Improving Patient Safety and Quality of Care in a Community
Emergency Department by Incorporating Evidence Into Practice:
...
Disclosure
Presentation Content
The Beginning
(Oct 2012 - May 2013)
1.
2.
3.
4.
5.

Context
Problem
Intervention
Measurement
Challeng...
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 De...
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 a...
3. Intervention
What is Quality?
3. Intervention
Quality Framework
• Model for Improvement
– Aim Statements
– Measurement
– PDSA Cycles

• Clinical Educati...
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
p...
4. Measurement
Issue: Delays at Triage and Registration
• Arrival to Triage Wait Time exceeds CTAS Guidelines
• Average wa...
4. Measurement
Test: Pivot Nurse at Triage
• Concept: streaming patients
at first point of contact
– Two defined care stre...
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-201...
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 Engagemen...
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

patie...
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
...
• 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 ...
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 ...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Improving Patient Safety & Quality of Care in a Community Emergency Department by Incorporating Evidence into Practice: Us...
Upcoming SlideShare
Loading in …5
×

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

691 views

Published on

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

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
691
On SlideShare
0
From Embeds
0
Number of Embeds
32
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

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

  1. 1. 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
  2. 2. Disclosure
  3. 3. 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)
  4. 4. 1. Context Lions Gate Hospital
  5. 5. 1. Context North Shore/Coast Garibaldi HSDA
  6. 6. 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
  7. 7. 2. Problem Access Block and Overcrowding
  8. 8. 2. Problem Access Block and Overcrowding
  9. 9. 2. Problem Access Block and Overcrowding
  10. 10. 2. Problem Access Block and Overcrowding
  11. 11. 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
  12. 12. 3. Intervention What is Quality?
  13. 13. 3. Intervention Quality Framework • Model for Improvement – Aim Statements – Measurement – PDSA Cycles • Clinical Education and Role Modeling • Culture • Sustainability
  14. 14. 3. Intervention Value Stream Map of Current State
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 4. Measurement Reception: Where’s the Patient?
  20. 20. 4. Measurement Triage Desk: How many Patients are Waiting?
  21. 21. 5. Challenges & Lessons Learned Success and Limitations • Success – – – – – – Time Organizational Support Staff Engagement Communication Culture Sustainability • Limitations – – – – – Time Resources Staff Engagement Communication Culture
  22. 22. 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
  23. 23. 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
  24. 24. • If it was up to you would you continue with the role of the Pivot Nurse? 1/33 NO 31/33 YES
  25. 25. • Does the Pivot Nurse reduce the time to care provider? 75/25
  26. 26. • Does the Pivot nurse reduce triage workload during surges? 100% YES
  27. 27. 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.”
  28. 28. LGH Recipe
  29. 29. Questions? • Peter.Chan@vch.ca Health System Planning Advisor • Sherry.Stackhouse@vch.ca Emergency Clinician
  30. 30. 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

×