To guarantee the safety practices and avoid AE, we have to do implementation strategy in many settings [15,16,17,18,19,20,21,22,23,24,25]:
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1.
Infrastructure requirements
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2.
Basic clinical management process and protocols for quality emergency care
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3.
Establishing a unit quality department
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4.
Measuring quality of performance (quality indicators)
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5.
Sharing best practices
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6.
Adapting to changing realities
4.1 Infrastructure Requirement
The factors which influence the emergency department size and design include a general scope of clinical services provided in the Health Care Organizations (HCO), average volume of ER visits, total number of beds in the HCO, availability of other support services like Radiology & Lab, total floor space, geographical location, demography of the patients who will be handled in the ER (pediatric vs geriatric), or (medical emergencies vs trauma) maximum number of possible users in a given time.
The emergency department design includes:
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Entrance with:
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1.
Direct access from the road for ambulance and vehicles—clearly marked and with temporary vehicle parking space for cars and other means of patient transport.
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2.
Ramp for wheel chair/stretcher.
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3.
Stretcher and wheelchair placing area.
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4.
Well lit entrance with wide doors which can open both ways or one way opening into the ER.
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5.
The doors should be wide enough to move a patient in an emergency trolleys comfortably in and out. The ideal width would be minimum 6 ft when both the door are wide open.
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Waiting area can be of a total size that includes seating, telephones, display for literature, public toilets, and circulation space.
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Triage area should be able to accommodate patients in wheel chair/emergency stretcher/walking in. The ideal space would depend on the volume of patients received in the department. There is a close operational relationship between triage and reception where registration counter is located.
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Resuscitation room (priority 1)
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1.
Should be at least one resuscitation room with a single dedicated bed in the ER.
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2.
Ideally there should be an individual closed space with provision for emergency stretcher bed, multi-paramonitor, defibrillator, crash cart, ventilator in each room.
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3.
The room should accommodate 4–5 staffs including doctors comfortably and to be able to move around the patient.
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Urgent care (priority 2, 3)
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1.
Minimum recommended space between centers of two adjoining beds is 2 m.
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2.
Each bed can be separated by a screen on all three sides for providing privacy.
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Consultation room (priority 4) for examination and treatment of priority 4 patients.
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Emergency short stay unit (if applicable)
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1.
This facility may be provided either within or adjacent to the emergency unit for the prolonged observation and ongoing treatment of patients who are planned for subsequent discharge (directly from the ED). Mostly applicable to high volume ED.
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2.
The types of patients planned to be admitted to this unit will determine the number and type of beds provided, and the design of associated monitoring and equipment however 8 beds is considered to be the minimum functional size.
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3.
The configuration of the short stay unit should be a minimum of 1 bed per 4000 attendances per year.
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Nursing station: a staff room/utility storage room/security room/toilets/pharmacy substores.
The design described below is important to manage patient flow:
The emergency department can have two types of patient input-throughput and output flow based on the volume and space available in the health care institution.
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For a large volume department, the entry and exit point of the emergency department are separate. The triage room and registration can be done at the entry, and there is also facility for registering the patient at the entry point. After triage, the patients are moved to the appropriate pre-identified bed space/area for further care. All priority 1 patients are moved to the resuscitation room. Priority 2 and 3 are treated in the urgency care areas which can also be the observation area. Priority 4 patients are triaged out to outpatient department (OPD) or can be handled in emergency room in a predesignated fast track room or doctor consultation room (especially in non-OPD hours) in the emergency department, and an emergency bed is not necessary for these category of patients. On disposition, the patients are moved into the hospital or discharged through an exit, away from the entry area. Billing counters can be situated at the exit. Bed side billing can also be done.
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For low volume emergency departments and HCOs with limited space, the entry and exit is through the same point and the registration and billing counter is essentially located at the entry/exit point. No separate triage room or space is provided and all the patients visiting ER are allotted a bed straight away and a bed side triaging is done. All priority 1 patients are either moved to the bed identified for resuscitation purpose or resuscitation can happen in the same bed. Priority 2, 3, and 4 are treated in emergency beds (Priority 4 can also be treated in ER doctor consultation room (if available). On disposition, the patients are moved into the hospital or discharged through the same entry/exit point. Billing counters can be situated here and bed side billing can also be done.
