Canadian Journal of Emergency Nursing (CJEN)
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Improving assessments and follow-up for pediatric emergency department mental health visits
No full textBackground: Over the past decade, the number of children presenting to emergency departments (ED) with mental health (MH) concerns has increased substantially. EDs struggle to respond to this increase with approaches that comprehensively address patient needs. The lack of standardized processes to perform risk stratification, assess severity, and ensure access to follow-up care pose barriers to the provision of safe MH care. Our team addressed this gap by introducing an evidence-based care bundle to Alberta’s two pediatric EDs. This report presents the quality improvement (QI) approach used to ensure fidelity of implementation at one of the EDs. This initiative was funded by Alberta Innovates (Partnership for Research and Innovation in the Health System; PRIHS).
Methods: We used the Model for Improvement to test and implement each bundle element: suicide risk screening (Ask Suicide-Screening Questions [ASQ]) at ED triage; a tool (HEADS-ED) to streamline and standardize MH assessments by ED-based MH nurse); and an urgent, single-session ‘Choice Appointment’ with a MH professional within 96 hours of the ED visit for patients lacking access to appropriate and timely MH follow-up care. The two ED-based bundle elements did not require additional resources or funding and are expected to reduce length of stay. The follow-up clinic option for ED patients without resources is intended to prevent crisis escalation and match patients with supports. Each new practice was introduced sequentially over a 2-week period. For each practice, we identified 1 to 2 improvement aims, developed key driver diagrams, and selected primary outcomes and measures. Each practice was implemented using Plan-Do-Study-Act (PDSA) cycles with initial tests of change starting small and becoming larger as learning accrued from previous cycles. Our QI team included families with lived experience, patient care and unit managers, nurse educators, frontline healthcare providers, content experts, and clinical leaders who supported staff and led change management strategies. A nurse was hired as a QI lead to support execution of PDSA cycles. We developed a sustainability plan which included embedding education regarding new practices in new healthcare staff orientation, having a measurement strategy to ensure that improvement was maintained, and planning for transition of responsibility for these processes to operational and medical leadership.
Evaluation Methods: Primary aims included: 80% of targeted patients would receive the ASQ and HEADS-ED and 100% of children eligible for an Urgent, single-session ‘Choice Appointments’ would be offered it within 96 hours. We used clinical data from the electronic health record (Epic/Connect Care) as well as patient experience data collected via parent/caregiver surveys to determine if the aims for each practice were achieved. We included balancing measures to test whether changes in care in one part of the system introduced unintended consequences in other parts. We evaluated results for the primary aims using run charts to rapidly detect change according to established rules for detecting special cause. We discussed the results from each PDSA cycle in the context of existing healthcare resources to support implementation of each element of the bundle.
Results: Tests of change to introduce suicide risk screening began February 1st, 2021. Performance was measured in weekly intervals. The median initial use of ASQ by triage nurses was with 77% of MH patients (686/901 patients), and over time, improved to 93% (319/350 patients), with special cause (shift) in noted September 2021. Tests of change to introduce the HEADS-ED tool began February 16th, 2021. Initial use of the HEADS-ED by MH nurses was 81% (440/555) and improved to 87% (201/227) with special cause (shift) noted August 2021. Urgent, single-session ‘Choice Appointments’ were offered to all patients who did not have timely and access to urgent follow-up with an existing mental healthcare provider with 89.1% having an appointment booked within 96 hours of the ED visit (139/156).
Advice and Lessons Learned: Three plans were viewed as crucial to the success of this initiative: 1) a robust strategy to develop proposed changes based on best evidence combined with patient and staff engagement; 2) a comprehensive QI strategy to test, measure, and implement changes; and 3) regular communication and collaboration among ED staff, mental healthcare staff, patients/families, and hospital leadership. There were also lessons learned regarding what could have further enhanced project success: 1) enhanced communication strategies using multiple methods to ensure that project communications reached all stakeholders, including those not regularly present in the ED; 2) hiring the QI lead earlier to begin change management prior to bundle implementation; and 3) outlining a transition plan for clinical data management and bundle monitoring earlier to ease the QI transition to clinical leadership
Que signifie la TA : suivez-vous LA TAM?
