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CPIP: Clinical Process Improvement Leadership Program

Project Title : Improved Management of Intoxicated Patients in

the Emergency Department

Names: Dawn Williamson, RN,MSN,PMHCNS-BC,CARN-AP

Leslie Milne, MD

Institution: Massachusetts General Hospital

Keywords: alcohol, emergency department, lack of capacity, intoxication


Disclosures

� Neither I nor my spouse/partner has a

relevant financial relationship with a commercial interest to disclose.


Objectives- Learner will be able to ID:

� Difficulties of managing intoxicated patients that leave the ED before completing medical evaluation

� A process improvement plan to intervene

� PDSA cycle directed at decreasing patients LWCT

� Outcomes of implementing a standard process of management

� Ongoing efforts to enhance patient care for impaired patients in the ED

3

CPIP: Clinical Process Improvement Leadership Program4

Problem Statement

� 15% of patients presenting to the emergency department with acute alcohol intoxication, leave

the department without being seen (lwbs) or without completing treatment (lwct).

� If not clinically sober at the time of departure,

they are at risk of fall or other injury from their impaired state.


Treatment Disparities

� National median percentage of LWBS 2.6%

� Disparities in rates LWBS R/T income

� Stigma toward patients with substance use

disorders

� Measure of impaired health care access

� Represents a failed attempt at entering the health care system

5


Institute of Medicine’s Quality Chasm Report

Health care should be:

� Safe—avoiding injuries to patients from the care that is intended to help them.

� Effective—providing services based on scientific knowledge to all who

could benefit and refraining from providing services to those not likely to benefit.

� Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient

values guide all clinical decisions.

� Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.

� Efficient—avoiding waste, including waste of equipment, supplies, ideas,

and energy.

� Equitable—providing care that does not vary in quality because of personal

characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

6

Institute of Medicine (IOM) in Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001)


Background

Quality and safety issue:

� Events of intoxicated patients who left before able to do so safely

� Falls while attempting to leave

� Sustained injuries after leaving with rapid return to ED

(cardiac arrest, head bleed)

� John Doe

� Falls with injury are serious reportable event (SRE) to Department of Public Health

� Potential impact on reimbursement

7


Massachusetts General

Hospital (MGH)� 1046 bed urban academic

medical center

� 48,587 annual admissions

� >26,000 employees

� First Magnet hospital in the state

� >120,000 emergency department (ED) visits annually

� ED sees >9,000 substance use disorder (SUD) patients annually

� 1,989 admitted SUD patients

Setting


Actions Steps

9


Team Members

Project Leaders:

� Leslie Milne, MD

� Dawn Williamson APRN, ED CNS

Project sponsors:

� Mary Fran Hughes, RN

� Theodore Benzer, MD

Project coach:

� Laura Prager, MD

Team members:

� ED nursing:

� Inez Luciani-McGillivray, RN

� Rebecca Klug, RN

� Kim Cosetti, RN

� Patricia Mian, RN, psych CNS

� Jane Reardon, RN

� ED physicians:

� Samantha Stoll, MD

� David Peak, MD

� Curtis Wittmann, MD (psychiatry)

� ED physician assistant:

� Jason Parente

� MGH security:

� William McLaughlin

� ED administration:

� Ellen English

� Ruth Stokes

� Boston EMS:

� Steve McHugh, PM

10

Hi


Multi-disciplinary Team

� Right balance of personalities

� Highly motivated individuals

� Some with a particular interest in working the

population

� Informal leaders in their peer groups

� Working Group

11


Significance

� Reviewed incidences of patient injuries and rate that intoxicated patients lwct

� No regulations/legislation in MA

� Literature review revealed a paucity of information

� Lack of best practice standards

� Majority of material provided on sobriety testing

done by law enforcement

� Need to create clinical protocol to offer direction

when caring for this population

12


Aim Statement

� To reduce the percentage of intoxicated

patients who leave the ED without being seen/left without completing treatment

from 15% to 11.25% (25% reduction) by July 1, 2015.


