 for the effectiveness of the care bundle.ResultsApneic oxygenation was not performed in all 22 RSIs during the baseline period. Among 25 RSIs in the post-intervention observation period, providers performed apneic oxygenation in 17 (68%) cases. There was no significant difference in the utilization of apneic oxygenation among emergency physicians and pediatric anesthetists performing RSIs in the pediatric ED.ConclusionsWe successfully implemented a care bundle targeted at incorporating apneic oxygenation as a routine standard of care during emergency intubations performed in ED. This method could be adopted by other pediatric EDs to improve airway management in critically ill children.
| S-EPMC7190240 | biostudies-literature
Project description:IntroductionAirway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period.MethodsAn airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means.ResultsEM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = -7.9%, 95% CI -13.4% to -2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%).ConclusionThe use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events.
| S-EPMC6625676 | biostudies-literature
Project description:The initial management of transient ischaemic attacks (TIAs) effectively triages patients into either high or low risk categories. The literature demonstrates that the identification of high risk patients significantly reduces the subsequent risk of stroke. The administration of aspirin following a TIA reduces the risk of stroke by approximately 25%. A full cycle retrospective audit which included a baseline audit with two improvement cycles was completed. The notes of every patient presenting to Croydon University Hospital's emergency department (ED), who were subsequently diagnosed with a TIA were reviewed, with the aim of identifying areas for improvement and to implement sustainable long term interventions aimed to improve patient safety. The patient's notes were compared with the guidelines for the management of TIA. The baseline audit demonstrated results requiring an immediate intervention. A teaching session was provided for new FY2 doctors starting their emergency medicine rotations, which covered the initial management of TIA and the importance of following the local guideline. The first improvement cycle saw an improvement in all outcomes measured. A statistically significant improvement (P-value = 0.05) was seen in the documentation of symptoms in the prior week and the prescription of antiplatelets in the department. Furthermore, where only 31% of TIA patients received antiplatelets at the baseline measurement, 86% received this treatment during the first improvement cycle. This means that 55% more patients received improved initial management, subsequently reducing their stroke risk by 25%. Similar results were seen in the second improvement cycle, thus demonstrating the intervention had been both successful and sustainable. In conclusion, a simple intervention can provide significant and sustainable improvements to the management of TIA in the ED.
| S-EPMC4645805 | biostudies-other
Project description:Introduction:Discharge prescription errors from the pediatric emergency department (ED) are common. Despite the implementation of clinical pathways for common infections recommending specific antibiotic therapy and aids built into the electronic health record, errors in antibiotic prescriptions for patients discharged home from the ED persist. Methods:We developed and implemented ED antibiotic discharge order panels for urinary tract infection (UTI) and skin and soft tissue infections (SSTI) that modeled antibiotic therapy from our institutional clinical pathways. We aimed to reduce antibiotic prescription errors by 50% within 6 months of implementation. Results:With the implementation of the ED discharge order panels, the overall error rate for prescriptions for UTI and SSTI improved from a baseline rate of 29.3% to 12.6% (P < 0.001). Individually, the baseline number of prescriptions with errors for UTI and SSTI improved from 26.1% and 32.8%, respectively, to 13.8% and 12.5% within 6 months. Sustained improvement continued for 17 months after the implementation of the order panels. Conclusions:Development and implementation of ED antibiotic discharge order panels decrease antibiotic prescription errors for UTI and SSTI by improving compliance with institutional clinical pathways. Additional order panels should be developed and implemented for other conditions to help reduce discharge prescription errors.
