This intervention was carried out at Toronto General and Toronto Western Hospital (UHN) in Toronto, Ontario. Between the two sites, there are approximately 117, 000 visits per year.
Description of the innovation
Treat & release (T&R) patients are patients that have been seen in the ED and asked to return in 12-72 hours for follow-up care (i.e. semi-urgent ultrasound, wound care, or IV medication). These patients are a paper-based hand over and thus rely on quality of documentation to complete their second visit.
Initially, a brief form existed for these patients, but their care was often delayed due to a missing chart, or inadequate, incomplete, or missing information in the chart. This resulted in a significant part of the assessment being duplicated, causing frustration for both the patient and clinician.
The form was provided to the patient as a ‘golden ticket’ to return to the ED and receive expedited care. The original form provided no additional information to the provider on the return visit. The form was refined to include key information for the return visit to help inform the follow-up provider and cue the original provider regarding what documentation is required.
We refined the form with key stakeholder engagement, and engaged with the larger group of MD/NP/PAs on the importance of quality documentation and plans of care to ensure these patients have an expedited second visit to the ED.
Was a quality improvement methodology used?
The model for improvement (IHI) with iterative PDSA cycles was used for this project.
What Data was used?
Chart audits for measuring quality of documentation using a modified version of QNOTE, a validated score, and time to disposition (defined as the interval from physician initial assessment (PIA) to discharge).
Who was on the team?
What performance measures were used?
Time to disposition (from PIA to discharge)
How was it implemented?
A form for T&R patients already existed. Once the new form was developed with key stakeholder input, we replaced the old form with the new one. This essentially was a ‘forcing function’ requiring the use of the new form.
An education session on use and documentation requirements was provided to the MD/NP/PA group concurrently with the form change.
How did you get buy in from physicians, nurses, administrators and other allied professionals?
We engaged with key stakeholders from the outset of the project team requesting feedback and input throughout the entire project.
What were some of the barriers to success?
- Change management: Due to the focus of this project being on documentation practices, it was challenging to have all 80+ health care providers (MD, PA, NP) change their personal practice.
- Sustainability: given that this is a form and still requires the providers to use the form and complete it, they can slip back to old behaviours and habits.
If you could do it all over again, what changes would you make?
Engagement early on with Information Technology (IT) to try to make IT changes happen. Although this is on ‘the list’, it may take years if ever to become a part of our current EHR.
This post was copyedited by Jung-In Choi.