R E V I E W S & A N A LY S E S Patient Flow in the Emergency Department: Phase III— after Disposition Decision through Departure Mary C. Magee, MSN, RN, CPHQ, CPPS INTRODUCTION Senior Patient Safety/Quality Analyst Pennsylvania Patient Safety Authority For emergency department (ED) patients, the time between disposition decision and departure from the ED (i.e., phase III) often comprises waiting for discharge instruc- tions or completed inpatient orders, transportation to another facility, or transfer to ABSTRACT the next level of care (e.g., inpatient bed, procedural area). Most evaluations have been completed, emergent care has been provided, and disposition decisions have been In 2013, Pennsylvania hospitals made, and patients wait for that decision to be acted on. For caregivers, the primary reported 23,749 events to the function in phase III is to care for and monitor the patient until departure from the Pennsylvania Patient Safety Authority in ED by way of discharge, transfer, or admission. which the emergency department (ED) was selected as the care area. Of these In 2010, the Pennsylvania Patient Safety Authority published an article that delineated reports, 540 (2.3%) involved patients the patient’s ED stay into the following phases:1 undergoing care in the time between —— Phase I: patient arrival in the ED up to diagnostic evaluation disposition decision through departure —— Phase II: diagnostic evaluation through disposition decision from the ED (i.e., phase III); reported consequences ranged from no-harm —— Phase III: after disposition decision through departure from the ED events requiring monitoring to events Figure 1 depicts each phase, including components and potential hazards to patient resulting in harm or even death. Several safety. The components of phase III are as follows: components of this phase have poten- —— Monitoring of the patient until a bed is available or until the patient is discharged tial safety hazards. Two hundred and or transferred thirty-nine events (44.3% of the 540 ED —— Communication or handoffs to the next facility, unit, or caregiver phase III events) involved monitoring the —— The discharge process, including patient teaching patient until an inpatient bed was avail- able or until the patient was discharged —— Transportation or transfer or transferred, and 199 events (36.9%) Potential patient safety hazards during phase III include the following: were gaps in care unrecognized by ED —— Gaps in treatment responsibility and oversight personnel (i.e., identified by another —— Unmonitored patients, including patients who have inpatient bed assignments caregiver or department). This article, and are awaiting transfer; patients whose ED care is complete and who are waiting the third in a series that addresses for inpatient orders, discharge, or transfer; and admitted patients who are board- patient safety related to ED flow, focuses ers waiting in the ED for an undetermined length of time on strategies to improve processes of care and patient safety during ED —— Rushed, incomplete, or inaccurate patient assignments phase III. (Pa Patient Saf Advis 2015 —— Poor communication and handoffs Dec;12[4]:132-40.) —— Incomplete or no patient and family education —— Transportation and transfer difficulties The March 2015 Pennsylvania Patient Safety Advisory article on phase II describes the components, potential patient safety hazards, risk reduction strategies, and best prac- tices specific to the time from diagnostic testing through disposition decision.2 This article addresses phase III of the ED flow experience and discusses risk reduction strat- egies and best practices. METHODS Analysts queried the Authority’s Pennsylvania Patient Safety Reporting System (PA-PSRS) database for reports submitted during calendar year 2013 that identi- Scan this code fied the ED as the care area; facilities reported 23,749 such events. An illustration with your mobile of the data analysis methodology, “Emergency Department (ED) Flow Phase III device’s QR reader to access the Methodology Algorithm,” is available exclusively in the online version of this article at Authority's toolkit http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Dec;12(4)/ on this topic. Pages/132.aspx. Page 132 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority Figure 1. Emergency Department Flow Phases PHASE I PHASE II PHASE III Patient Arrival in the Diagnostic Evaluation After Disposition Emergency Department through Disposition Decision through (ED) up to Diagnostic Decision Departure from the ED Evaluation Includes: Includes: Includes: Evaluation Monitoring patient until Patient arrival in ED Treatments and procedures bed or unit is available or until the patient is Patient triage Diagnostic testing discharged Placement in Monitoring and Communication or treatment area reassessment (including handoff to next facility, Practitioner arrival/initial continued physician and unit, or care setting assessment nursing assessments) Patient teaching