4.2 Basic Clinical Management Process and Protocols for Quality Emergency Care
Each emergency department is unique as the patient profile varies with locality of the hospital infrastructure within the same city and level of acuity which that particular hospital can handle. Also the disease profiles and health care systems vary across the globe.
Clinical management protocols are based on evidence-based recommendations and best practice recommendation where a clinical evidence is not possible.
Clinical protocols have to be region based applicable to the population demography of the hospital and their health needs.
For example, a trauma center hospital may look into how efficiently they can manage a patient of poly trauma and process to better clinical outcome, like initiating a massive transfusion vs a peripheral pediatric hospital where the nature of emergencies tend to be more medical in nature than surgical.
Irrespective of the locality—the protocols need to be tested and constantly upgraded based on recent updates.
Appropriate mock assessments periodically and audits are a must to ensure the policies and processes and implemented at the ground level.
4.3 Establishing a Unit Quality Department
Establishment of quality department is essential in order to examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of quality. Various key performance indicators (KPI) may be set by an identified champion from the emergency department who may be certified through various national or international training programs for being an internal auditor program or quality implementation in hospital and with help from external accrediting agencies.
Reviews on various aspects of improving KPI must be taken up as a continuous process in order to reduce errors. Coordinate care among settings and practitioners and ensure relevant, accurate information is available when needed as critical elements in providing high level of care.
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It is extremely important in achieving quality control of the highest standard in medical equipment: Periodic checks at least once a year is essential in achieving this goal. Can be done for a range of equipment including defibrillators, ventilators, pulse oxymeters, infusion pumps, patient monitors, etc. This may be done as part as set of national and international standards by trained engineers with the help of specialized testing and calibrating equipment as per manufacturer recommendations. It should be concluded by documenting test results and issuing a calibration report. Any measuring equipment or device needs to be tested and checked for its accuracy and calibrated whenever need arises. Testing is done as per domestic standards which implies in accordance with manufacturer specifications, for both safety and performance tests. The results need to be formally documented.
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Key parameters for testing and calibrating in emergency department may include
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1.
Defibrillators: Electrical safety tests, biphasic energy measurements, ECG, performance and arrhythmia simulation, wave form simulation
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2.
Pulse oxymeter: Electrical safety, O2 saturation, heart rate, pulse amplitude, selectable pigmentation, and ambient light condition
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3.
Infusion pumps: Flow rates, occlusion alarm tests, pressure
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4.
Ventilators: Modes, lung parameters, etc.
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The entire activity must be subjected to appropriate methods of internal control and inspection.
