Development and implementation of an emergency department telephone follow-up system.

Implementing a telephone follow-up system after a patient's emergency department (ED) visit is challenging, but it may improve patient safety and care. This study's objective was to describe the development and implementation of a comprehensive ED telephone follow-up system over a 9-year period. Discharged patients who received a follow-up telephone call within 48 hours of their ED visit included all pediatric patients, those who left without being seen by a provider, and any adult patient with a "high-risk chief complaint," which was defined as a headache, visual problem, chest pain, dyspnea, abdominal pain, syncope, trauma, and neurological-related problems. There were 127 524 cases that met criteria to receive a follow-up call, with 138 331 attempted calls being made and 46 114 (36.2%) cases successfully followed up. Forty-two percent of pediatric cases and 16% of patients who left without being seen were successfully contacted with a follow-up call; 1.6% of cases were referred to the CQI Committee. In the 9 years prior and after implementation of this follow-up system, there were 3.5 (95% confidence interval [CI] = 2.1-5.9) and 2.5 (95% CI = 1.3-4.5) medical malpractice lawsuits per 100 000 ED patient visits, respectively; this represented a 28.6% reduction. A comprehensive telephone follow-up program can be developed and implemented utilizing available resources.

Decreasing Time to Pain Relief for Emergency Department Patients with Extremity Fractures.

Significant delays occur in providing adequate pain relief for patients who present to the emergency department (ED) with extremity fractures. The median time to pain medication administration for patients presenting to our ED with extremity fractures was 72.5 minutes. We used a multidisciplinary approach to implement three improvement cycles with the goal of reducing the median time to pain medication by 15% over an eight month time period. First, we redesigned nursing triage and treatment processes. Second, we improved nursing documentation standardization to ensure accurate tracking of patients who declined pain medication. Third, through consensus building within our physician group, we implemented a department-wide standard of care to provide early pain relief for extremity fractures. Median time to pain medication for patients with an extremity fracture reduced significantly between the pre-and post-intervention periods (p=0.009). The average monthly median time to medication was 72.5 minutes (95% CI: 57.1 to 88.0) before the intervention (Jan 2013-Oct 2014) and 49.8 minutes (95% CI: 42.7 to 56.9) after the intervention (November 2014 to June 2016). In other words, monthly median time was 31% faster (22.7 minute difference) in the post intervention period. Implementing three key interventions reduced the time to pain medication for patients with extremity injuries. Since June 2016 the reductions in median time to medication have continued to improve.

Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs.

INTRODUCTION: Academic emergency department (ED) handoffs are high-risk transfer of care events. Emergency medicine residents are inadequately trained to handle these vital transitions. We aimed to explore what modifications the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) handoff system requires to be effectively modified for use in ED inter-shift handoffs. METHODS: This mixed-method needs assessment conducted at an academic ED explored the suitability of the I-PASS system for ED handoffs. We conducted a literature review, focus groups, and then a survey. We sought to identify the distinctive elements of ED handoffs and discern how these could be incorporated into the I-PASS system. RESULTS: Focus group participants agreed the patient summary should be adapted to include anticipated disposition of patient. Participants generally endorsed the order and content of the other elements of the I-PASS tool. The survey yielded several wording changes to reflect contextual differences. Themes from all qualitative sources converged to suggest changes for brevity and clarity. Most participants agreed that the I-PASS tool would be well suited to the ED setting. CONCLUSION: With modifications for context, brevity, and clarity, the I-PASS system may be well suited for application to the ED setting. This study provides qualitative data in support of using the I-PASS tool and concrete suggestions for how to modify the I-PASS tool for the ED. Implementation and outcome research is needed to investigate if the I-PASS tool is feasible and improves patient outcomes in the ED environment.

Teaching and Assessing ED Handoffs: A Qualitative Study Exploring Resident, Attending, and Nurse Perceptions.

INTRODUCTION: The Accreditation Council for Graduate Medical Education requires that residency programs ensure resident competency in performing safe, effective handoffs. Understanding resident, attending, and nurse perceptions of the key elements of a safe and effective emergency department (ED) handoff is a crucial step to developing feasible, acceptable educational interventions to teach and assess this fundamental competency. The aim of our study was to identify the essential themes of ED-based handoffs and to explore the key cultural and interprofessional themes that may be barriers to developing and implementing successful ED-based educational handoff interventions. METHODS: Using a grounded theory approach and constructivist/interpretivist research paradigm, we analyzed data from three primary and one confirmatory focus groups (FGs) at an urban, academic ED. FG protocols were developed using open-ended questions that sought to understand what participants felt were the crucial elements of ED handoffs. ED residents, attendings, a physician assistant, and nurses participated in the FGs. FGs were observed, hand-transcribed, audio-recorded and subsequently transcribed. We analyzed data using an iterative process of theme and subtheme identification. Saturation was reached during the third FG, and the fourth confirmatory group reinforced the identified themes. Two team members analyzed the transcripts separately and identified the same major themes. RESULTS: ED providers identified that crucial elements of ED handoff include the following: 1) Culture (provider buy-in, openness to change, shared expectations of sign-out goals); 2) Time (brevity, interruptions, waiting); 3) Environment (physical location, ED factors); 4) Process (standardization, information order, tools). CONCLUSION: Key participants in the ED handoff process perceive that the crucial elements of intershift handoffs involve the themes of culture, time, environment, and process. Attention to these themes may improve the feasibility and acceptance of educational interventions that aim to teach and assess handoff competency.