Authors: Ahmed Taher, Olivia Ostrow
You are working a busy shift in your busy emergency department (ED), when you are called by the microbiologist about a positive blood culture gram stain on a patient discharged home. You call the patient’s caregiver and they relay that the patient is doing well. You believe that the culture may be a contaminant from skin flora, but ask the patient and their caregiver to return to the ED for reassessment, possible admission to hospital for observation, and potential empiric antibiotic therapy until the full culture results are reported. You wonder whether this practice is resource-appropriate, and how often your ED is calling patients to return that may not need to return to the ED. You also wonder about unnecessary admissions, the risks it may pose to patients, and the additional strain on the system.
Welcome back to our final post on the Ontario ED Return Visit Quality Program (RVQP). In our first post we discussed the utility of return ED visits as triggers for potential quality improvement (QI) initiatives related to care provided during the first ED visit. In our second post we discussed the health informatics architecture that supports this provincial continuous quality improvement program. In this final post on the RVQP, we highlight some of the accomplishments of the program. You will find that the main accomplishment of the program is that it has helped raise the profile of the quality improvement culture in the EDs. Practically speaking, what happens when clinicians and various stakeholders in the healthcare system routinely strive for better quality? Moreover, what happens when the philosophy of quality improvement is infused in the day-to-day work of EDs?
Program Accomplishments
The program completed 12,852 return visit case audits between 2016–2018. In the 2018 cohort review period, the program identified quality issues in 131/315 (42%) sentinel cases, and 1,027/4,933 (21%) from all-cause return visits that were reviewed.(1) Overall, it has raised the profile of the importance of QI activities in EDs across Ontario, seeking to learn and improve future performance. Most of the quality issues identified were grouped in eleven common themes under three main categories.
These common categories are suggested by the guidance documents as part of the functional standards (common way of doing things) of the program.(2) The two most common themes identified included “patient risk profile”, which is a failure to account for high-risk characteristics of patients (e.g., comorbidities, psycho-social status, etc.) when determining evaluation and management. The other commonly noted quality theme was “physician cognitive lapse”, which is a knowledge gap or failure to act on signs and symptoms. The identified categories are illustrated below in Figure 1 and they were developed by ED physicians with QI expertise with the results of the program’s first-year results.
How does this compare to your practice setting? In a busy ED where there are many interruptions and decisions that need to be made quickly, should similar quality issues be anticipated? By identifying these issues, better systems can be designed to prevent recurrence. For example, developing a trigger tool in the electronic health record that requires the discharging provider to confirm that patients with no fixed address have been offered resources for local shelters could address a potential quality issue in the “patient risk profile” category.
Another accomplishment of the program was that 34% of hospitals noted collaborating with other sites or hospitals to complete chart reviews, while 40% worked with other organizations on QI initiatives arising from the program. Not only can collaboration help sites find high-yield solutions to common problems, but it can reduce the need to re-invent the wheel every time a similar quality problem is faced by another ED!
82% of hospitals reported implementing at least one QI initiative at their site since starting the program, with some sites reporting multiple initiatives. Many of the initiatives had a direct impact on patient care such as sites starting to implement expanded diagnostic imaging hours, and increasing physician education on select patient conditions or local resource availability. Other initiatives included improving patient documentation through better tools and systems, and improving triage accuracy through education and process improvement.(1) Some sites have utilized the lessons from this provincial program to run local return visit audits as often as every month.(3)
The achievements, however, go beyond the sheer number of initiatives raised. We would argue that the main accomplishment, which is in line with the program’s mission, is enhancing the QI culture across EDs by providing an opportunity to work in teams to identify potential system issues and effective solutions.
This approach supports a cultural shift from one which blames clinicians and tells them to work harder and smarter, to one where transparency is championed and clinicians are empowered to share information. In this QI culture, there is a shared goal of improvement, and a commitment to the highest level of patient care.
Case resolution
“SickKids has a Culture Follow-Up and Escalation Algorithm”
So what can be done about the discharged ED patient with the positive gram stain from the blood culture? It’s a common clinical scenario that many EDs encounter. Thankfully due to the return visit audits completed at SickKids, this quality problem came to light and a QI initiative was developed. The monthly audits revealed that children were being called back to the ED for positive preliminary blood cultures leading to unnecessary resource utilization, including hospitalization and intravenous antibiotics, when the culture ended up growing a contaminant. Recognizing that there was significant practice variation contributing and learning from colleagues at UHN that had addressed this problem through the development of an algorithm, SickKids created a similar blood culture algorithm based on best practice guidelines with risk stratification for pediatrics. Results have shown that practice variation has significantly decreased, and more importantly, so has the number of unnecessary hospitalizations for children.
That is for our last post on the Ontario ED RVQP – a continuous QI program that leverages health information technology. Join us next time as we continue our discussion of different QI applications in the ED environment.
Thank you to Lisa Fuller, Emily Hayes, and Ivan Yuen from Ontario Health (Quality), formerly Health Quality Ontario, for their input.
If you are interested in contributing to future posts, whether you are a learner, staff physician, allied health members, or administrators with interests in QI, let us know! hiquips@gmail.com.
Senior Editor: Lucas Chartier
Copyedited by: Ed Mason
References
1. Health Quality Ontario. The Emergency Department Return Visit Quality Program: Report on the 2018 Results. Health Quality Ontario, Toronto; 2019:1-15.
2. Quality Improvement: Emergency Department Return Visit Quality Program. Health Quality Ontario. Published 2020. Accessed February 2020. Accessed from: https://www.hqontario.ca/Quality-Improvement/Quality-Improvement-in-Action/Emergency-Department-Return-Visit-Quality-Program.
3. The Emergency Department Return Visit Quality Program: Results from the First Year. Health Quality Ontario. Published 2017. Accessed February 2020. Accessed from: https://www.hqontario.ca/Portals/0/documents/qi/ed/report-ed-return-visit-program-en.pdf.