4.4 Measuring Quality of Performance (Quality Indicators)
However, institutions need to adapt appropriate quality indicators, and the following quality indicators can represent the quality of emergency departments:
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Door-to-triage time
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Door-to-doctor time
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Door-to-needle time in stroke thrombolysis
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Pain score assessment
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Investigation return time
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Nurse/patient ratio
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Patient satisfaction level
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Time taken for discharge
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Mortality (Adjusted)
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Length of stay
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Left without been seen by a doctor
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Pain assessment/reassessment
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Safety—patient falls, medication error, failed intubation rate
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Incident reporting and RCA
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Infections—hand-hygiene compliance
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Door-to-triage time
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Description: Time interval of patient arrival to nurse triage
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Type of parameter: Outcome
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Formula: Time from patient arrival to time when triage is completed for a particular category of patients
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Benchmark: Does not exist
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Action plan: Ensures quality in design, conformance
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Door-to-doctor time
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Description: In case of emergency the time shall begin from the time the patient’s arrival at the emergency till the time that the initial assessment is completed
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Type of parameter: Outcome
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Formula: Sum of the time taken for assessment/total number of patients in emergency
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Benchmark: Does not exist
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Action plan: Ensures quality in design, conformance
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Door-to-needle time in stroke thrombolysis
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Description: In case of acute onset ischemic stroke in window period
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Type of parameter: Morbidity in stroke
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Formula: Number of stroke patients thrombolyzed/number of eligible stroke patients for thrombolysis
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Benchmark: Does not exist
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Action plan: Ensures quality in design, conformance
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Mortality parameter
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Description: Standardized mortality rate (SMR)
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Type of parameter: Outcome
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Formula: Number of deaths/number of discharges and deaths × 100
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Benchmark: None
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Action plan: Ensures quality in design and conformance
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Patient satisfaction (effective communication)
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Description: Efficacy of communication
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Type of parameter: Process
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Formula: Quarterly average score/Max score possible × 100
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Benchmark: Not known
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Action plan: Through patient satisfaction
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Patient fall rates
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Description: Patient fall rate
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Type of parameter: Safety; morbidity
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Formula: Number of falls/number of bed days
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Benchmark: 8.46/1000 bed days
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Action plan: Ensures quality in design (beds) and conformance (sedation)
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Medication errors
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Description: Medication error
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Type of parameter: Safety
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Formula: (Number of errors/number of bed days) × 1000
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Benchmark: 1.2 to 947/1000 bed days (reported)
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Action plan: Clinical pharmacists; process (2-people check)
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Compliance to hand-hygiene protocols
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Description: Compliance to hand hygiene
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Type of parameter: Infection; outcome; safety
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Formula: (Number adhered/total number of procedures) × 100
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Benchmark: 90% adherence
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Action plan: Surveillance; health education
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Investigation return time
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Description: Radiology CT investigation report
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Type of parameter: Adherence to protocol
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Formula: Time of order to time of reporting
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Benchmark: 60 min
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Action plan: Clinical audit
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Length of stay in ER
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Description: Average length of stay
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Type of parameter: Adherence to protocol, safety
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Formula: Total length of stay of all patients in hours/total number of patients
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Benchmark: 240 min
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Action plan: Audit
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Nurse patient ration in ER
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Description: Nurse per bed per shift
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Type of parameter: Safety, mortality, morbidity
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Formula: Number of nurse/number of beds in each shift
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Benchmark: Does not exists
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Action plan: Audit
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Pain management in ER
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Description: Proportion of patients presenting with pain in whom validated pain score is documented
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Type of parameter: Key performance indicator
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Formula: Patients with pain assessment using validated score/total number of patients presented with pain × 100
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Benchmark: Does not exists
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Action plan: Audit
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Time taken for discharge
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Description: Discharge is the process by which a patient is shifted out from the ED with all concerned medical summaries after ensuring stability
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Type of parameter: Safety
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Formula: Sum of time taken for discharge/number of patients discharged
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Benchmark: Does not exists
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Action plan: Audit
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Left against medical advice
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Description: Percent of patients who leave the ED before examination
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Type of parameter: Safety
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Formula: Total number of patients who leave ER before seen by doctor/total number presented to ER during the time of study × 100
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Benchmark: Does not exists
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Action plan: Audit
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Non-conformance control and management
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Any non-conformance observed should be properly reported through incident reporting system which will be reviewed by a multidisciplinary committee and quality department of the hospital.
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The non-conformances could be
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(a)
Near-miss
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(b)
Medical error
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(c)
Sentinel event
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Configuration control and management under quality of design
4.5 Sharing Best Practices
A “Best Practice” can be defined as a technique or methodology that has proven reliably to lead to a desired result.
At a minimum, a best practice should:
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Demonstrate evidence of success
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Affect something important (e.g., safety, wait time)
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Have the potential to be replicated to other settings
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Evidence-based protocols/guidelines must be incorporated to deliver care
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Guidelines can improve patient safety, streamline methods of care, lower costs and increase efficiency
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Communication and academic discussions among Clinicians and Department staff may ensure a smooth process for implementation of guidelines, e.g., hand washing practices/reducing rates of central venous catheter-related infection
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Ensure guidelines are updated regularly
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Institutional support from leadership and making evidence-based guidelines a habit among all levels of staff
4.6 Adapting to Changing Realities
4.6.1 Digitization
Opportunities for using data to improve the health system are partially driven by technological advances. New analytical methods, more efficient processing, and automation of routine analyses and analytics, for example, make it easier to draw insights from health data and to present the resulting information in an actionable format.