and Consults discharge Patient safety hazards: Diagnosing (including Transportation Patients who leave medical decision making) without triage Disposition decision Patient safety hazards: Unmonitored patients in Gaps in treatment waiting area Patient safety hazards: responsibility and oversight Rushed or inaccurate Patients who leave without being seen, leave without Unmonitored patients triage process treatment, or leave against Unmonitored boarders Patients who leave without medical advice in the ED being seen Unmonitored patients in Rushed, incomplete, Unmonitored patients treatment room or inaccurate patient in rooms assessment Errors in ordering, Rushed, incomplete, or executing, and resulting Poor communication inaccurate patient Delays in ordering, and handoffs assessment executing, and resulting Incomplete patient and Rushed, incomplete, or family education inaccurate patient assessment Transportation difficulties Diagnostic decision errors or failure to diagnose MS15645 Analysts expanded the data analysis PA-PSRS uses an adaptation of the harm and no-harm events.3,4 The analysts performed for the phase II article and National Coordinating Council for excluded 2,164 of the 2,784 reports from identified events associated with phase III Medication Error Reporting and the analysis because they were submitted by means of relevant keywords (e.g., “dis- Prevention harm index and the US as unsafe conditions or no-harm events charge,” “dispo,” “inpatient,” “admit”) in Department of Veterans Affairs National (i.e., harm scores of A through C). Analysts the narratives, resulting in 2,784 reports. Center for Patient Safety severity assess- retained for analysis the remaining ment code system to distinguish between 620 reports submitted as no-harm events Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 133 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S requiring monitoring (i.e., harm score D) or Figure 2. Percentage of Emergency Department Flow Phase III Event Reports, by as events resulting in harm or even death Component, Submitted to the Pennsylvania Patient Safety Authority in Calendar Year (i.e., harm scores E through I) and also 2013 (N = 540) included 221 phase III reports meeting Other the same harm criteria identified during 1.5% the previous phase II analysis. Through individual analysis of the resulting 841 phase III events, analysts excluded remain- ing non-ED (n = 199), phase I (n = 3), Patient and phase II (n = 99) reports, leaving 540 teaching or reports in the final data set. discharge Analysts conducted a review of the litera- 8.5% ture to identify risk reduction strategies Transportation and best practices for the management of or transfer the phase III components. 9.6% RESULTS Monitoring Communication 44.3% Analysts reviewed the 540 phase III event (including handoffs narratives and categorized the reports and reporting) into one of the following components: 11.7% monitoring, communication (including handoffs and reporting), patient teaching or discharge, transportation or transfer, unplanned returns requiring admission, or other. See Figure 2. Unplanned returns Once sorted by component, analysts requiring admission reviewed the narratives and identified the 24.4% following four types of key vulnerabilities (see also Figure 3): MS15648 1. Gaps unrecognized by ED personnel: events discovered by non-ED person- nel (e.g., radiology personnel) or discovered after the patient left the ED adverse reactions, complications), as home. RN [registered nurse] near the 2. Delays: delays in care, treatment, or depicted in the PA-PSRS event narratives room heard a thump and found the services below:* patient lying against the wall com- 3. Insufficient oversight: events involv- An elderly patient with an extensive plaining of left arm pain. ing unclear oversight or lack of cardiac history was evaluated in The majority of events involving monitor- oversight responsibility the ED and was in the 302 process ing were unrecognized by ED personnel 4. Lack of prompt transition: patients awaiting placement for behavioral (53.1%, n = 127 of 239); for example: who were admitted but remained in health. Suddenly, the patient had a A medication was ordered to be the ED as “boarders” cardiac arrest, which was witnessed started in the ED prior to admission by staff; [patient was] resuscitated to the inpatient unit. The [attend- Examples of Event Reports and admitted to the hospital. ing] physician discovered that the Related to ED Phase III Patient was sitting up in the chair treatment had not been started. Rec- Components awaiting transport back to nursing ommendation: admission orders need Monitoring. The predominant number to be initiated when ordered regard- * The details of the PA-PSRS event narratives of events reported in phase III involved less of the location of the patient. in this article have been modified to preserve monitoring (44.3%, n = 239) (e.g., falls, confidentiality Page 134 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority Figure 3. Number of Reports Mentioning Key Vulnerabilities Submitted to the recommendation] was entered by the Pennsylvania Patient Safety Authority in Calendar Year 2013 (N = 288), by ED nurse. The patient arrived to the Emergency Department (ED) Phase III Component unit with a cardiac drip infusing. NO. OF Because the admitting unit was not REPORTS equipped to take patients on cardiac drips, the patient had to be trans- 200 5 3 ferred to a higher level of care. 180 14 6 160 ED staff brought the patient to the 44 inpatient unit but did not notify the 140 unit staff. The siderails were left 120 down, and the patient was not con- 100 nected to the telemetry pack. 80 Patient teaching or discharge. These 60 127 2 events (e.g., inability to use devices, inad- 40 10 7 equate discharge instructions, omissions) 20 MS15649 32 2 represented 8.5% (n = 46) of the phase III 22 14 0 reports; for example: Gaps unrecognized Delays Insufficient Lack of prompt The patient was instructed [on the by ED personnel oversight transition use of] crutches prior to disposition. KEY VULNERABILITY The patient attempted to walk with crutches and fell and is [now] unable Monitoring Transportation or transfer to bear weight on foot. Communication Unplanned returns The patient was treated with IV (including handoffs and reporting) requiring admission [intravenous] fluids and medication Patient teaching or discharge Other and was discharged. The [discharge] instructions indicated that the cause Note: Some reports did not specify vulnerabilities, and some identified more than one key vulnerability. of the pain and elevated [white blood cell] count is uncertain, but there is no evidence of an acute surgical The ED patient was admitted for it contained medications that the problem. The family complained nausea, vomiting, and abdominal patient was no longer taking. A fam- about the [discharge instructions] pain and has a history significant for ily member stated they gave the ED a because the only information com- abdominal surgery. The patient was current medication list that was never municated to them was via a showing significant symptomatology sent to the unit with the patient. handwritten note that did not [con- and was ordered an x-ray and CAT tain actual results]. There was a delay in transferring the [computerized axial tomography] patient to the inpatient unit. There Patient and family teaching events were un- scan. The patient was transported to was confusion about the admission recognized by ED personnel 13.0% (n = 6 the inpatient unit prior to having the orders, and poor communication led to of 46) of the time, as represented below: imaging studies completed; this led to a delay in medication administration. The patient was given the wrong a multi-hour delay in diagnosis and The medication was administered prescription [upon discharge]. The treatment. once the error was discovered. pharmacy noticed the wrong name Communication or handoffs. These events The majority of events involving commu- on the prescription and called the (e.g., inaccurate or inadequate medication nication and handoffs were unrecognized ED. The patient came back and [was reconciliation, inadequate reporting) rep- by ED personnel (69.8%, n = 44 of 63); given the correct prescription]. resented 11.7% (n = 63) of the phase III for example: Transportation or transfer. These reports; for example: The receiving [inpatient] nurse was events (e.g., falls, skin integrity issues, The patient reported that the ED unaware that an SBAR [situation, medication list was not correct, as background, assessment, and Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 135 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S complications) represented 9.6% (n = 52) A patient was seen and discharged unit due to [lack of bed] availability. of the phase III reports; for example: from the ED because teleradiology There was a delay in medication A patient was being transported out [verbally] reported that the ultrasound administration due to confusion and of the ED by ambulance attendants. was negative. The written ultrasound poor communication. The stretcher tilted over; the patient report was positive for [thrombosis], Insufficient oversight. This vulnerability was strapped to the stretcher and and the patient was called back was identified in 4.1% (n = 22) of the sustained an injury to the arm and and admitted. phase III reports; for example: shoulder. The patient was brought Events of unplanned ED returns requir- A [mental health] patient with [sev- back into the ED for treatment of ing admission were unrecognized by ED eral] medical conditions was awaiting abrasions. No other injuries noted. personnel 2.3% (n = 3 of 132) of the time, placement for [72 hours]. Psychiatric The patient was discharged. as seen in the example below: services did not provide care while the Following discharge from ED, the The [ED patient’s] initial CAT scan patient was in the ED. patient became [light-headed] while was read as