EP8EOb

 

Interprofessional Care EP8EO

 

Using the required empirical outcomes (EO) presentation format, provide one example from an ambulatory care setting of an improved outcome associated with an interprofessional quality initiative led or co-led by a nurse (exclusive of the CNO). 

 

 

Example b: Ambulatory Care Setting Improvement in Left Without Being Treated in the Emergency Department

Problem
Catholic Health Initiatives (CHI) St. Vincent Hot Springs’ (SVHS) Emergency Department (ED) battled with left without being treated (LWBT) percentages consistently above the national standard of 2% in the fall of 2022. Nursing shortages, bed shortages, and staffing shortages challenge the ED, stretching everyone thin and slowing down throughput.

 

In these challenging situations, liability and risk for the patients in the waiting room increase for all providers and CHI SVHS. Not having a process in place not only does the patient a disservice but also increases the risk to SVHS.

 

Pre-Intervention

Renee Fechuch, MSN, BSN, RN, Clinical Director of Nursing, recognized that the LWBT patients were at an all-time high, due to system-wide issues that affected SVHS’s ability to care for patients. Fechuch is responsible for reviewing LWBT data and developing action plans to address the problem.

 

The percentage of patients who had LWBT in October 2022 was 7.28%. The LWBT percentage is calculated by dividing the total number of patients in a month who left without being treated by the total number of patient registrations that month, multiplied by 100.

 

Fechuch realized this was more than a nursing issue and would need an interprofessional approach. Fechuch discussed these data with Joshua Keithley, MD, MBA, ED Medical Director. Keithley agreed that a change needed to be made to improve these percentages.

 

Plan
In October 2022, Fechuch led the LWBT quality initiative and collaborated with Kayla Bullard, BSN, RN, Nurse Manager, and Keithley to discuss areas of opportunity as the LWBT patients consistently stayed above the national standard of 2%. Fechuch, Bullard, and Keithley worked on a Provider-in-Triage (PIT) plan to improve the LWBT percentages. A strong clinician in triage can effect a positive change.

 

Patients are assured from the first encounter that a provider and a clinical nurse are evaluating them and that orders will be initiated and started before a bed becomes available. Patients feel taken care of and kept informed of the treatments they will receive, which prevents them from LWBT.

 

Goal Statement

Decrease the CHI SVHS ED LWBT percentage.

 

Participants

 

 

ED LWBT Workgroup

 

Name/Credentials

Discipline

Title/Role

Department

Renee Fechuch, MSN, BSN, RN

Nursing

Clinical Director of Nursing/Lead

Nursing Administration

Kayla Bullard, BSN, RN

Nursing

Nurse Manager

Emergency Department

Joshua Keithley, MD, MBA

Physician

Medical Director

Emergency Department

David Moore, PA

Physician

Physician Assistant

Emergency
Department

Missy Puckett, APRN, FNP-C

Nursing

Advanced Practice Provider

Emergency Department

Tori Laduke, APRN, MNSc

Nursing

Advanced Practice Provider

Emergency Department

 

Description of the Intervention

November 2022
Do
The ED team implemented the PIT process in November 2022. The PIT process operates anytime “pull to full” is not possible. In other words, PIT operates when there are too many patients arriving at the ED to be roomed immediately. PIT functions as follows:

  • The patient is pulled from registration to Triage 1 in order of acuity of presenting complaint, per the existing process by the clinical nurse. Vitals are taken, relevant screenings are performed, and protocols are ordered.
  • When the initial triage process is completed, the paramedic moves the patient from Triage 1 to Triage 2 through the back hallway.

 

Keithley collaborated with David Moore, PA, Physician Assistant; Missy Puckett, APRN, FNP-C, Advanced Practice Nurse; and Tori Laduke, APRN, MNSc, Advanced Practice Nurse, as the ED Advanced Practice Providers (APP). They discussed how the APPs perform a brief, focused history of present illness (HPI) and physical exam (PE) in Triage 2. The APP reviews orders and adjusts as necessary. The APP opens a blank ED note and completes and signs a Medical Assessment Exam Note (PITNOTE).

  • The HPI should be a short, one- to two-line excerpt, based on the chief complaint.
  • The PE should be basic and focused on the complaint.
  • Advanced imaging and orders outside of nurse protocols can be ordered at this time.

 

Keithley and the APPs discussed the need for the APP scripting that they would use below:

 

APP Scripting: Incorporating Acknowledge, Introduce, Expectations, Duration, and Thank You (AIDET): “I am working with the nursing staff to start your evaluation and make sure that your workup is on the right track. We will place you back in the waiting room as your workup is being completed and rooms become available. A physician will continue and complete your evaluation as your labs and/or imaging result.”

  • The APP places the patient back into the waiting room and prepares for the next patient.
  • If the APP determines a patient needs to be brought back immediately or could be a time-sensitive patient, then they communicate with the charge and triage nurse. Examples of time-sensitive patient issues include stroke, sepsis, or STEMI.

 

Patient care techs (PCT) are the employees who place the patients in a room during triage. There is a PCT assigned to triage every shift. Fechuch and Bullard developed PCT scripting and educated one-on-one with the PCTs, which included the following:

 

Patient Care Tech (PCT) Scripting: “I am taking you to be seen by a provider, so you can be evaluated and your workup can be started. The provider will see you, continue your care, and place you back into the waiting room as your workup is being completed and rooms become available.”

 

Study/Act
Fechuch monitored and reported LWBT data daily in the hospital-wide safety huddles. As the LWBT data improved regularly and was below the national standard of 2%, the ED LWBT workgroup felt that there were not any additional changes that needed to be made during this time.

 

The PIT intervention was fully implemented by the end of November 2022.

 

An interprofessional quality initiative (PIT) from an ambulatory care setting (ED), led by Fechuch, was associated with an improvement in LWBT percentages at CHI SVHS ED.

 

References

Franklin, B. J., Li, K. Y., Somand, D. M., Kocher, K. E., Kronick, S. L., Parekh, V. I., Goralnick, E., Nix, A. T., & Haas, N. L. (2021). Emergency department provider in triage: Assessing site‐specific rationale, operational feasibility, and financial impact. Journal of the American College of Emergency Physicians Open, 2(3). https://doi.org/10.1002/emp2.12450

 

Smalley, C., Meldon, S., Simon, E., Muir, M., Delgado, F., & Fertel, B. (2021). Emergency department patients who leave before treatment is complete. Western Journal of Emergency Medicine, 22(2). https://doi.org/10.5811/westjem.2020.11.48427

 

Outcome