In the clinical setting, secondary use of health data can improve quality initiatives and the effectiveness of frontline care. For health system management, health data can be used to manage and improve the effectiveness and efficiency of the health system by informing program, policy, and funding decisions. For example, costs can be reduced by identifying ineffective interventions, missed opportunities, and duplication of services.
To facilitate health research, health data can be used to support research that informs clinical programs, health system management, and population and public health. Such research spans multiple fields.
4.6.2 Measuring Patient Feedback
Patient feedback systems are used to know their experiences when visiting the hospital, understanding of the services hospitals offer and opinions on changes you may have recently introduced or plan to make.
With a good feedback system, one can increase your understanding of what patients think about a hospital, understand areas of concern and take action to transform the experience for patients. One can make changes and use the system to monitor patient reaction, gradually improving the practice based on accurate feedback.
Patient experience measures:
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should be developed with patient input to ensure that they are representative of their needs, values, and preferences
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reveal critical information about the extent to which care is truly patient centered
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provide a rigorous, validated alternative to the subjective reviews that are posted on a large number of review sites
4.6.2.1 Service Excellency
Other than the time lines mentioned at the 4 priority levels, other measures that may be undertaken to reduce times:
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Gather prior information about arrival of patient
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Delegate documentation to other trained staff
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Create appropriate policies in order to reduce time
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Use telecommunication systems to deliver relevant information about patient from the time of first paramedic contact
4.6.2.2 Clinical Audit
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The review of clinical performance against agreed standards, and the refining of clinical practice as a result—a cyclical process of quality improvement in clinical care.
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The systematic critical analysis of the quality of health care, including the procedures used for diagnosis, treatment and care, the use of resources, and the resulting outcome and quality of life for patients.
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Monitor the use of particular interventions, or the care received by patients, against agreed standards. Any deviation from “best practices” can then be examined in order to understand and act upon the causes.
There are different modalities with which we can do a clinical audit:
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Standards-based audit (criteria-based audit)
This is the recommended process. Current practice is compared against defined criteria, standards, or best practices, through the “audit cycle”
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Peer review audit
With the benefit of hindsight, the quality of services provided is assessed by a team, reviewing case notes and seeking ways to improve clinical care. This is especially applicable in “interesting” or “unusual” cases.
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Significant event audit
Adverse occurrences, critical incidents, unexpected outcomes, and problematic cases causing concern are reviewed systematically and solutions implemented. Surveys targets for opinions or suggestions may include patients or special focus groups. Information gathered is then analyzed and change implemented as appropriate.
Stages of an audit
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1.
Prepare and plan for the project
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2.
Select an area to audit
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3.
Defining criteria and setting up standards
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4.
Collection of data
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5.
Analyze results
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6.
Identify solutions for improvement and implement changes
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7.
Re audit to monitor the impact of changes (close audit loop)
This must be led by senior clinicians in the department and must be reported to the audit review boards and discussed with higher stakeholders for implementation and continuous improvement.
4.6.3 Test Optimization
In the emergency department, accurate diagnosis in a minimum of time is critical to ensure the best patient outcomes. Every minute is essential. High-risk patients with potentially life-threatening conditions must be identified quickly and appropriate treatment initiated. At the same time, cost containment and optimized patient flow management are also essential.
Use of protocols play an important role, for example, the latest guidelines for diagnostic management of acute venous thromboembolism, which recommend using algorithms that combine clinical probability assessment with a quantitative D-Dimer test. This limits the number of required imaging tests, offering cost saving and prevention of patient harm or Troponin I may safely rule-out and accurately rule-in acute Myocardial infarction (non-ST elevation myocardial infarction) in 70% of suspected chest pain patients when sent at an appropriate time.
