Assessing the Impact of ED Triage Directives on Febrile Oncology Patient Wait Times.

INTRODUCTION: Fever during chemotherapy is a common and potentially severe complication being increasingly evaluated in emergency departments to minimize morbidity and mortality. Streamlining triage of these patients may improve health outcomes and wait times in the health care system. METHODS: A retrospective chart review of febrile patients undergoing chemotherapy was conducted at a local emergency department to assess the impact of nurse-initiated protocols on wait times. RESULTS: We identified 315 patients undergoing current chemotherapy presenting with fever. Of these, 140 (44%) and 87 (28%) were initiated on the sepsis and febrile neutropenia nurse-initiated protocols, respectively. In total, 197 (63%) were admitted. The febrile neutropenia protocol had a shorter wait time from triage to disposition than the sepsis protocol (403 minutes [SD = 23] vs 329 minutes [SD = 19], t = 1.71, P = 0.01). Furthermore, the febrile neutropenia protocol demonstrated shorter times from both triage to lab results reported, in addition to the physician initial assessment in the admitted patient subgroup. DISCUSSION: Decreased wait times from triage associated with the use of a febrile neutropenia protocol could be accounted for by a lower number of lab results required through this protocol in addition to shorter physician assessment times in the admitted population. This study shows that nurse-initiated protocols may influence door-to-antibiotic time for patients undergoing chemotherapy. By having a targeted protocol for the cancer population, health care centers may be able to demonstrate decreased health care expenditure and increased resource availability. Furthermore, as the current population of patients undergoing chemotherapy is at a high risk for neutropenia, prompt management is crucial to minimize mortality.

Design and Implementation of a Trauma Care Bundle at a Community Hospital.

The Niagara Health System (NHS) in Ontario, Canada is comprised of three non-designated trauma center (NTC) hospitals which provide primary care to approximately 100 trauma patients annually. NTCs often lack standardized resources such as trauma surgeons, trauma-trained emergency room physicians, Advanced Trauma Life Support certified staff, trauma protocols, and other resources commonly found at designated trauma centers. Studies indicate that these differences contribute to poorer outcomes for trauma patients treated at community hospitals in Ontario, including the NTC hospitals of the NHS. In other settings healthcare checklists and bundles have proven effective in streamlining processes to ensure effective, efficient and timely patient care. Quality Improvement (QI) tools and methods were used to design, implement, and evaluate a trauma care bundle at one of the NHS's community hospitals. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015 - November 2015. A Safety Attitudes Questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Between July-November 2015, 39 patients were treated at the St. Catharines Hospital that were identified as either Canadian Triage and Acuity Scale (CTAS) I or CTAS II trauma patients. Of those 39 major trauma patients, 15 received care using the trauma care bundle, representing a 38% uptake. Patients who received care with the trauma bundle had an average Emergency Department (ED) length of stay (LOS) of 1.7 hours, compared with those patients in whom the bundle was not used, whose average ED LOS was 3.4 hours. The SAQ administered to ED physicians who used the bundle (n=10) highlighted the impact on ED patient safety. These early findings suggest that the bundle provides a substantial improvement to the current trauma care process within the Niagara Health System.