Framework

� Institute for Healthcare Improvement (IHI)

� Process mapping

� Cause and Effect Diagram

� Analysis of possible causes

� Narrow down area to act on

� Group members involved with the process

� Priority/Pay-Off Matrix

Ishikawa (2012)14


Process Map


Cause and Effect Diagram

16

gray area of addictions

vs. psych


Identification of Cause

Six major factors

� Categorized as:

� Patient issues

� Staff issues

� Environmental issues

� Legal issues

� EMS issues

� Communication issues

� Priority polling

� 39 issues identified

� Members asked to vote for the top four factors

� Priority pay off matrix

17


Team Members Priority Polling (11 team members)

18

Priority Ranking of Cause/effect by team members

= #1= #2

= #3= #4

gray area of addictions

vs. psych


Pareto Chart

0%

20%

40%

60%

80%

100%

120%

0

5

10

15

20

25

30

Fre

qu

en

cy

Reasons Intoxicated Patient Leave ED

frequency

Cumulative %

Data source:#’s based on

team members

voting for top 4 of 39

identified issues.

Weighted vote: .

#1 choice=4 points, #2 choice=3 points, etc


Number One Issue

� No standard procedure for evaluation

� Wide variety in practice including:

� How the patient was triaged

� What section of the ED these patients sent

� How to assess for their level of intoxication

� How quickly they were evaluated

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Prioritized List of Changes (Priority/Pay-Off Matrix)

High

Low

Easy Difficult

Ease of Implementation

Imp

ac

t

1. Changing attitudes toward

these patients/education2. More stretcher

space/cohort area3. More sitters

4. Frequent re-assessment

1. Create an

assessment/capacity tool2. Remove patient clothing

3. Higher visibility4. Safety belts for wheelchairs

1. Getting nurses to fill-out safety report of fall

2. Lowering the number of

patients in CDU area3. Educating staff about

capacity

1. Give staff a hand-out describing intervention

2. Reward good behavior

(coffee central coupons)


Capacity Assessment Tool

� Developed to standardize the procedure for evaluating intoxicated patients when they arrived at the ED

� Provides guidance for care givers faced with patients unable to make informed decisions about their health care as a result of their level of

intoxication

� Decisions often need to be made quickly to

prevent patient from leaving the facility while still unsafe

� Starts at triage

22


Materials Developed

23

Check-

sheet

outlining process for

nursing.

Identifies

patient at risk.

Nurse contacts MD

NP or PA to rapidly

assess

patient.


Materials Developed

24

“Yellow Paper”Form that defines

capacity for staff and provides

order template for managing

impaired patients.

Filled-out by NP

PA or MD after triage nurse

identifies patient at risk.

Patient taken

from triage to stretcher and

observation


Lack of Capacity to Make Healthcare Decisions

� Inability to understand information about proposed health care

� Inability to understand their current situation and consequences of their decisions

� Inability to use that information as part of their decision-making process

� Inability to communicate their decision

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Measures

Process Measure Outcome Measure Balance Measure

What is your measure?

Using monthly ED statistics, determine the

percentage of patients who presented

with alcohol intoxication as their chief

complaint or discharge dx (denominator)

and compare to those same patients who

left without being seen (LWBS ) or left

without completing treatment (LWCT)

(numerator)

The percentage of patients who leave

LWBS or LWCT after CPIP intervention

1. Possible longer length of stay by

the target population

2. Beds not available for other ED

patients

3. Possible increase in number of

sitters needed

4. Possible repeat visits as patients

using ED as shelter

Patient population

(exclusions if any)