Patient-centered outcomes research as applied to optimization in tests such as those mentioned above or diagnostic imaging includes the engagement of patients in the decision-making process to order imaging, deliver the results to patients and caregivers, and follow-up incidental findings from the diagnostic test. One aspect of patient-centered care is the process of shared decision-making, which allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.
Clinical decision rules (CDRs) are evidence-based algorithms derived from original research and are used to provide guidance for clinical decision-making. They can either be “directive” (suggesting a course of action) or “assistive” (providing evidence to enhance clinical judgment).
Well-validated CDRs can potentially reduce the use of diagnostic tests and empower clinicians with risk assessments for a given constellation of clinical symptoms and signs. They can also serve to reduce inappropriate variation in practice by offering evidence to assist the clinician at the point of care.
4.6.4 Work Culture
4.6.4.1 Safety
Various factors compromise the security of working doctors in the emergency rooms. Few of these include:
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1.
24 h accessability of the emergency department
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2.
Lack of adequately trained armed or security guards
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3.
Patient pain and discomfort
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4.
Family member stress due to patient’s condition and fear of the unknown
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5.
Family member anger related to hospital policies and the health care system in general or cramped space
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6.
Long wait times
At a minimum, workplace violence prevention programs should:
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1.
Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions.
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2.
Ensure that managers, supervisors, coworkers, clients, patients, and visitors know about this policy.
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3.
Ensure that no employee who reports or experiences workplace violence faces reprisals.
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4.
Encourage employees to promptly report incidents and suggest ways to reduce or eliminate risks.
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5.
Require records of incidents to assess risk and measure progress.
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6.
Outline a comprehensive plan for maintaining security in the workplace. This includes establishing a liaison with law enforcement representatives and others who can help identify ways to prevent and mitigate workplace violence.
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7.
Assign responsibility and authority for the program to individuals or teams with appropriate training and skills.
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8.
Ensure that adequate resources are available for this effort and that the team or responsible individuals develop expertise on workplace violence prevention in health care and social services.
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9.
Affirm management commitment to a worker-supportive environment that places as much importance on employee safety and health as on serving the patient or client.
4.6.4.2 Reference to Standards
Developing benchmarks to incorporate best practices is absolutely essential to maintain quality in health care. Quality governing bodies such as QCI and accreditation boards like the NABH work in collaboration with hospitals across the country to achieve the same. Benchmarking of a particular standard may be derived from the best evidences in clinical practice or standards set by external agencies such as the WHO. Further, continuous audits and statistical analysis by existing quality departments across hospitals may ensure implementation and impact of implementation as a prerequisite to continuous quality improvement. Potential key performance indicators may also be identified. Also benchmarks can be internal based on the measured performances of the department.
4.6.4.3 Communication Best Practice
All emergency departments have to ensure that the patients, relatives, the primary physician are well informed about the clinical status of the patient through a structured communication protocol. A communication checklist to ensure adequate communication has taken before disposition needs to be implemented in all emergency departments.
4.6.4.4 Culture of Safety
Culture of safety with promotion of reporting errors, teamwork, communication openness, transparency with feedback, learning from errors, and administrative collaboration. Identify champions of quality and patient safety in ER.
4.6.4.5 Standardize
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Communication
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Crucial information
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Verifying comprehension
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Discharge process
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Hand off
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Measures (e.g., kgs vs lbs)
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Documentation
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Time shifts
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Checklists
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Transparency
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Public posting/reporting of quality data
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Patient satisfaction and experience scores
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Feedback reviews
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Communication and Resolution Programs (CRP)
4.6.4.6 Regulation
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Professional self-regulation
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Maintenance of certification
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External accreditation
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Leadership program for emerging units
4.6.4.7 Financial Incentive
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Incentive for performance
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“No pay” for preventable complications
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Accountable care organization—Group incentive to deliver coordinated care and outcome
4.6.4.8 Liability Reform