Full text linkThe purpose of this case study is to help determine if emergency nursing education should include a focus on mean arterial pressure (MAP) and Pulse Pressure (PP) as part of their regular curriculum. We also considered if monitoring and trending BP, MAP and PP in patients who present with symptoms that may indicate a pulmonary and/or cardiac complaint, along with abnormal vital signs or abnormal lab values, would result in more timely intervention. Through this case study we hope to show that trending MAP may help identify early hypovolemic shock, severe sepsis and other significant life threatening conditions.L’objectif de cette étude de cas est d’examiner le profild’un patient du service des urgences qui se plaint dedouleurs dorsales chroniques et d’essoufflement. Nousproposons que la vérification et l’évolution de la pressionsanguine, de la pression artérielle moyenne et du poulsdes patients qui présentent des symptômes pouvantindiquer un problème pulmonaire ou cardiaque, ainsi quedes signes vitaux anormaux ou des valeurs de laboratoireanormales, permettent d’intervenir plus rapidement.Par cette étude de cas, nous espérons encourager lesprofessionnels de la santé à considérer l’importance dela tendance de la pression artérielle moyenne pour aiderà identifier de manière précoce le choc hypovolémique,la septicémie grave et d’autres conditions importantesmettant la vie en danger, ainsi du besoin qu’a le personnelinfirmier de formation continue
An electronic audit tool to track the donning and doffing practices of personal protective equipment in the emergency department
Full text linkAn electronic audit tool to track the donning and doffing practices of personal protective equipment in the emergency department
Maya Jusza, Ramya Sridhar, Jennifer Woods, Sharon Drury
Background: Maintaining the safety of patients and healthcare professionals is a priority in all healthcare settings. Infection prevention measures such as donning and doffing practices of personal protective equipment (PPE) have become even more imperative in light of the SARS-CoV-2 pandemic. Potential PPE breaches and the degree of frontline compliance are currently being analyzed through the use of paper PPE audit tools which can be laborious and time-consuming. The development of an electronic alternative would improve frontline safety and enhance the efficiency of data collection, while optimizing the ability to share these observations with the frontline team in real time. Two nursing leadership students from the University of Alberta were tasked with developing an electronic PPE audit tool prototype for the University of Alberta Hospital’s emergency department.
Implementation: An electronic PPE audit tool prototype was developed using Google Forms which provided a user-friendly interface. Google applications were used as no confidential or patient data was collected during PPE audits. The prototype auto-populated the data entries into linked spreadsheets and interactive data dashboards that visualized the data using graphs in real time. This enabled users to easily identify trends and direct educational interventions as required. Instructional one pagers and screencast videos were also created to accompany the prototype.
The prototype was reviewed by and received extensive support from: Unit Managers, Patient Care Managers, Process Improvement Nurses, Infection Prevention Control (IPC), the Executive Director of the University of Alberta Hospital and Stollery emergency department and Edmonton Zone medicine programs, and the University of Alberta Hospital and Mazankowski Executive Leadership Team. Several changes and improvements were made using the Plan-Do-Study-Act cycle. This prototype has currently been replicated onto an Alberta Health Services (AHS) server and has completed the formal testing phase with a planned application launch date.
Evaluation Methods: Plan-Do-Study-Act cycles were used to guide the implementation of this audit tool prototype. After development, the prototype was tested and revised which included six rounds of audit trials at the University of Alberta Hospital’s emergency department and on some inpatient medicine units. This prototype was consistently evaluated at various stages of development and changes were made to include feedback. After approval was received to recreate this prototype onto an AHS compatible server, additional changes were made to ensure functionality. These changes included adding designations and simplifying certain questions. IPC was consulted to ensure the steps outlined for donning and doffing in the prototype were accurate and reflected requirements in the clinical environment.
Results: This audit tool prototype has gathered tremendous support through various demonstrations of its ability to streamline data collection in the healthcare setting. This data is relevant to the safety of both frontline workers and patients as it identifies inconsistencies in donning and doffing practices. In addition, the prototype also complements the Edmonton zone-wide PPE coaching initiative by allowing for a quantitative measurement of its efficacy. This has prompted the fast-tracked replication of an AHS compatible version with the assistance of a dedicated team that includes the creators of the prototype tool, IPC, Quality Assurance, Information Technology, and Clinical Services Development. This version has a scheduled launch date on March 22, 2021 and is to be initially rolled out to University of Alberta’s emergency department and medicine units. The objective is to eventually make this the standardized PPE audit tool throughout Alberta.
Advice and Lessons Learned:
1) In order to be sustainable and implemented site-wide, an AHS compatible tool isrequired. The use of Google applications is not preferred as data will be stored outside ofthe AHS server. Even though there is no confidential information, wide-spread use mayoverwhelm the Google platform and a Gmail account is required to view data. An in-house AHS alternative has been developed.
