HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH REGISTER		Author Keyword(s) Vol Page [Advanced]

Quality Ideas

Please Note: Inclusion on this page does not imply endorsement by QSHC or the BMJ Publishing Group Ltd
Most recent comments are listed first
 

Speeding up Patient Management in the emergency department

Quality Assurance Assessor - Significant Event Analysis

Educational tool to explain what asthma is and other related topics

Speeding up Patient Management in the emergency department
Posted 22nd April 2004
 

Author	Chii-Hwa Chern
Occupation	Emergency Physician
Place of Work	Emergency Department, Veterans General Hospital-Taipei
Email	chchern2002{at}yahoo.com.tw

Overcrowding is a global emergency department (ED) problem.(1-7) To solve the problem, researches have usually focused on the patient management flow to try to relieve the overcrowding in the ED.(8) In Taiwan, overcrowding is prevalent in many large teaching hospitals and, sometimes, we have to face episodic overwhelming numbers of patients presenting to the ED. Beside the patients waiting to be seen and waiting results of examinations and consultation, there are also on average 40 patients staying in the observation room at any time in my hospital. For the leaders of many EDs, one of the challenges facing them is coming up with solutions to counter the problem. Some have done it by reviewing the literature, the suggestion of their colleagues, the conclusions of some conferences, and, most importantly, designs from their insight to the problem. However, basic ideas and strategies developed may be good, but the implementation usually faces some problems. When required to manage ED patients expediently as outlined by the ED chief, with or without some proved strategies, unforeseen complications occur. The staff may just take the information of increasing the speed of patient management but do not get adequate message or training to alleviate the potential side effects of the speedy management.

"Overcrowding can increase adverse events mainly through inadvertently discharging patients that do not have adequate evaluation and observation"

Overcrowding can increase adverse events in the ED. Miro O et al and Richards JR have found overcrowding in the ED decreased health care quality and may lead to poor patient outcomes.(9,10) From our ED data, the return visit rates were higher in busy seasons. Moreover, we found the rate of clinically significant adverse events was more than 0.5% in discharged patients during the overcrowding months.(11) Under the pressure of overcrowding, emergency physicians (EPs) are frequently required to facilitate the patient management flow that is thought to be important for relieving the pressure. In the meantime, EPs might have legal risks due to multiple factors resulting from the increased patient number. First, because of the overwhelming number, patients might be prematurely discharged without adequate evaluation. Additionally, discharging high-risk patient is also more frequently encountered due to inadequate hospital in-patient beds and overcrowding of the observation room. Furthermore, due to the noisy and uncomfortable ED environment, some patients who need observation and hospitalization do ask to leave the ED. In most cases, discharging some high-risk patients from the EPs could not relieve the overcrowding of the ED (This can be seen from the truth that it is impossible to make the ED space more clean during the busy ED seasons!), but it actually increases the legal risk. To overcome the situation, we think, EPs have to prepare psychologically to accustom themselves to the ED frequent situation- overcrowding. From this baseline, a changing strategy to manage the ED overcrowding can be developed.

1. Accepting that overcrowding is a constant state is necessary
Overcrowding is complicated issue due to multiple factors. Potential solutions for ED overcrowding will require multidisciplinary system-wide support.(12) However, the cause of ED overcrowding generally lies outside the ED and overcrowding is symptom of system failure.(13) Many aspects of these factors are difficult to be managed due to the internal culture of a hospital and external insurance and social factors. In Taiwan, overcrowding is constant state in many hospitals and most ED staffs have got accustomed to this phenomenon and already developed personal ways to counter it, especially psychologically. Overcrowding does not indicate a bad event itself. During the overcrowding condition, EDs should manage to arrange adequate medical staff and require them to give adequate evaluation and management of patients. The baseline and goal is no legal problem. The occurrence of an adverse event is less acceptable than noise and discomfort from the ED overcrowding.