| S-EPMC7339249 | biostudies-literature
Project description:IntroductionClinical alarms promote patient safety by alerting clinicians when there is an indication or change in a condition requiring a response. An excessive volume of alarm fires, however, contributes to sensory overload and desensitization, referred to as alarm fatigue, which has significant implications when alarms are missed. This evidence-based, practice project aimed to implement and evaluate a program that reduces the number of clinically nonactionable, physiologic alarms in an emergency department. Although alarm fatigue is an important negative consequence, the focus of this project is not on alarm fatigue but on measures to reduce the volume of clinically nonactionable alarms that lead to alarm fatigue. The Iowa Model was used as a conceptual framework.MethodsThis project involved adjusting default alarm settings and implementing an education plan on the safe use of alarms. The sample population included all patients on physiologic monitors at an emergency department. Retrospective data were collected, and regression discontinuity design was applied to compare the rate of alarm fires triggered by the physiologic monitor between pre- and postimplementation of an alarm protocol.ResultsA significant change in the rate of alarm fires occurred with an estimated reduction of 14.96 (P = 0.003). There were no reports of adverse outcomes such as a delay in responding to a change in patient condition or delay leading to cardiopulmonary arrest.DiscussionA reduction in nonactionable, physiologic alarms was attained after implementing multimodal strategies inclusive of adjusting default settings, staff education on managing alarms, and emphasis on staff accountability.
| S-EPMC7071970 | biostudies-literature
Project description:ObjectivesEmergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding.MethodsThis was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures.ResultsThe mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005).ConclusionsAn increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.
| S-EPMC4046120 | biostudies-literature
Project description:Constipation is a common problem in pediatric patients. Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department for diagnosis despite their poor reliability to rule out underlying pathology or prognostic ability to determine the degree of constipation. The goal of this quality improvement (QI) initiative was to standardize the diagnosis and management of constipation in the pediatric emergency department and urgent care in patients ages 6 months to 21 years and decrease AXR use by 20% and sustain this reduction for 12 months.MethodsThis prospective QI project involved a multidisciplinary team at a large urban pediatric tertiary care center. The study team constructed a key driver diagram and identified interventions, such as creating a standardized evaluation and management algorithm for constipation, using free open-access medical education platforms, incorporating the electronic medical record interface, and expanding educational conferences to include standardized approach and discharge instructions for patients with constipation across all acuity levels. The primary measure of AXR utilization was tracked overtime on a statistical process control chart to evaluate the impact of interventions.ResultsThe percentage of visits for constipation that included an AXR decreased from a baseline of 49.6%-37.1%, a 25% reduction. Length-of-stay, return visits within 7 days, and inpatient admissions remained unchanged by the interventions.ConclusionsQI methodology successfully decreased AXR utilization in the evaluation of constipation across a broad spectrum of acuity levels. Further interventions may help to decrease the length of stay and further decrease AXR utilization.
| S-EPMC7952117 | biostudies-literature
Project description: Not available
| S-EPMC10715784 | biostudies-literature
Project description:IntroductionFirearm injury prevention discussions with emergency department (ED) patients provide a unique opportunity to prevent death and injury in high-risk patient groups. Building mutual understanding of safe firearm practices between patients and providers will aid the development of effective interventions. Examining ED patient baseline characteristics, perspectives on healthcare-based safety discussions, and experience with and access to firearms, will allow practitioners to craft more effective messaging and interventions.MethodsUsing an institutional review board-approved cross-sectional survey modified from a validated national instrument, we recruited 625 patients from three large, urban, academically affiliated EDs in the South to assess patient baseline characteristics, perspectives regarding firearms and firearm safety discussions, and prior violence history, as well as firearm access and safety habits. We compared the degree to which patients were open to discussions regarding firearms across a variety of provider types and clinical scenarios between those with and without gun access.ResultsOf the 625 patients consented and eligible for the study, 306 had access to firearms. The patients with firearm access were predominantly male, were more likely to have military experience, live in an urban or suburban region, and have experienced prior violence when compared to those without firearm access. Patients with and without gun access view firearm safety discussions with their healthcare provider as acceptable and analogous to other behavioral health interventions (i.e., helmet/seat belt use, alcohol/cigarette use). Patients were also accepting of these firearm safety discussions in many clinical contexts and led by multiple provider types. Of the patients with gun access, storage of each type of firearm was reviewed and the primary reason for ownership was for personal protection across all firearm types.ConclusionPatients in the ED indicate openness to firearm safety discussions delivered by a variety of providers and in diverse clinical scenarios. Healthcare providers engaging firearm owners in appropriate risk-benefit discussions using a trauma-informed approach is a critical next step in research and intervention.
| S-EPMC8203031 | biostudies-literature