2) Several discussions took place regarding discretions on what steps can be auditedaccording to IPC protocols. For example, some clinical nurse educators prefer handhygiene to be completed between donning steps, while this is not mandatory or auditableaccording to IPC. In addition, several discussions took place to identify the operationaland business owners of this tool which are required to support the AHS compatibleversion of the application.
3) PPE audits are vital across all hospital departments to improve the quality of healthcare.The use of PPE during patient care has grown exponentially due to the SARS-CoV2pandemic and has amplified the need for an electronic alternative to the existing paperPPE audit tool. The electronic audit tool offers an innovative way to accurately andefficiently collect and display data which will promote an improved quality of care
Cover Art - Vol. 43, No. 2, Fall 2020
No full textAnna Roth Trowbridge is an Emergency Nurse with an interest in harm reduction, mental health, psychedelic research, and community-based alternatives to policing in healthcare. She studied Cognitive Science and English Theatre at McGill University before completing her nursing degree at University of British Columbia. Anna is currently embarking on a new nursing position in the community in Vancouver, providing care to pregnant folks and their families on the Downtown Eastside
Un commentaire sur le plan d’action pour moderniser le genre, le sexe et l’orientation sexuelle en matière d’information dans les systèmes de santé numériques canadiens
Full text linkPractice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project
Full text linkPractice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project.
Megg Wylie, Amelia Srajer, Kevin Lonergan, Philippa Brain, Eddy Lang
Background: Practice variation in the management of spontaneous abortion exists in the Emergency Department (ED). We developed a multisite retrospective study to assess how the management of spontaneous abortion has changed over 2014-2019 across four Calgary EDs, with emphasis on assessing variation and trends between non-operative (medical/expectant) and operative (dilatation and curettage) management. Medical management has been increasingly indicated as effective, yet a knowledge gap exists regarding its use. Knowledge of that proportion and physician-level practice variation will facilitate educational and audit and feedback style initiatives. Results provide justification and supporting data for said initiatives, which may be extrapolated to elsewhere.
Implementation: Two medical students are heading the day to day work of this project, with support from a principal investigator with the Department of Emergency Medicine in Calgary. We also have the support of a data manager and the head of pregnancy loss in the region. This study was implemented as a quality improvement project. Therefore, the Conjoint Health Research Ethics Board at the University of Calgary was consulted to ensure the project qualified as a quality improvement and that our privacy protections were appropriate. With approval from the ethics board, we needed the data to analyze and assess. To do so, we utilized Sunrise Clinical Manager (SCM) to retrospectively collect data. Sunrise Clinical Manager, a system utilized in Calgary EDs to track patient and department information, was accessed to collect administrative data. Sustaining this work will involve the continued efforts of the described team, largely in writing up the results and disseminating them via audit and feedback procedures.
Evaluation Methods: Using SCM, data were retrospectively collected for patients coded with International Classification of Disease (ICD-10) codes O03.4 (incomplete spontaneous abortion without complication) or O02.1 (missed abortion) who presented to an ED in Calgary (Foothills Medical Centre, Peter Lougheed Centre, South Calgary Hospital, and Rockyview General Hospital) over 2014-2019. We collected patient and environmental factors to allow for the examination of unintended associations. Hemoglobin, HCG level, CTAS code, PIA (time to MD), and U/S result (to confirm diagnosis) were collected. Variables regarding length of stay, procedures received (D&Cs, or other), and returns to care (within 72 hours, and 7 days) were collected. Return to care for future D&C was considered a proxy for failed non-operative management. Demographic and practice data were collected on ED physicians who saw a minimum of 15 patients from our cohort, to gain understanding of trends in practice. Data were analyzed using Chi-square and Mann-Whitney U tests.
Results: Within our cohort, 1110 (28.9%) patients received a D&C. The remaining 2735 (71.1%) patients were managed non-operatively. Variation and trends were present between sites, with rates of D&Cs ranging from 15.8% to 33.5% (p <0.001). The rate of D&Cs decreased from 34.2% in 2014 to 22.6% in 2019 across all sites (p <0.001), and 11.6% absolute and 33.9% relative reduction; yet there was minimal variation over time in rates of ED returns and returns resulting in D&Cs. 78.6% of physicians who saw ≥ 15 patients were female, with female physicians responding to 81.8% of our cohort
Advice and Lessons Learned:1) Our first suggested lesson is to have a clear plan regarding deadlines and timelines, but toalso have room for flexibility. At some times the work on this project was slowed to alloweffective collaboration with the obstetrics and gyneocology department, or to allow for therefinement of data management. By setting realistic timelines, team members wereencouraged to progress the work in a timely fashion. However, by having flexibility the teamwas able to adapt to roadblocks along the way.