Adults who present to the emergency

department with alcohol intoxication and

concern by staff for lack of capacity or

unsafe ambulation

same same

Calculation

methodology

Calculate difference between monthly

LWBS and LWCT percentage before and

after intervention

Current percentage is 15%, will deduct

new monthly percentage from this

figure

Calculate the average length of stay

for this patient population and

determine if it is longer than our

pre-intervention baseline

Data source EDIS EDIS EDIS

Data collection

frequencyMonthly same same

Data Quality

Requires assistance of ED administrator

Requires MD/PA participation in “yellow

paper” initiative

ED administrative assistance ED administrative assistance


Baseline Data

27


PDSA Plan (Tests of Change)

Date of PDSA

cycle

Description of

intervention

Results Action steps

Pilot project

Implementation of an assessment tool (“yellow paper”) for evaluation of patients who lack capacity due to intoxication.

Overall there was a decrease in the percentage of patients who left the emergency department while still impaired (lacking capacity or unsafe ambulation)

1. Create visible indicator on electronic record to identify patient is on a “hold”

2. Establish location for triage of target patients

Dec. 2,

2014 –Dec. 31,

2014


Change Data

29


Results of Pilot

� Reduction from 15% to 8.4% (44% reduction) of intoxicated patients who lwct

� Locating patients in area where MD are stationed leads to more rapid re-assessment of

sobriety

� Removing patient clothing decreases patients

lwct

� Placing patient on a stretcher in an area of high

visibility decreases patients lwct

� Length of stay in this patient population was not

increased by this intervention


Key to Success

� Process provided a consistent message for the care of this population

� Staff understood the reason behind the practice and provided advice about what did not work

� During the pilot month the evaluation tools were reviewed daily and feedback was given back to

staff on a weekly basis

� Staff members that did particularly well with

completing the tool were given personal recognition

� Co-chairs were available by page 24/731


Next Steps

Things to consider

Additional tests of change � Did other ED patients leave without being seen due to lack of beds or delays caused by priority being given to these patients?

� Did length of stay increase for these patients?� Did return visits by these patients go up or down?

System based changes � Creating an indicator on the ED electronic census to identify patients on a “yellow paper”

� Create protocol� Creating an electronic order template so this type of “hold”

becomes part of the permanent record

Measurement & reporting� Data is collected monthly and reported every 6 months to ED

administration� Project leaders will continue to monitor monthly data and review

“lwbs and lwct” with responsible staff members

People � Personally contacting responsible nurse or MD who had intoxicated patient leave unannounced while under their care

� Share cumulative data results with physician, nursing, MD, and security teams. Congratulate them on their hard work and success.


Sustainability

� Formal policy developed and adopted that reflected the process

� Indicator created on the ED electronic census to identify patients on a “yellow paper”

� Electronic order template implemented

� Data continues to be collected and reported monthly during ED Quality Improvement

� Following-up with care givers who were involved with patients who lwct to determine obstacles as re-educate about the initiative

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Tracking Board

34


Updated Data

� Trend continues to improve and during the next several months that followed the pilot study the

number of patients that LWCT dropped even lower

� The team continues to meet on a quarterly basis

and is made aware of progress in order to maintain the improvements in patient care

35


Ongoing Improvement

36


Summary

� Actions taken to address quality/safety issues

� ED CPIP Team supported change

� Definition of capacity and provided an order

template

� Triage nurse identify at risk patients and contact

provider to rapidly assess patient

� Patients placed in an area of high visibility for

monitoring

� Evaluation for discharge when stable

� Policy worked on by QI team

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Ongoing Measures

� LOS for this group has not increased

� No increase in patient observer usage

� Ongoing monitoring in QI

� Decreased falls

� No change in lwct rate for other patients

� Decrease in recidivism

� 24 hour returns monitored

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Returns to ED in 24 hours

39

12/1/14 to 9/30/15


Expanding Process

� Policy can apply to other populations

� Dementia patients

� Others with altered mental status

� CPIP Project Impact Award

� Model for other Partners programs

40


References

� Institute of Medicine (IOM) in Crossing the Quality Chasm: A New Health

System for the 21st Century (IOM, 2001)

� Ishikawa, K. (2012). Introduction to quality control (3rd edition). Netherlands:

Springer Publications, Inc.

