Improving Quality and Safety in the ED
What have we learned from reviewing incidents and RCAs?
We know Emergency Medicine is an inherently challenging area of clinical practice. Over time, guidelines, policies and pathways have been developed and re-developed to assist emergency clinicians in the management of the entire spectrum of disease and conditions. Yet we continue to see a significant number of adverse events in our departments, with some being repeated over and over again.
Few emergency patients present in a manner that can be managed according to a well-prescribed pathway. Many patients with potentially life-threatening conditions will present in an unusual or atypical manner and/or fail to respond to initial management for a condition as expected. It is these presentations in high-risk or complex patients that constitute a significant proportion of ED-related incidents and adverse events.
The Emergency Care Institute undertakes regular reviews of Root Cause Analyses (RCA) undertaken by hospitals into SAC (Severity Assessment Code) 1 incidents that occur in NSW Emergency Departments. From these reviews, it can be concluded that there are some common themes of poor assessment and management that continue to feature in spite of recent changes to clinical care (eg. DETECT, BTF). In their July-December 2010 report, the Clinical Excellence Commission stated that “the most frequently identified issue in RCA reports continues to be management of patients whose condition deteriorates under our care”.
Commonly in cases of patient deterioration, thought-based errors are implicated whereby clinicians have committed oversights attributable to pattern matching (an ‘overly’ automated approach to interpreting information and identifying underlying patterns), mindset/narrow thinking or confined to rule-based thinking, and relying on a false hypothesis (wrong diagnosis) with insufficient evidence.
The ECI has developed a suite of resources for clinicians and administrators involved in managing incidents locally. These can be accessed here.
Distilled wisdom: Avoiding error in the complex environment of the ED
Remembering these points will assist in delivering the right care, first time.
- Often, patients do not fit the classic mould
While guidelines provide a uniform approach to management of patients who present in a typical manner for immediately or imminently life-threatening conditions, many patients with potentially life-threatening conditions will present in an atypical manner, and/or fail to respond to the initial management as expected. Atypical presentations pose an increased risk of an adverse outcome or event.
- Atypical presentations
Atypical presentations or patients whose progress or response to treatment is not as expected, should trigger clinicians to consider early reassessment, investigation and consultation. This may not only manifest as deterioration, but also where there is no change in condition.
- Start Over
Re-assessment means starting from scratch, and approaching the patient with no preconceptions. Clinicians must ignore a “diagnosis” that has been previously given. For example, labelling abdominal pain in an elderly person as constipation before serious surgical diagnoses have been ruled out, and simultaneously, clinicians should consider all information available from other sources.
- Representing patients pose a higher risk
Any recent presentation to an ED or any other medical provider for the same complaint should flag this patient as high risk.
- Use “red flags”
“Red flags” are indicators in the patient history or examination that alert us to potential serious diagnoses that may be mimicked by more common and less sinister conditions. Excluding potential serious diagnoses must be a conscious and active process once red flags are identified, even if the patient looks well. The ECI Red Flags Educational Modules use a case based discussion format to highlight the pitfalls and the evidence about “Red Flags”. See ECI developed e-learning RED FLAG modules here.
- Keep an open mind
It is acceptable to not know the diagnosis as clinical signs will evolve. Deliberately keeping an open mind, thinking broadly and seeking advice while addressing early stabilisation and therapy, will generally avoid the wrong clinical path. Initially “undifferentiated” patients constitute a high risk group and lack of a clear diagnosis may prevent assignment of the patient to a familiar care pathway. In this situation, re-assessment and early consultation is essential and keeping an open mind will reduce the risk of initiating inappropriate treatment.
Supporting Quality and Safety in Small EDs
Quality improvement practices are an important part of the activities of Emergency Departments (EDs), with the overriding goal being an improvement in patient outcomes and service provision. In NSW, approx 35% of all ED presentations occur in rural areas. These often occur in smaller EDs (Level 1 to 3 EDs) which may be predominantly staffed by nurses, with medical staff on-call or only available by telehealth, or staffed by non-specialist emergency medical staff. These sites still manage acutely unwell patients and studies have shown they see a similar proportion of triage category 1 and 2 patients, compared with the Australian average.
The ECI has initiated a program of monthly teleconference meetings (E-QuEST) to simulate an M&M style meeting that are usually only held in larger emergency departments. For more information on E-QuEST click here.
Further References and Resources
- Developing a “whole system” quality culture - Bernadette Eather, Director of Patient Safety, Clinical Excellence Commission at the ECI Nursing Leadership Forum 19 May 2017
- What I've learned from doing RCA reviews - Anne Hawkins, Critical Care CNC, Murrumbidgee LHD & IAC Co-Chair at the ECI Nursing Leadership Forum 27 May 2016
- An ED Quality Program: a how to guide - Claire Hutchinson, Clinical Nurse Consultant, The Canterbury Hospital and Lindy Collins, Nurse Unit Manager, The Canterbury Hospital at the ECI Nursing Leadership Forum 27 May 2016
- Never Events: Case Vignettes, Dr Jacqui Irvine and Anne Hawkins at the ECI ED Leadership Forum 31 July 2015
- Care Quality Commission - Meeting the Quality Challenge: Sharing examples of best practice from clinical leaders in Emergency Departments (November 2017)