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

1. Implementation and Impact of Clinical Network-Managed Evidence-Based-Practice
Implementation Projects in Emergency Departments in Victoria, Australia
The ECIICN
The Emergency Care Improvement and Innovation Clinical Network
(ECIICN) is a group within the Department of Health, Victoria. Its members
are the 40 public emergency departments (EDs) of varying size, capacity and
geographical location that report data to the Victorian Department of Health.
More than half are outside the metropolitan area of Melbourne.
The Problem
The implementation of evidence-based practice in EDs can be challenging.
Barriers include; access to and interpretation of information, adaptation of
evidence for local application, high service demands, limited non-clinical time
for senior clinicians to design and lead change, high staff turnover and lack
of tools to facilitate change.
ECIICN’s model for working with EDs
Anne-Maree Kelly, Jan Pannifex on behalf of the Emergency Care Improvement and Innovation Clinical Network (ECIICN), Commission for Hospital
Improvement, Department of Health, Victoria, Australia
Measuring impact
For all projects, both qualitative and quantitative data was obtained. Each participating EDs
undertook before and after clinical audits against pre-identified clinical indicators as well as
completing qualitative feedback about their processes and success factors and barriers.
Projects 2009 – 2012: 4 cycles
Emergency Care Improvement and Innovation Clinical Network member emergency departments
Albury 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 Melbourne
Hospital, 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, West
Gippsland Healthcare, Western District Health, Western Hospital, Williamstown Hospital and Wodonga Regional Health Service
ECIICN 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 collaboration
Conclusion
Clinical network managed, locally led evidence-based care implementation projects based on
knowledge transfer theory can be successful in facilitating change in EDs care and result in
meaningful improvements in clinical care.
Results
22
64
0
10
20
30
40
50
60
70
Before After
Percent
Proportion of patients with fractured hip receiving nerve block
4
25
0
5
10
15
20
25
30
Before After
Percent
Nerve block <90 mins from ED arrival
Nerve block as adjuvant analgesia for fractured hip
Controlled oxygen therapy in COPD
8 participating EDs over 2011 and 2012 with both results achieving statistical significance: p < 0.01
6 participating EDs over 2011 and 2012 with result achieving statistical significance: p < 0.01
58
70
0
10
20
30
40
50
60
70
80
Before After
Percent
Proportion of patients with COAD receiving controlled oxygen therapy
Management of Renal Colic
5 participating EDs in 2012 with all outcome measures achieving statistical significance: p < 0.01
26%
74%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Before After
NSAID within 60 minutes
20
64
0%
10%
20%
30%
40%
50%
60%
70%
Before After
Discharge on NSAID
Management of Paediatric Gastroenteritis
4 participating EDs in 2012 with all outcome measures achieving statistical significance: p < 0.01
other 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 _cell
count and MSU performed increased from 44% to 79%
60%
84%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Before After
Weightrecorded
5%
63%
0%
10%
20%
30%
40%
50%
60%
70%
Before After
Rehydration commencedin waiting room
other results:
• proportion of patients with formal assessment of hydration documented increased from 2% to 53%
Management of Asthma
2 participating EDs in 2011 and 2012 with all outcome measures achieving statistical significance (p < 0.01)
9
46
0
5
10
15
20
25
30
35
40
45
50
Before After
Percent
Proportion risk stratified for asthma severity
4
63
0
10
20
30
40
50
60
70
Before After
Percent
Proportion with PEFR as part of initial assessment
other results:
• proportion of patients discharged on course of steroids increased from 63% to 87%
26
53
0
10
20
30
40
50
60
Before After
Percent
Proportion of patienst with blood tests taken < 30 minutes from ED
arrival
Management of Early Pregnancy Bleeding
10 participating EDs in 2011 and 2012 with all outcome measures achieving statistical significance (p < 0.01)
6
81
0
10
20
30
40
50
60
70
80
90
Before After
Percent
Proportion of patients managed according to a local evidence-based
pathway
other results:
• proportion of women documented as having been provided with written patient information at the time of _triage
increased from 1% to 41%
Management of TIA
16 participating EDs in 2010 and 2011 with discharge on anti-platelet agents endpoint achieving statistical significance (p
< 0.01)
76
88
0
10
20
30
40
50
60
70
80
90
100
Before After
Percent
Proportion discharged on anti-platelet agents unless contraindicated
59
67
0
10
20
30
40
50
60
70
80
Before After
Percent
Proportion of patients discharged <24 hours
Management of Chest Pain
17 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 promoting
uptake of evidence based care to reduce variation in practice and to build staff
capacity to lead.
An added challenge in the Victorian context is the devolved clinical
governance environment where health services are responsible for their own clinical
governance.