Closing the Gap: The Role of Discharge Nurses in an Emergency Department.

INTRODUCTION: Patients discharged from the emergency department may require a follow-up appointment with an outpatient specialty clinic. Referral processes vary by clinic, some requiring faxed referrals, some providing appointments immediately, and others contacting the patients directly. The frequency with which patients are successfully connected with outpatient follow-up services is largely unknown. METHODS: The ED discharge nurse role was developed to facilitate the navigation of patient follow-up and confirm that patients successfully connect with specialty outpatient clinics. Eight emergency nurses were recruited into this position to study the problem using a quality improvement approach. The ED discharge nurses reviewed referrals, contacted clinics and patients discharged from the emergency department, and intervened when barriers to transition occurred. RESULTS: The ED discharge nurses were able to determine specific causes and themes of missed appointments experienced by patients. Systemic problems identified include lost faxes, illegible contact information, incomplete referrals, and referral refusals by the clinics without patient notification. Considering the variability of clinic processes outside the emergency department's control, the ED discharge nurse role became crucial in minimizing the risk of lost/unsuccessful follow-up for patients discharged from the emergency department. DISCUSSION: Implementing the ED discharge nurse role created a contact for outpatient clinic referrals, patient inquiry, and a process to track errors and data to better understand the frequency of missed follow-up. In this quality improvement initiative, the role of the ED discharge nurse addressed the risk of patients falling through the cracks of a complex system.

A blueprint for building an emergency department quality improvement and patient safety committee.

The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, "Leading Change." Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a "burning platform," select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.

RéSUMé: Le domaine de l'amélioration de la qualité de la pratique clinique et de la sécurité des patients (AQSP) s'est considérablement développé en médecine d'urgence au cours de la dernière décennie. Alors qu'il y a quelques années, les projets d'AQSP étaient autonomes, mal alignés sur le plan stratégique et conçus de manière incohérente, les responsables des services d'urgence (SU) reconnaissent aujourd'hui que la mise en place d'une infrastructure d'AQSP plus solide permet de hiérarchiser et d'organiser les projets pour qu'ils aient plus de chances de réussir et d'avoir un impact sur les patients et le système. Ce processus comprend le développement d'un comité d'AQSP départemental bien défini, responsable et soutenu. On peut y parvenir efficacement en utilisant une approche délibérée et structurée, comme celle décrite par le professeur John Kotter de la Harvard Business School dans son ouvrage phare intitulé « Leading Change ¼. Dans le présent document, nous présentons un plan à l'aide de ce cadre et incluons des exemples pratiques tirés de notre expérience de l'élaboration d'un comité et d'une infrastructure d'AQSP de SU solides et réussis. Les étapes comprennent la façon d'élaborer une « plateforme brûlante ¼, de sélectionner une coalition de dirigeants, d'élaborer une vision et des initiatives stratégiques, de recruter une armée de membres bénévoles, de permettre des actions pour le comité, de générer des succès à court terme, de maintenir le rythme du changement et enfin, permettre à l'infrastructure de soutenir les améliorations en cours. Cette feuille de route peut être reproduite par des équipes d'urgence de tailles et de contextes différents pour structurer, hiérarchiser et rendre opérationnelles leurs activités d'AQSP et, en fin de compte, améliorer les résultats de leurs patients.

Improving Emergency Department flow through optimized bed utilization.

Over the last decade, patient volumes in the emergency department (ED) have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion has spilled over to the ED waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. The aim of this quality improvement project was to decrease the 90th percentile of wait time between triage and bed assignment (time-to-bed) by half, from 120 to 60 minutes, for our highest acuity patients. We engaged key stakeholders to identify barriers and potential strategies to achieve optimal flow of patients into the ED. We first identified multiple flow-interrupting challenges, including operational bottlenecks and cultural issues. We then generated change ideas to address two main underlying causes of ED congestion: unnecessary patient utilization of ED beds and communication breakdown causing bed turnaround delays. We subsequently performed seven tests of change through sequential plan-do-study-act (PDSA) cycles. The most significant gains were made by improving communication strategies: small gains were achieved through the optimization of in-house digital information management systems, while significant improvements were achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie). In the post-intervention phase, time-to-bed for the 90th percentile of high-acuity patients decreased from 120 minutes to 66 minutes, with special cause variation showing a significant shift in the weekly measurements.

Theoretical framing of high-fidelity simulation with Carper's fundamental patterns of knowing in nursing.

Many nursing programs integrate high-fidelity simulation(HFS) into the curriculum. The manikins used are modeled to resemble humans and are programmed to talk and reproduce physiological functions via computer interfaces.When HFS design negates a theoretical framework consistent with the interpersonal and relational nature of nursing,it can problematically focus simulation on psychomotor skills and the physical body. This article highlights a theorized approach to HFS design informed by Carper's seminal work on the fundamental patterns of knowing in nursing(i.e., empirics, esthetics, personal knowing, and ethics). It also describes how a team of Canadian nurse educators adopted these patterns of knowing as a theoretical lens to frame scenarios, learning objectives, and debriefing probes in the context of maternal and newborn assessment. Institutions and practitioners can draw on Carper's work to facilitate focusing on the whole person and expanding the epistemological underpinnings of HFS in nursing and other disciplines.