Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Using a Pivot Nurse to Improve Access to the Appropriate Level of Care
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Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Using a Pivot Nurse to Improve Access to the Appropriate Level of Care

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This presentation was delivered in session D3 of Quality Forum 2014 by: ...

This presentation was delivered in session D3 of Quality Forum 2014 by:

Peter Chan
Health System Planning Advisor
Vancouver Coastal Health

Sherry Stackhouse
Emergency Clinician, Lions Gate Hospital
Vancouver Coastal Health

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    Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Using a Pivot Nurse to Improve Access to the Appropriate Level of Care Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Using a Pivot Nurse to Improve Access to the Appropriate Level of Care Presentation Transcript

    • Improving Patient Safety and Quality of Care in a Community Emergency Department by Incorporating Evidence Into Practice: Using a Pivot Nurse to Improve Access to the Appropriate Level of Care Quality Forum 2014 Rapid Fire Session D3 February 27, 2014 Peter Chan and Sherry Stackhouse
    • Disclosure
    • Presentation Content The Beginning (Oct 2012 - May 2013) 1. 2. 3. 4. 5. Context Problem Intervention Measurement Challenges & Lessons Learned The Journey (Jun 2013 – Feb 2014)
    • 1. Context Lions Gate Hospital
    • 1. Context North Shore/Coast Garibaldi HSDA
    • 2. Problem Background • Access Block and ED Overcrowding lead to long wait times, and avoidable delays in the Emergency Department (ED) • Patient and staff dissatisfaction with the care they receive and provide
    • 2. Problem Access Block and Overcrowding
    • 2. Problem Access Block and Overcrowding
    • 2. Problem Access Block and Overcrowding
    • 2. Problem Access Block and Overcrowding
    • 3. Intervention Project Overview • Union of two separate initiatives: – A Quality Advisor led stakeholder engagement and applied a framework to guide improvement work – A Clinical Nurse Leader led evidence in practice initiatives and provided clinical coordination and leadership • Goals were aligned and priorities were established at the beginning
    • 3. Intervention What is Quality?
    • 3. Intervention Quality Framework • Model for Improvement – Aim Statements – Measurement – PDSA Cycles • Clinical Education and Role Modeling • Culture • Sustainability
    • 3. Intervention Value Stream Map of Current State
    • 4. Measurement Clinical Issues Tested • PDSA Results: – Reduced time to analgesia from 81 to 32 minutes during analgesia protocol use – Reduced ALOS from 121 to 108 minutes for returning IV antibiotic patients – Registered Nurses (RNs) participating in a research project regarding RN initiated extremity X-Ray ordering
    • 4. Measurement Issue: Delays at Triage and Registration • Arrival to Triage Wait Time exceeds CTAS Guidelines • Average wait time is over 30 minutes – Outliers greater than 90 minutes – This time is currently not being measured
    • 4. Measurement Test: Pivot Nurse at Triage • Concept: streaming patients at first point of contact – Two defined care streams in the ED (Acute and Fast Track) – Improve patient experience – Reduced interruptions for triage nurses and registration clerks • Results: Reduced average arrival to triage wait time from 30 to 7 minutes
    • Measure 0:36 0:21 4-Dec-2012 4-Dec-2012 4-Dec-2012 4-Dec-2012 4-Dec-2012 11-Dec-2012 11-Dec-2012 11-Dec-2012 11-Dec-2012 11-Dec-2012 14-Dec-2012 14-Dec-2012 14-Dec-2012 17-Dec-2012 17-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 21-Dec-2012 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 7-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 13-Feb-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 14-Mar-2013 Time in Minutes 4. Measurement PDSA Cycles: Pivot Nurse at Triage Run Chart - Lions Gate Hospital - Emergency Department - PDSA Cycles: Arrival to Triage Wait Time (Observed Patients) 1:04 0:57 0:50 0:43 PDSA Cycle #1: Lower Surge Protocol 0:28 PDSA Cycle #2: Pivot Nurse - Quick Admit Date of Observation Median PDSA Cycle #3: Pivot Nurse - Clipboard PDSA Cycle #4: Pivot Nurse - Clipboard Clinical Nurse Leader - First Aid 0:14 0:07 0:00
    • 4. Measurement Reception: Where’s the Patient?
    • 4. Measurement Triage Desk: How many Patients are Waiting?
    • 5. Challenges & Lessons Learned Success and Limitations • Success – – – – – – Time Organizational Support Staff Engagement Communication Culture Sustainability • Limitations – – – – – Time Resources Staff Engagement Communication Culture
    • Time to triage/reg with Pivot pivot observations time in minutes 20 15 time 10 5 0 1 3 5 7 9 11 13 15 17 patient visit 19 21 23 25 27 29
    • Arrival to triage Feb 8 2014 arrival time to triage completion 40.00 35.00 minutes 30.00 11:31 2 pm 25.00 20.00 15.00 10.00 5.00 0.00 Arrival to Triage (Min) 6:20 pm 11:20 pm
    • • If it was up to you would you continue with the role of the Pivot Nurse? 1/33 NO 31/33 YES
    • • Does the Pivot Nurse reduce the time to care provider? 75/25
    • • Does the Pivot nurse reduce triage workload during surges? 100% YES
    • Pivot survey Jan 2014 (n=33) • • • • “Make the pivot role more versatile.” “There can be a lot of standing around..” “It depends on who is working.” “The most helpful pivots take charge of the WR.” • “It can be stressful….limit length of shift.” • “When its done well its incredibly helpful.”
    • LGH Recipe
    • Questions? • Peter.Chan@vch.ca Health System Planning Advisor • Sherry.Stackhouse@vch.ca Emergency Clinician
    • Appendix • Evidence: – Martin, M. (2012) A Pivot Nurse at Triage, Journal of Emergency Nursing, 38 (1) – Mc Hugh, M., Van Dyke, K., Mc Clelland, M. & Moss, D. (2011) Improving Patient Flow and Reducing emergency Department Crowding: A Guide for Hospitals, Agency for Healthcare Research and Quality – AHRQ, Accessed at http://www.ahrq.gov – Victorian Government (2008) Discussion Paper, Streaming Care; Fast track services in hospital emergency departments, Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services, Melbourne, Victoria; Accessed at www.health.vic.gov.au/emergency