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Davee Excellence in Emergency Medicine Project

Advancing Emergency Care Delivery

Davee Excellence in Emergency Medicine was created through the generosity of the Davee Foundation as an initiative with three overarching goals:

•Promoting seamless transitions in patient care
•Utilizing medical informatics to improve patient care
• Implementing evidence-based practices in patient care and management

The provision of high-quality patient care requires an effective transmission of information at critical times of transition, including ED presentation from the primary care setting, discharge from the ED, and hospital admission. Medical informatics can facilitate effectual transitions by improving information exchange between providers, as well as providing important resources to patients and families. Moreover, technology represents an invaluable resource to enhance evidence-based patient care by providing innovative strategies to support and reinforce clinical decision-making. As part of this initiative, our team is working to develop strategies, practice changes, and technologic innovations that ensure that patients receive consistent, high-quality and evidence based care while in the ED and experience smooth and well-supported transitions into and out of our department.

The first phase of our efforts has focused on the transition in care at discharge from our department. These are critical transitions, occurring at ED or hospital discharge, and are recognized as high risk times for communication failures and, in turn, adverse patient events. Our phase 1 data confirms previous research demonstrating that many patients leave the ED without a complete understanding of the care and instructions they receive. Our recent work builds on past research by providing further detail about the variation in comprehension deficits across different aspects of ED discharge instructions. Our study results indicate that patients have the greatest difficulty understanding home care and return instructions, while they have less difficulty recalling their diagnosis, medications and follow-up instructions. These findings raise significant concerns for adherence and outcomes following an ED visit.

As part of this project, we have begun efforts to enhance the transition in care at discharge by directly targeting identified comprehension deficits through a literacy and patient-guided approach to the development of diagnosis-specific discharge instruction documents for several common diagnoses. Our process has been based on input from emergency providers, relevant subspecialty providers, and communication and literacy experts. In addition, we have conducted focus groups with patients in an underserved community to critically review and revise these documents. Patients have driven substantial revisions by providing invaluable input regarding the content, organization, and presentation of information in these documents. During this process, we have identified numerous themes in the feedback we have received from patients that have included the simplification of complex words and content, but also have addressed more general issues, such as the desire for a contextual or motivational framework for recommended care or instructions (eg, why should I follow these instructions, what happens if I do or do not follow them). As our project continues to develop, we look forward to testing our newly revised discharge instructions for patient preference and comprehension. Through this work, we hope to move closer to creating discharge documents and a process that will effectively provide patients with information they can use and, in turn, help them to avoid poor outcomes at these critical times of transition from ED to home.

Highlights:

• Baseline patient comprehension has been assessed for patients following an ED visit through follow-up phone calls by a nurse. Comprehension deficits have been found to be common and significant.  Approximately 80% of patients have demonstrated deficits for home care and/or return instructions, while less frequent deficits have been found for diagnosis (15%), medication (23%) and follow-up (41%) instructions.
  
• Diagnosis-specific discharge instructions for five common ED diagnoses have been created with input from emergency providers, relevant subspecialty providers, and communication and literacy experts, as well as patients. Patient input was achieved through focus groups conducted in an underserved community.
  
• Our new diagnosis-specific discharge instructions have undergone early assessments for patient preference that indicate that patients prefer these documents over currently-existing standards due to their layout and organization, as well as their content and pictures.
  
• A major component of the project this year has been the development and leveraging of medical informatics tools to improve patient transitions and coordination of care throughout the patient experience in the Northwestern Healthcare System.
  
• Major IT and process changes have led to improved capture of pertinent patient information prior to arrival in the ED (“prearrival information”). IT solutions included standardization of the existing electronic prearrival forms and broad implementation of an electronic form within the Cerner Electronic Medical Record System that allows outpatient physicians to input this information themselves. Major process improvement changes were also implemented in order to capture the information via phone communication to the unit secretaries and nursing, followed by transfer of the data to the standardized form within the electronic system.
  
• IT and process changes have vastly improved the capture of readily viewable Primary Care Physician (PCP) information within the electronic system. The IT solution incorporates the name of the patient’s PCP in a readily viewable area on upper banner bar of the patient chart. The process change involved improved capture of the PCP name during the patient registration process and input of the data into the electronic system.
  
• Significant IT changes were made to the patient discharge portion of the electronic system. The electronic depart process was streamlined in order to more accurately reflect physician and nurse workflow. In addition, a much improved Patient Specific Discharge Document was created using the principles learned from the broader Davee discharge instruction projects. The discharge form was revised in order to make the form more user friendly for providers, to provide information in a more clear and comprehendible manner, and to make it more visually appealing, with the ultimate goal of improving patient care and outcomes.
  
• The utilization and information contained within the ED Resources web page (a central repository of information for use by providers in the clinical care of patients in the ED) also continues to grow.