2) A second lesson would be the importance of meaningful collaboration between departments.Though the setting of the project was within Calgary EDs, the topic and content have clearrelevance to obstetics and gynaecology. By consulting with members of the obstetrics andgynaecology department we were able to clarify our objectives and have a betterunderstanding of local contextual factors that influenced our results
An analysis of individual and department triage variances to identify, quantify, and improve markers of triage nurse accuracy
Full text linkAn analysis of individual and department triage variances to identify, quantify, and improve markers of nurse triage accuracy.
Rebecca Cotton, Richard Drew, Matthew Douma, Domhnall O’Dochartaigh, Candice Keddie, Karen Muncaster, Christopher Picard
Background: Canadian Emergency Departments (ED) use the five-point Canadian Triage Acuity Scale (CTAS) to sort and prioritize patients according to acuity. CTAS scores are used to make decisions on patient flow, staffing complement, and funding. Despite this, there is a paucity of literature describing how CTAS data can be audited, and how the data can inform quality improvement/assurance (QI/QA).
Implementation: Triage data downloaded from Tableau were analyzed using Microsoft Excel and IBM SPSS 26. Staff were informed of the audit using email and social media, and invited to discuss the results with educators and administrators. Staff identified for intervention were approached individually with the administrative plan. Anonymized versions of the work plan were posted on the departmental audit board. Nurses triaging greater than 50% department average were offered the option to triage less frequently, while nurses triaging less than 50% the department average were preferentially placed in triage. Nurses triaging fewer than 100 patients per year were informed they would be relieved of triage responsibility unless their rates increased above threshold. Nurses “down-triaging” patients at rates greater than 2 SD were informed that if their practice remained outside 2 SD at repeat audit they would be relieved of triage responsibility until they voluntarily completed CTAS refresher training. Nurses with average assigned CTAS scores > 2 SD department average had 20 visits randomly audited per month for error/appropriateness.
Evaluation Method: Computer-assisted analysis of complete triage records was conducted for August 2019 to August 2020 at the Misericordia Hospital Emergency. Complete triage entries of every patient triaged by all triage trained nurses in the department were examined. Nurse’s with practice variation two deviations from department mean were identified and received additional detailed audits. Items examined for error were: FTE adjusted triage frequency; average CTAS score assigned; triage score manual override “down/up-triage” rate; proportion of absent Numeric Pain Scores (NPS) for patients with primary presenting complaints of pain; and vital signs modifier error rates. Initial department averages were used for benchmarking individual nurses; zone averages were used to benchmark department performance. Nurses were interviewed, audit results and action plans were posted. Repeat audits were performed on a three-month basis and benchmarked to initial measures, and a staff awareness campaign was enacted to improve NPS scoring. Data were extracted using text-parsing algorithms programmed into Microsoft Excel and analyzed using IBM SPSS 26. Data were normally distributed and descriptive statistics were calculated using means and standard deviations. T-testing was used for comparisons, and all testing was two-tailed with a pre-defined significance set at 0.05.
Results: After the 3rd quarterly audit and associated interventions, global improvements were appreciated in triage nurse practice. There was a 68% reduction in the need for administrative action (n=51, n=18) with reduced variance in individual nurse triage rates and a 50% reduction in nurses who triaged >50% more patients than their peers. 50% fewer nurses had a mean triage rate >.02 above or below department average, there was an 86% reduction in high risk vital sign error rates, a 78% reduction in ”down-triage” rates, and a 6.5% improvement in documentation of numerical pain scores.
Advice and Lessons Learned:1) Triage data analytics can rapidly identify staff with significant deviations from the average,making auditing and QI/QA activities more efficient and effective.
2) Having a concrete performance management framework and dissemination plan in place areessential for auditing to have a significant impact on triage consistency and quality over time.
3) Future QI/QA work should consider expanding computer-assisted text parsing to identifypatients at risk for mis-triage for reasons other than vital sign derangement, which will allowfor broader ED rollout across the Edmonton Zone and beyond
Time modifier billing code - an interrupted time series analysis
Full text linkTime modifier billing code: Interrupted time series analysis.