negative by the [telera- Lack of prompt transition. This vulnerabil- using the restroom in the waiting area, diology service]. Several hours later, ity was identified in 3.0% (n = 16) of the fell, and hit his head on the [sink]. the [teleradiology service] called the phase III reports; for example: Transportation/transfer events were ED to report that the CAT scan was positive. The patient was called back A [psych] patient was in the ED for unrecognized by ED personnel 26.9% [48] hrs and did not receive [his] psych (n = 14 of 52) of the time, as represented and admitted. meds. The patient began acting out, below: Other. These events represented 1.5% which required [interventions]; the The patient was admitted with a (n = 8) of the phase III reports. As stated lack of prescribed medications may [respiratory diagnosis] and was trans- previously, these events did not meet the have [contributed to this behavior]. ported to CAT scan and ultrasound criteria for classification into any of the prior to being transported to the unit. phase III components and were analyzed DISCUSSION: IMPROVING FLOW The patient was to be on oxygen con- separately. AND PATIENT SAFETY tinuously but was transported without it. On arrival to the floor, [the Examples of Event Reports Monitoring/Rounding patient’s] oxygen saturation was in the Related to Key Vulnerabilities Patients waiting to depart from the ED 70s, [his] heart rate was tachycardic, There were 288 instances in which a key via discharge, transfer, or admission and [he] was complaining of chest vulnerability was mentioned in the 540 ED remain in the care of ED staff until the [tightness]. Oxygen was immediately flow phase III event report details. Some patient’s departure. Routine monitoring applied and [he] received an EKG reports did not specify vulnerabilities, (observing) of patients is a basic nursing [electrocardiogram], lab work, and and some identified more than one key intervention and can help prevent untow- breathing treatment. [He] responded vulnerability. ard events (e.g., falls).5 Hourly intentional to treatment within a half hour. rounding promotes safety, comfort, and Gaps unrecognized by ED personnel. This patient satisfaction.5, 6 There are specific Unplanned returns requiring admission. vulnerability was identified in 36.9% (n = rounding elements to address with ED These events (e.g., errors or complications 199) of the phase III reports. An example patients: pain management, plan of care, related to procedures, treatments, or tests) is as follows: duration (i.e., length of stay), and expecta- represented 24.4% (n = 132) of the phase The ED patient was ordered [normal tion management.6-9 III reports; for example: saline solution] at [100mL/hr]. Upon Toolkits, protocols, and policies are avail- A [pediatric] patient was seen in the arrival to the inpatient unit the admit- able for improving patient monitoring.2,5,10 ED for nausea and vomiting and ting nurse found [5% dextrose in water Hourly rounding has been associated decreased urine output. The patient solution infusing at 100mL/hr]. with increased patient satisfaction and was discharged with a [gastrointesti- This vulnerability was identified Delays. decreased number of falls with signifi- nal infection] diagnosis and given a in 9.4% (n = 51) of the phase III reports; cant injury, call light use, and number prescription. The parents brought the for example: of patients leaving the ED without being patient back with worsening symp- There was a delay in transferring treated or against medical advice.5,6,8,11 As toms, and [the patient] was admitted. the [ED] patient to the inpatient a proactive intervention, hourly rounding Page 136 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority enables nurses to anticipate and assess for patient to the inpatient unit.20 Use of admissions, department of medicine safety hazards and patients’ needs.5 an admission consultant response time resources, and hospital bed occupancy is guideline was successful in reducing the directed by a hospitalist, ED throughput Communication and Handoff time between disposition decision and and ambulance diversions are improved.26,27 Patient handoffs are variable.12-16 The inpatient departure from the ED.21 handoff is not merely about communicat- Studies have shown that high hospital Discharge Process and ing information from one caregiver to inpatient occupancy impedes ED flow Patient/Family Teaching another but also involves transfer of care and affects inpatient occupancy of the Discharge planning and ensuring a safe and responsibility for the patient.12,14,15 ED, leading to prolonged ED stays and transition to the home or community is a Studies suggest that the handoff process is boarding.20,22,23 One simulation study fundamental element of emergency care.28 highly complex and may be optimized by revealed that a hospital inpatient occu- The Agency for Healthcare Research standardization.12,13,16 pancy rate below 85% lowers the risk of and Quality (AHRQ), in its 2014 