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Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1027 — The ED-PACT Tool: Communicating Veterans' Care Needs after Emergency Department Visits via Electronic Messages

Lead/Presenter: Kristina Cordasco, COIN - Los Angeles
All Authors: Cordasco KM (VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP); UCLA) Saifu HN (VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)) Rubenstein LV (VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP); UCLA) Khafaf M (VA Greater Los Angeles Healthcare System; UCLA) Hsiao J (VA Greater Los Angeles Healthcare System; UCLA) Orshansky G (VA Greater Los Angeles Healthcare System; UCLA) Ganz DA (VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP); UCLA)

Communication failures between the Emergency Department (ED) and primary care (PC) threaten patient safety. A best practice for supporting communication across transitions is to use standardized "closed-loop" communication processes that leverage technology and are embedded into providers' workflow. We iteratively developed and assessed the reliability and user acceptability of an electronic tool (the ED-PACT Tool) for sending messages from ED physicians to patients' assigned PC nurses for Veterans discharged home from the ED with urgent or specific follow-up needs.

We initially developed the ED-PACT Tool in two VA Greater Los Angeles (GLA) Healthcare System Patient Aligned Care Team (PACT) clinics. Following deployment, we used chart audit to monitor adherence with tool processes, noting failures (e.g., no action on a message) and investigating causes of these failures. We assessed user acceptability through nurse questionnaires and leadership interviews. We audited 150 messages for types of follow-up needs. We utilized this information to iteratively revise the ED-PACT Tool and processes, while spreading to 11 additional GLA clinics.

Pre-implementation, PACT leadership endorsed improving post-ED care communication as a high priority. Post-implementation, 23 of 29 nurses were "confident" or "extremely confident" in their ability to use the tool. Between November 1, 2015 and March 31, 2017, the ED-PACT Tool was voluntarily used to send 2755 messages to 93 PACT teams across 13 sites. Care needs included: symptom recheck (55%); care coordination (16%); wound care (5%); medication adjustment (5%); laboratory recheck (5%); radiology follow-up (3%); and blood pressure recheck (3%). Nurses successfully acted on 88% of messages (weekly range, 72% - 100%). PACT leaders perceived the tool as substantially beneficial for care coordination; they thought nurse training and "buy-in" facilitated implementation, while insufficient staff posed a barrier.

The ED-PACT Tool was sufficiently reliable for clinical use. ED and PACT users endorsed its ability to facilitate communication between providers during a vulnerable care transition.

PACT nurses can fill an important role in receiving and triaging post-ED care coordination messages. Deployment of similar tools should include attention to the organizational, human and technical factors revealed by our evaluation.