Terrence McDonald, Brendan Cord Lethebe, Alistair McGuire, Lee Green
Background: Alberta has the highest percentage of fee-for-service Family Physicians in Canada at over 80%. In 2019 as part of a cost containment strategy, the Alberta government proposed a policy change to eliminate the most used fee code that compensates family physicians for extended visit times (16-25 minutes). Optimal length for patient visit times varies throughout the world and countries with health systems that place emphasis on relational continuity demonstrate a trend towards longer appointment times. In Canada, the relationship between visit length and outcomes is not known.
Implementation: What would be the likely consequences of eliminating the extended visit code? We examined this question using two different observational methods, to improve confidence in our findings: a retrospective longitudinal cohort (time series) around the time the code was introduced in 2009, and a cross-sectional cohort at current time. We explored the usage patterns of that fee code, its association with the outcomes of emergency department visits and hospitalizations, along with physician billings.
Results: We found rates of emergency department visits decreased after the time-modifier code was implemented starting in 2010. This effect was maintained in the years that followed. A similar but less pronounced effect was observed in the hospitalization rates. The cross-sectional analysis had to include an interaction term because family physicians selectively extend visits for patients at risk, but when that is accounted for, the same effect is observed as in longitudinal results. The code was not used ubiquitously among primary care providers, especially in rural areas. Female physicians used it more often. Users use it for an average of 40% of 03.03A office visits. Non-users of the code earned more income than their user-colleagues.
Conclusion: We believe our findings will fill an important gap in informing the importance of an extended time service billing code in a fee-for-service system in reducing ED visits and hospitalizations.
Advice and Lessons Learned:
The fee-for-service time-modifier code, introduced in 2009, resulted in reduced ED visits and hospitalizations. It is likely that discontinuing the code would result in increased ED and hospital utilization, costing much more than removing the code would save. Usage of the time-modifier code was not uniform among primary care. Users of the code had different practice patterns and provider demographics. Our next step is to model the uptake of the code by primary care providers and explore the health system utilization and down-stream costs between users and non-users of the code
The Alberta Health Services Emergency Strategic Clinical Network Quality Improvement and Innovation forum 2021
Full text linkThe Alberta Health Services Emergency Strategic Clinical Network Quality Improvement and Innovation forum 2021.
Patrick McLane and Eddy Lang on behalf of the Emergency Strategic Clinical Network
Evidence-based research and quality improvement work are pivotal to health systems meeting their goals. Translating findings and disseminating innovative practices to new settings occurs in part through knowledge translation events, such as conferences and workshops.
The Emergency Strategic Clinical NetworkTM (ESCN) Quality Improvement and Innovation forum fills a gap between local and national events. It is devoted to sharing methods and results of emergency department projects in Alberta among those working in emergency care. 2021 was the third consecutive year the ESCN has held this event.
The event provides an opportunity for those working on quality improvement in emergency medicine to network with one another, share innovative projects, share know how and translate promising works to new settings. In addition, the event provides an opportunity to identify projects for potential development through local, provincial, or national funding opportunities.
In light of the ongoing pandemic, this year’s forum was held virtually with the support of the University of Calgary Continuing Medical Education group. Funding was kindly provided by the College of Physicians and Surgeons of Alberta. Nineteen teams presented their projects orally. Invited nurse and clinician scientists ranked all submissions to the forum, and the top ranked submissions were recognized in the following categories:Submissions by ESCN staff and the event sponsor were not eligible for recognition.
A new feature this year was a presentation by ESCN patient advisors on their perspectives on quality improvement, which was well received by all.
Strong attendance shows the value practitioners see in the forum. In 2021, the forum was attended by approximately 140 educators, managers, nurses, physicians and researchers from across Alberta. This is a marked increase over previous years. Post-event evaluation survey feedback suggests that the online format was greatly appreciated and made the event more accessible. Requests for more rural oriented content in event feedback may also indicate that the event drew more rural attendees this year.
We are pleased to partner with the Canadian Journal of Emergency Nursing to make abstracts from the event widely available. Individual presenters have had the option of submitting their abstracts for publication in CJEN. In some instances, abstracts have already been published through other conferences and so could not be submitted to CJEN.
The findings presented in the abstracts are solely the work of the submitting authors. The ESCN does not guarantee the accuracy of any reported information. The views expressed in the abstracts are solely the views of the authors and do not represent the ESCN or Alberta Health Services.
Correspondence to: [email protected]