2. A practice emphasizing the uncertainty of many ED patient conditions should be an important issue in the ED training Due to increased population of old age, increased patients with chronic multiple diseases, and the development of new immuno-compromised conditions, patients frequently present to the ED with atypical pattern.(14-16) In addition, many patients present to the ED with early and poorly defined clinical manifestations. Under these factors, EPs (emergency physicians) need more history taking, physical examinations, laboratory and radiological exams and, more importantly, time to make clear patient conditions. With the implementation of many strategies to increase the patient management flow, EPs might discharged some patients with uncertain or risky conditions that need more observation or treatment, just to avoid keeping patients in the ED. Therefore, it is possible that some patients with abdominal pain might be routinely considered to have acute gastroenteritis or gastritis and a patient with fever to be common cold or upper respiratory viral infection. Under this situation, the problem is not whether the doctors on ED duty have the ability to treat major severe diseases or whether they can make differential diagnosis for a specific situation, but that EPs might discharge many patients without considering they have serious diseases. They heighten the threshold to consider severe diseases in some clinical condition. Increasing the speed and emphasizing the correct diagnosis of patient¡¦s condition in many ED situations should be done in parallel. In our study, we found that an ED education emphasizing that many ED patients have some uncertain conditions and the use of ED resources to manage the problem was effective in decreasing clinical significant adverse events in ED discharged patients.(17) For many patients with uncertain and undiagnosed conditions, the times spending in observation, examination, and decision making might be beyond what people usually think. Giving the patient a ¡§definite¡¨ diagnosis (for example, acute gastroenteritis for many patients with acute abdomen) without adequate evaluation and observation is one of the root causes of developing adverse events in the ED.

3. Many ED conditions are so trivial but can also be complex that a rapid cleaning of patients from the registration log might be inappropriate
Traditional training has put emphasis on rapid, dramatic decision and management in the ED. This is true for many major and prominent clinical conditions (acute myocardial infarction, septic shock, massive gastrointestinal bleeding, acute pulmonary edema, stroke with increased intracranial pressure, major trauma, hemorrhage shock, etc.). However, for many ED patients, their clinical conditions are not frequently straightforward and clear-cut. Therefore, time is important for ED management for those patients. Time is needed for getting adequate evaluation (clinical and laboratory data), repeated evaluation, and observation for patient condition. Most importantly, time is also important for physician to establish the relation with patients and their family and get a sense of the real patients¡¦ condition. A training bias that neglects basic approaches should not be developed. More often than not, there are difficult cases in the hands of the EPs that they cannot clear them immediately. Accepting this concept should be a basic part in the ED education.

4. Developing follow-up mechanisms for ED patients is important procedure in the ED quality improvement (QI)
Before discharging patients with uncertain or high-risk clinical conditions (stroke, chest pain, upper gastrointestinal bleeding, presence of evidence of potential severe infection, abdominal pain with laboratory abnormalities, intoxication, etc.), EPs should re-evaluate patients and determine the necessity of follow-up. Sometimes, EPs can select high-risk patients for follow-up through the review of ED charts after patients are discharged. The follow-up of patients can be done through multiple ways. A next-day telephone is ideal for most patients, but some patients (patients with acute abdomen, neurological conditions, and potentially serious infections, for example) should be followed up in a more aggressive way. For patients with less urgent conditions, an arrangement of out-patient clinical follow-up is also a good way. Scheduled return and call-in are also an alternative way for emergency patient follow-up.

5. Decreasing overcrowding by facilitating patients¡¦ management process always need more ED resources
Using interventions including increased emergency physician coverage, the designation of physician coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures, Cardin S et al have demonstrated decreasing crowding reduced the mean length of stay for patients discharged from the ED from 13.8 to 5.9 hours, without resulting in increased return visits to the ED or hospital readmission.(18) Kelen GD et al have shown an ED-managed acute care unit can have significant impact on ED overcrowding and ambulance diversion.(19) A solution of overcrowding is not simply by speeding up the patient management flow. We always have to pay to overcome overcrowding.

To overcome overcrowding in the ED is important, but we have found it is difficult. Therefore, when emphasizing the rapid management during overcrowding period, we also have to tell the physicians on ED duty that many clinical conditions are uncertain and need more evaluation and, sometimes, observation and follow-up after patients are discharged.