� Lewin, K. (1947). Frontiers in Group Dynamics: Concept, Method and Reality in Social Science; Social Equilibria and Social Change. Human

Relations, 5-41.

� Marquis, B.L. & Huston, C.J. (2011). Leadership roles and management

functions in nursing: theory and application (7th edition). Philadelphia: Lippincott, Williams & Wilkins.

� Northouse, P.G. (2015). Introduction to leadership: concepts and practice

(Kindle Edition). Los Angeles, CA: Sage Publications, Inc.

� Porter O’Grady, T. & Malloch, K. (2014). Quantum leadership: advancing innovation, transforming healthcare (4th edtition). Sudbury: Jones & Bartlett

Publishers, Inc.

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MOC Part IV Requirements for Physician Participation

Completed (Yes/No)

Requirement Example

yes

Review and reflect on personal or practice level data (e.g., completing a data collection form for his/her patients, completing a survey regarding impressions of baseline data, or discussing data with colleagues)

Collected baseline data to determine percentage of patients who lwct or lwbs. Reviewed with project team.

yes

Participate in developing interventions or selecting from pre-identified interventions (e.g., discussing the planned intervention with others in the practice or completing a survey related to potential interventions)

Project members met to discuss possible interventions and chose and created the “yellow paper”intervention

yesReview post intervention data (e.g., completing a data collection form, completing a survey related to impressions on the data, discussing data with colleagues)

Reviewed pre-intervention and post-intervention data with entire MD, PA, and nursing staff

1) Please check off completed requirements and provide one example of how the requirement was fulfilled:

2) Please list other participating MDs who should receive these credits as well:� Curtis Wittmann, MD

Leslie Milne, MD- Emergency Department attending

Dawn Williamson, APRN, Emergency Department CNS

Improved Management of Intoxicated Patients in the Emergency Department

Mass General Hospital Emergency Department

AIM: To reduce the percentage of intoxicated patients who leave the ED without being seen/left

without completing treatment from 15% to 11.25% (25% reduction) by July 1, 2015.

TEAM:

ED nursing: Rebecca Klug, Inez

Luciani-MaGillvray, Kim Cosetti, Jane

Reardon, Patricia Mian

Psychiatry: Curtis Wittmann, MD,

ED security: William McGaughlin

ED MD’s: Samantha Stoll, David Peak

ED PA: Jason Parente

Boston EMS: Steve McHugh

PROJECT SPONSORS:

� Theodore Benzer, MD

� Mary Fran Hughes, RN

INTERVENTION: Intoxicated patients were identified in the triage area of the emergency department. An

MD or PA was then asked to do a rapid assessment of the patients capacity and ambulatory status. If

patient was clinically felt to be unsafe to leave the emergency department, a “yellow paper” was filled

out that placed the patient on a temporary “hold” until they were re-assessed as having capacity and

stable gait. The patient was taken to a stretcher in a supervised area, shoes and outer clothing were

removed and side rails of the stretcher were put up to prevent falls. Patient was allowed to sober. If

patient was a “flight-risk”, closer supervision with a sitter or restraints could be administered. For ease of

use, the yellow paper included the definition of “capacity” as well as orders to maintain patient safety

and to help assure patient would not leave prior to re-assessment.

CONCLUSIONS

� Exceeded target goal of 25% reduction. Reduced

intoxicated patients leaving from 15% to 8.4%

(44% reduction)

� Removing outer clothing and placing patient on

stretcher in high visibility area resulted in fewer

patients leaving while still intoxicated.

�Length of stay was not increased for this patient

population after intervention.

NEXT STEPS:

� Creating a designation on the patients electronic

chart so all staff is aware patient is on “yellow

paper”

� Dedicated, supervised area to cohort these

patients for easier management

� Make order template part of electronic record

RESULTS

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