report One standardized method of communica- hospital bed shortage, enabling the ED on improving the ED discharge process, tion that can be used to enhance handoffs inpatient demands to be met.24 identified three primary functions of the is situation, background, assessment, and Efforts to improve inpatient bed ED discharge process: “communicate recommendation (SBAR). SBAR uses a flow include early alert systems for with/educate patients,” “support post- predictable pattern of communication that hospital-wide awareness of reduced bed ED discharge care,” and “coordinate care allows for the recognition of missing infor- availability, admission guidelines, daily with other providers and services.”29 See mation.13 Practicing and evaluating the use bed huddles, early rounding practices, “Characteristics of a High-Quality ED of standardized methods of handoff com- early discharge practices, and discharge Discharge.” munication can enhance patient safety.13,16 lounges for inpatients waiting to be There are multiple factors that contribute discharged.20,22,23 Overcrowding calcula- to a poor discharge, including limited Transfer and Admission tors, such as the Emergency Department literacy.30,31 The ED can be a noisy, cha- Interfacility transfers. The Emergency Work Index and the National Emergency otic environment with distractions and Nurses Association’s position statement Department Overcrowding Scale, are use- interruptions. Patients are anxious to on interfacility transfers recommends that ful early warning systems.25 leave once their care is complete. All of transport teams have specialized train- Improvements can be seen when hospital- these conditions affect comprehension.30 ing, patients be rapidly transferred with ists are involved in the admission process. According to Alberti and Nannini’s litera- certain provisions, and patient safety and Specifically, when management of ED ture review on patient comprehension of level of care be maintained.17 The handoff communication strategies are of import and applicable to successful transfers, whether for transporting a patient back CHARACTERISTICS OF A HIGH-QUALITY ED DISCHARGE to a skilled nursing facility or to another A high-quality emergency department (ED) discharge contains three main facility for definitive care.13,15,16 characteristics: Sethi and Subramanian, in their review of 1. It informs and educates patients on their diagnosis, prognosis, treatment plan, the literature, identified practice guidelines and expected course of illness. This includes informing patients of the details of that promote “pre-transport coordination their visit (e.g., treatments, tests, procedures). and communication, qualified and trained accompanying personnel, appropriate 2. It supports patients in receiving post-ED discharge care. This might include transport equipment, standard monitoring medications, home care for injuries, use of medical devices/equipment, further and documentation as key elements of a diagnostic testing, and further healthcare provider evaluation. safe transfer.”18 Before transfer, the patient 3. It coordinates ED care within the context of the healthcare system (e.g., other should be stabilized to the extent possible healthcare providers, social services). by the transferring facility.18,19 Source: Agency for Healthcare Research and Quality. Improving the emergency department Admission processes. Once the deci- discharge process: environmental scan report [online]. AHRQ Publication No. 14(15)-0067-EF. 2014 Oct [cited 2015 Jun 24]. http://www.ahrq.gov/professionals/systems/hospital/edenviron- sion to admit has been made, efficient mentalscan/index.html processes can expedite the transfer of the Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 137 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S ED discharge instructions, clinicians do including dedicated equipment and sup- narratives. Return visits to the ED can not routinely assess patients’ comprehen- plies, resulting in increased patient and be considered a discharge failure or an sion, and actual patient comprehension staff satisfaction.38 The Emergency Nurses indicator of poor initial care and may was limited in the studies that used only Association supports a systems approach negatively affect patient safety, satisfac- verbal and/or written instructions.30 Many to improving patient flow.39 tion, and care.29,42,43 interventions are available to improve For psychiatric patients, the Illinois Care coordination with ambulatory patient and family teaching, such as multi- Hospital Association recommends spe- providers could reduce unplanned ED media tools, illustrations, simple text, and cially trained staff and dedicated space returns, but in their systematic review of discharge facilitation.28-30 Studies recom- providing specific areas in the ED or the literature, Katz et al. found that ED mend using the “teach-back” method to alternative locations in which the patient care coordination interventions had vari- enhance patient