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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

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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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Page 1: 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

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

Page 2: 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

Disclosure

Page 3: 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

Presentation Content

The Beginning (Oct 2012 - May 2013)

1. Context 2. Problem 3. Intervention 4. Measurement 5. Challenges & Lessons

Learned

The Journey (Jun 2013 – Feb 2014)

Page 4: 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

1. Context Lions Gate Hospital

Page 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

1. Context North Shore/Coast Garibaldi HSDA

Page 6: 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

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

Page 7: 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

2. Problem Access Block and Overcrowding

Page 8: 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

2. Problem Access Block and Overcrowding

Page 9: 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

2. Problem Access Block and Overcrowding

Page 10: 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

2. Problem Access Block and Overcrowding

Page 11: 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

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

Page 12: 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

3. Intervention What is Quality?

Page 13: 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

3. Intervention Quality Framework

• Model for Improvement – Aim Statements – Measurement – PDSA Cycles

• Clinical Education and Role Modeling

• Culture • Sustainability

Page 14: 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

3. Intervention Value Stream Map of Current State

Page 15: 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

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

Page 16: 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

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

Page 17: 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

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

Page 18: 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

4. Measurement PDSA Cycles: Pivot Nurse at Triage

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

0:57

1:04

4-De

c-20

124-

Dec-

2012

4-De

c-20

124-

Dec-

2012

4-De

c-20

1211

-Dec

-201

211

-Dec

-201

211

-Dec

-201

211

-Dec

-201

211

-Dec

-201

214

-Dec

-201

214

-Dec

-201

214

-Dec

-201

217

-Dec

-201

217

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

221

-Dec

-201

27-

Feb-

2013

7-Fe

b-20

137-

Feb-

2013

7-Fe

b-20

137-

Feb-

2013

7-Fe

b-20

137-

Feb-

2013

7-Fe

b-20

137-

Feb-

2013

7-Fe

b-20

137-

Feb-

2013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

13-F

eb-2

013

14-M

ar-2

013

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ar-2

013

14-M

ar-2

013

14-M

ar-2

013

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ar-2

013

14-M

ar-2

013

14-M

ar-2

013

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013

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ar-2

013

14-M

ar-2

013

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ar-2

013

14-M

ar-2

013

Tim

e in

Min

utes

Date of Observation

Run Chart - Lions Gate Hospital - Emergency Department - PDSA Cycles: Arrival to Triage Wait Time (Observed Patients)

Median

Measure

PDSA Cycle #1:Lower Surge Protocol

PDSA Cycle #2:Pivot Nurse - Quick Admit

PDSA Cycle #3:Pivot Nurse - Clipboard

PDSA Cycle #4:Pivot Nurse - ClipboardClinical Nurse Leader - First Aid

Page 19: 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

4. Measurement Reception: Where’s the Patient?

Page 20: 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

4. Measurement Triage Desk: How many Patients are Waiting?

Page 21: 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

5. Challenges & Lessons Learned Success and Limitations

• Success – Time – Organizational Support – Staff Engagement – Communication – Culture – Sustainability

• Limitations – Time – Resources – Staff Engagement – Communication – Culture

Page 22: 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
Page 23: 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
Page 24: 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
Page 25: 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
Page 26: 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

Time to triage/reg with Pivot pivot observations

0

5

10

15

20

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

patient visit

time

in m

inut

es

time

Page 27: 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
Page 28: 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
Page 29: 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

Arrival to triage Feb 8 2014

arrival time to triage completion

0.00

5.00

10.00

15.0020.00

25.00

30.00

35.00

40.00

Arrival to Triage (Min)

min

ute

s

11:31 2 pm 6:20 pm 11:20 pm

Page 30: 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

• If it was up to you would you continue with the role of the Pivot Nurse?

1/33 NO 31/33 YES

Page 31: 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

• Does the Pivot Nurse reduce the time to care provider?

75/25

Page 32: 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

• Does the Pivot nurse reduce triage workload during surges?

100% YES

Page 33: 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

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.”

Page 34: 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

LGH Recipe

Page 35: 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
Page 36: 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
Page 37: 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

Questions?

• [email protected] Health System Planning Advisor

• [email protected] Emergency Clinician

Page 38: 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

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


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