References

1. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med 1991;20:980-986

2. Graff L. Overcrowding in the ED: an international symptom of health care system failure. Am J Emerg Med 1999;17(2):208-209

3. Shih FY, Ma MM, Chen SC, et al. ED overcrowding in Taiwan: facts and strategies. Am J Emerg Med 1999;17(2):198-202

4. Schnerder S, Zwemer F, Doniger A, et al. Rochester, New York: a decade of emergency department overcrowding. Acad Emerg Med 2001;8(11):1044-1050

5. Derlet R, Richards J, Kravitz R. Frequent overcrowding in US emergency departments. Acad Emerg Med 2001;8(2):151-155

6. Derlet DW: Overcrowding in emergency department: Increased demand and decreased capacity. Ann Emerg Med 2002;39(4):430-432

7. Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J 2003;20(5):406-409

8. Miro O, Sanchez M, Espinosa G, et al. Analysis of patient flow in the emergency department and the effect of an extensive reorganization. Emerg Med J 2003;20(2):143-148

9. Miro O, Antonio MT, Jimenez S, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med 1999;6(2):105-107

10. Richards JR, Navarro ML, Delert RW: Survey of directors of emergency departments in California on overcrowding. West J Med 2001:172(6):385-388

11. Chern CH, Wang LM, Lee CH. Decreasing adverse events in discharging patients through telephone follow-up and improvement processes in an overcrowded emergency department. Ann Emerg Med 2002;40(4):S32

12. Kollek D. Emergency department overcrowding. CMAJ 2002;167(6):626- 627

13. Trzeciak S , Rivers E P. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003;20:402-405

14. Rusnak RA, Borer J, Fastow JS. Misdiagnosis of acute appendicitis: common features discovered in cases after litigation. Am J Emerg Med 1994;12:397-402

15. Rusnack RA, Stair TO, Hansen K, et al. Litigation against the emergency physician: common features in cases of missed myocardial infarct. Ann Emerge Med 1989:18:1029-1034

16. Lee TH, Rouoan GW, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarct in the emergency department: results from a multicenter study. J Am Coll Card 1987;60;219-224

17. Chern CH, Huang HH, How C-K, et el. Evaluation and improvement of the emergency department management process. Emerg Med J 2002;19(suppl 1):A20

18. Cardin S, Afilalo M, Lang E, et al. Intervention to decrease emergency department crowding: does it have an effec on return visits and hospital readmissions? Ann Emerg Med. 2003; 41(2):173-85

19. Kelen GD, Scheulen JJ, Hill PM. Effect of an emergency department (ED) managed acute care unit on EDovercrowding and emergency medical services diversion. Acad Emerg Med. 2001;8(11):1095-100

Quality Assurance Assessor - Significant Event Analysis
Posted 9th March 2004
 

Author	Gillian E Jackson
Occupation	Quality and Information Manager
Place of Work	Royal College of General Practitioners, Northern Ireland Council
Email	gilllianjackson{at}dial.pipex.com

Significant Event Analysis February 2003

Three Tubes Tridimensional Model (TTT-M) is a simple and useful tool, to explain, in a few minutes, to children and families: What asthma is, How asthma medicines work and other application you can think about.

We use this model for a long time in our Regional Asthma Plan in Asturias (Community in the north of Spain, 1 million inhabitants). Also it has been used in courses for health care providers,  events (ie World Asthma Day 2003 by ASGA, an European Federation of Asthmatic Patients member) and in other Educational Programs both in Spain and South America.

This model can be used freely and is quite easy to make. You only need three tubes (any type of material: wood, metal, cardboard...)
 

First Tube	Second Tube	Third Tube
Thickness wall: Thin Inner part colour: white Meaning: Health Bronchi	Thickness wall: average Inner part colour: red Meaning: Bronchi with inflammation	Thickness wall: Thick Inner part colour: red Meaning: Bronchi with inflammation and asthma exacerbation

The full instructions (and photographs) to use the model are available on the Internet
http://www.respirar.org/eng/mttt/index.htm (in English)
http://www.respirar.org/trestubos.htm (in Spanish)

 

Back to top