comprehension.10,31 can remain for crisis stabilization. These able effectiveness.44 Having dedicated staff Sharing clinical information with post-ED areas should ensure privacy, comfort, and may address these issues.45,46 One study care providers (e.g., primary care physi- safety; be soothing and supportive; pro- showed a 17% improvement in completing cians) is essential for ensuring continuation mote healing; and help deescalate agitated follow-up cases within three days and an of care and timely follow-up.32,33 One study or psychotic patients.40 80% reduction of follow-up cases delayed identified eight best practices for safe care by more than seven days, attributable to transitions, including sending summary Gaps Unrecognized by ED the follow-up program.45 One study identi- and clinical information to the primary Personnel fied system improvements when analyzing care physician and to other “receiving A large portion of the phase III events were data on patients who returned to the ED, physicians upon discharge or transfer.”32 unrecognized by ED personnel (i.e., were including improving physician-to-patient Measuring and evaluating the ED dis- identified and reported by another care- communication, acute pain control, and charge process can enhance patient safety.29 giver or department). This data can provide availability of community resources to vul- valuable information when analyzed and nerable populations such as the elderly.42 Boarders considered for incorporation into the ED’s In an interview, Lindsay Lion, BSN, RN, According to the American College of performance improvement program. CEN, senior nurse navigator in the ED Emergency Physicians (ACEP), a boarded at Nazareth Hospital, described this new An AHRQ study demonstrated that patient is “a patient who remains in the role as one of partnership with the older the diagnoses made in the ED differed emergency department after the patient adults seeking emergency care.47 The from those made at the time of hospital has been admitted to the facility, but navigator calls patients who have been discharge 10% of the time. The study eval- has not been transferred to an inpatient discharged from the ED to ensure they uated an automated system for feedback unit.”34 ED overcrowding, including days understand the importance of and know to emergency medicine physicians about spent boarding, has been associated with how to prioritize their discharge instruc- the concordance between their initial increased inpatient mortality.35 ACEP tions, including follow-up appointments diagnoses and patients’ final diagnostic published a list of hospital recommenda- and filling prescriptions. Additionally, the outcomes and concluded that “timely fol- tions regarding boarding of admitted and navigator educates patients about medi- lowup is feasible in the ambulatory setting intensive care patients in the ED, and cal problems, answers questions, offers and may catch issues at an earlier stage.”41 this list can be accessed at https://www. emotional support, and connects patients acep.org/Clinical---Practice-Management/ with resources such as transportation and PATIENT FLOW BEST PRACTICES Boarding-of-Admitted-and-Intensive-Care- support groups. Patients-in-the-Emergency-Department.36 Return Visits and Postdischarge Another study speculated that lack of There are advantages to reducing board- Follow-Up a primary care physician contributed ing. According to the ACEP, “By reducing Once the patient is discharged from the to a high ED return visit rate; however, patient boarding, treatment of patients in ED, diagnostic test results may come back the study identified that patients who non-treatment areas such as hallways can positive or with a discrepancy. Patients returned to the ED within 30 days of be limited, and the number of patients may leave the ED without their discharge an initial visit may have contacted their leaving prior to evaluation or completion instructions and prescriptions. These primary care physician before returning, of medical treatment can be reduced.”37 issues can contribute to patients returning and many were insured patients with a One study duplicated the inpatient care to the ED for continued care or admis- primary care physician who were able to delivery model in the ED for boarders, sion, as depicted in some PA-PSRS event see them that same day.43 Ms. Lion also Page 138 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority communicates with the patients’ primary reports for which an ED location was during phase III of ED flow and beyond care physician to foster enhanced care misclassified would not have been cap- can improve care delivery and coordina- coordination.47 Early success is shown by tured. Similarly, removing reports based tion, minimize safety hazards, and directly increased Hospital Consumer Assessment on phase I and phase II keyword sort- contribute to the safety of patients in this of Healthcare Providers and Systems sur- ing at the beginning of the analysis may phase of