Implementation of evidence-based quality improvement in Victorian emergency departments


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Design and results of projects to improve quality of care in emergency departments in Victoria, Australia using latest evidence.

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Implementation of evidence-based quality improvement in Victorian emergency departments

  1. 1. Implementation and Impact of Clinical Network-Managed Evidence-Based-PracticeImplementation Projects in Emergency Departments in Victoria, AustraliaThe ECIICNThe Emergency Care Improvement and Innovation Clinical Network(ECIICN) is a group within the Department of Health, Victoria. Its membersare the 40 public emergency departments (EDs) of varying size, capacity andgeographical location that report data to the Victorian Department of Health.More than half are outside the metropolitan area of Melbourne.The ProblemThe implementation of evidence-based practice in EDs can be challenging.Barriers include; access to and interpretation of information, adaptation ofevidence for local application, high service demands, limited non-clinical timefor senior clinicians to design and lead change, high staff turnover and lackof tools to facilitate change.ECIICN’s model for working with EDsAnne-Maree Kelly, Jan Pannifex on behalf of the Emergency Care Improvement and Innovation Clinical Network (ECIICN), Commission for HospitalImprovement, Department of Health, Victoria, AustraliaMeasuring impactFor all projects, both qualitative and quantitative data was obtained. Each participating EDsundertook before and after clinical audits against pre-identified clinical indicators as well ascompleting qualitative feedback about their processes and success factors and barriers.Projects 2009 – 2012: 4 cyclesEmergency Care Improvement and Innovation Clinical Network member emergency departmentsAlbury Base Hospital, Angliss Hospital, Austin Hospital, Bairnsdale Health Service, Ballarat Health Service, Bass Coast Regional Health, Bendigo Hospital, Box Hill Hospital, Casey Hospital, Central Gippsland Health Service – Sale, Dandenong Hospital, Echuca Regional Health, Frankston Hospital,Geelong Hospital, Goulburn Valley Health, Hamilton Base Hospital, Latrobe Regional Hospital, Maroondah Hospital, Mercy Hospital for Women, Mildura Base Hospital, Monash Medical Centre, Northeast Health (Wangaratta), Rosebud Hospital, Royal Children’s Hospital, The Royal MelbourneHospital, Royal Victorian Eye and Ear Hospital, Royal Women’s Hospital, Sandringham and District Hospital, Southwest Healthcare (Warrnambool), St Vincent’s Hospital, Sunshine Hospital, Swan Hill District Hospital The Alfred Hospital, The Northern Hospital, Werribee Mercy Hospital, WestGippsland Healthcare, Western District Health, Western Hospital, Williamstown Hospital and Wodonga Regional Health ServiceECIICN provide:•An annual evidence-based care cycle•Short list of supported projects with recommended outcome measures• Evidence updates• Tools to aid implementation and evaluation• Constructive feedback on local project plans• Project management training• Data analysis and feedback• Coaching and mentoring• Forums for sharing and collaborationConclusionClinical network managed, locally led evidence-based care implementation projects based onknowledge transfer theory can be successful in facilitating change in EDs care and result inmeaningful improvements in clinical care.Results2264010203040506070Before AfterPercentProportion of patients with fractured hip receiving nerve block425051015202530Before AfterPercentNerve block <90 mins from ED arrivalNerve block as adjuvant analgesia for fractured hipControlled oxygen therapy in COPD8 participating EDs over 2011 and 2012 with both results achieving statistical significance: p < 0.016 participating EDs over 2011 and 2012 with result achieving statistical significance: p < 0.01587001020304050607080Before AfterPercentProportion of patients with COAD receiving controlled oxygen therapyManagement of Renal Colic5 participating EDs in 2012 with all outcome measures achieving statistical significance: p < 0.0126%74%0%10%20%30%40%50%60%70%80%Before AfterNSAID within 60 minutes20640%10%20%30%40%50%60%70%Before AfterDischarge on NSAIDManagement of Paediatric Gastroenteritis4 participating EDs in 2012 with all outcome measures achieving statistical significance: p < 0.01other results:• proportion of patients with pain score at ≤ 2 60 minutes after their ED presentation increased from 30% to 51%• proportion of patients who had a documented pain score, temperature measurement, renal function test, white _cellcount and MSU performed increased from 44% to 79%60%84%0%10%20%30%40%50%60%70%80%90%Before AfterWeightrecorded5%63%0%10%20%30%40%50%60%70%Before AfterRehydration commencedin waiting roomother results:• proportion of patients with formal assessment of hydration documented increased from 2% to 53%Management of Asthma2 participating EDs in 2011 and 2012 with all outcome measures achieving statistical significance (p < 0.01)94605101520253035404550Before AfterPercentProportion risk stratified for asthma severity463010203040506070Before AfterPercentProportion with PEFR as part of initial assessmentother results:• proportion of patients discharged on course of steroids increased from 63% to 87%26530102030405060Before AfterPercentProportion of patienst with blood tests taken < 30 minutes from EDarrivalManagement of Early Pregnancy Bleeding10 participating EDs in 2011 and 2012 with all outcome measures achieving statistical significance (p < 0.01)6810102030405060708090Before AfterPercentProportion of patients managed according to a local evidence-basedpathwayother results:• proportion of women documented as having been provided with written patient information at the time of _triageincreased from 1% to 41%Management of TIA16 participating EDs in 2010 and 2011 with discharge on anti-platelet agents endpoint achieving statistical significance (p< 0.01)76880102030405060708090100Before AfterPercentProportion discharged on anti-platelet agents unless contraindicated596701020304050607080Before AfterPercentProportion of patients discharged <24 hoursManagement of Chest Pain17 participating EDs in 2009 with all outcome measures achieving statistical significance (p<0.05)Results:· average ED length of stay of discharged patients decreased from 471 to 439 minutes· variation in practice, as shown in the inter-quartile range of ED length of stay, decreased from 353 to 267 minutes· proportion of patients risk stratified as part of their assessment increased from 11% to 49%The aim of ECIICN is to improve the quality of care in EDs, principally by promotinguptake of evidence based care to reduce variation in practice and to build staffcapacity to lead.An added challenge in the Victorian context is the devolved clinicalgovernance environment where health services are responsible for their own clinicalgovernance.