ED treatment. vey scores on the statement, “Staff cared have eliminated some phase III reports. ED discharge aftercare and care coordina- about you as a person.”47 Relevant information is derived from the tion are becoming ever more integral to Stony Brook University Hospital in Long event type taxonomy and from free-text the management of the ED patient, and it Island, New York, has an enhanced ED narratives in varying degree of detail, and is essential that ED clinicians participate follow-up program that uses dedicated in some cases, interpretation in context is in the design and implementation of nursing and clerical staff 7 days a week for made by the analysts. these processes. The Patient Protection 10 hours each day.46 A computerized track- and Affordable Care Act created a variety ing board is used for chart reviews, clinical CONCLUSION of incentives to promote care coordina- checks, test results, and callbacks. All tion, such as the patient-centered medical Potential and actual safety hazards occur nurse/patient interactions are documented home model. Seamless communication during phase III of the ED stay, from after in the electronic health record, and clerical and information sharing between the ED disposition decision through departure. staff fax information to the next provider The monitoring component of this phase and the medical home (including primary of care. Service recovery, additional patient and gaps in care unrecognized by ED per- physicians and after–ED care providers) is teaching, and improved communications sonnel were identified as vulnerabilities essential to process improvement, as well with transitions in care are among the suc- to patient safety. Analyzing and under- as education and support for patients once cessful program outcomes. standing all of the key components and they return home.33 The use of health infor- vulnerabilities of this phase, employing mation exchanges and patient portals may LIMITATIONS risk reduction strategies and best practices help form the structure for this direction. Data searched was limited to events in patient flow, and improving operations reported under the ED care area; relevant NOTES 1. Managing patient access and flow in the 5. Halm MA. Hourly rounds: what does the Jun 18]. http://www.guideline.gov/ emergency department to improve patient evidence indicate? Am J Crit Care 2009 content.aspx?id=36906 safety. Pa Patient Saf Advis [online] 2010 Nov;18(6):581-4. 11. Meade CM, Kennedy J, Kaplan J. The Dec [cited 2015 Mar 17]. http://patient 6. Baker SJ. Hourly rounding in the emer- effects of emergency department staff safetyauthority.org/ADVISORIES/ gency department: how to accelerate rounding on patient safety and satisfac- AdvisoryLibrary/2010/dec7(4)/ results. J Emerg Nurs 2012 Jan;38(1):69-72. tion. J Emerg Med 2010 Jun;38(5):666-74. Pages/123.aspx 7. Kaplan J. Clinical quality and service 12. Emergency Nurses Association. Position 2. Magee MC. Patient flow in the ED: excellence [presentation slides online]. statement: patient handoff/transfer phase II—diagnostic evaluation through 2011 May [cited 2015 Mar 17]. http:// [online]. 2013 [cited 2015 Jun 18]. disposition decision. Pa Patient Saf www.acep.org/uploadedFiles/ACEP/ https://www.ena.org/SiteCollection Advis [online] 2015 Mar [cited 2015 Mar Meetings_and_Events/Educational_ Documents/Position%20Statements/ 17]. http://patientsafetyauthority.org/ Meetings/EDDA/Phase_II/4%20 PatientHandoff.pdf ADVISORIES/AdvisoryLibrary/2015/ Kaplan%20Clinical%20Quality%20 13. Hohenhaus S, Powell S, Hohenhaus JT. mar;12(1)/Pages/07.aspx and%20Service%20Excellence.pdf Enhancing patient safety during hand- 3. National Coordinating Council for Medi- 8. Montesino B. Hourly rounding in the offs: standardized communication and cation Error Reporting and Prevention. emergency department and inpatient teamwork using the ‘SBAR’ method. Am J NCC MERP index for categorizing medi- areas [online]. 2008 Jun [cited 2015 Jun Nurs 2006 Aug;106(8):72A-72B. cation errors [online]. 2001 Feb [cited 19; link no longer available]. 14. Van Eaton E. Handoff improvement: we 2015 Jan 13]. http://www.nccmerp.org/ 9. Ignacio A, Choe N. 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American College of Emergency for the Emergency Department, Naza- Active bed management by hospitalists Physicians. Boarding of pediatric reth Hospital). Interview with: Mary C. and emergency department throughput. patients in the emergency department Magee. 2015 Sep 17. Ann Int Med 2008 Dec 2;149(11):804-10. [policy statement online]. 2012 Jan [cited 2015 May 4]. http://www.acep. 27. Howell E, Bessman E, Marshall R, et al. Hospitalist bed management effecting org/clinical---practice-management/ throughput from the emergency depart- boarding-of-pediatric-patients-in-the- ment to the intensive care unit. J Crit emergency-department Care 2010 Jun;25(2):184-9. Page 140 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 4—December 2015. 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