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Health Services Research & Development

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FORUM - Translating research into quality health care for Veterans

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Research Highlight

Multiple studies have documented that poor communication leads to poor patient outcomes, or "near misses," after patients are discharged from hospital care.1 Researchers have given less attention to the transition of care between emergency department (ED) and ambulatory care settings. However, the limited literature available suggests that patients' failures to receive follow-up care after being sent home from an ED visit are associated with poor patient outcomes, including return ED visits and hospitalizations.2

In an effort to support care management for patients discharged from the ED at VA Greater Los Angeles Healthcare System (VAGLAHS) and to investigate methods for optimally supporting patients during this vulnerable transition, a team at VAGLAHS embarked on the ED-PACT Tool Quality Improvement Project. This project was initiated as a Veterans Integrated Service Network (VISN) 22 PACT Demonstration Laboratory Innovation, with support from the VA Office of Patient Care Services and continued with support of the Care Coordination QUERI Program. Utilizing Plan-Do-Study-Act cycles, a multi-disciplinary stakeholder workgroup developed, formatively evaluated, and spread the ED-PACT Tool across five primary care locations within VAGLAHS. This tool utilizes a care coordination order within VA's Computerized Patient Record System (CPRS) to communicate a message with post-ED care recommendations to the PACT Registered Nurse (RN) Care Manager. The PACT RN care manager receives the message and communicates with the primary care provider and other PACT team members to address needed follow-up care.

The ED-PACT Tool facilitates communication using principles that have been studied and recommended in the literature and by patient safety organizations as "best practices" for supporting effective transitions.3 The ED-PACT Tool leverages CPRS to send communications across care settings, and subsequent messages are embedded in the workflow of the end users. When sending messages, providers use a standardized process and form, which identifies the information needed by the receiver for effectively assuming management of the patient's care. The last step involves the RN care manager "completing" the order, signaling receipt of the message and thereby creating a "closed loop" communication system.

The VAGLAHS team used quality improvement methods and formative evaluation to guide tool development and deployment. Before implementation, we assessed readiness to participate in the innovation with leadership interviews and RN care manager questionnaires. During deployment, we used an audit and feedback process to monitor adherence with correct use of the tool. We logged all user comments, tracked all failures (i.e., a PACT nurse not acting on a message) and their causes, and used 'run' charts to assess weekly variations. We audited a random sample of 150 messages to capture the types of care needs for which messages were sent. We interviewed leaders in two clinics about perceptions of usability and value as well as implementation facilitators and barriers.

Between November 2015 and June 2016, the ED-PACT Tool was used to send 853 messages from the VAGLAHS ED to 35 PACT teamlets across five primary care clinics. Care needs included: symptom recheck (55 percent); care coordination (16 percent); wound care (5 percent); medication adjustment (5 percent); laboratory recheck (5 percent); radiology follow up (3 percent); and blood pressure recheck (3 percent). On average, nurses successfully acted on 90 percent of messages (weekly range, 72 to 97 percent). Reasons for failure included human error, staffing shortages, and technical errors.

Interviews with clinic leaders revealed that the ED-PACT Tool is perceived to provide substantial benefit for coordinating post- ED care by effectively communicating with patients' PACT nurses. Leaders also reported that nurse training and "buy-in" facilitated implementation, while insufficient staff presented a barrier. These formative data suggest that implementation of this messaging system between ED and PACT is feasible, although addressing organizational and technical issues would enhance its value. Next steps include identifying contextual factors essential for successful implementation and ascertaining the tool's potential effect on patients' clinical outcomes, experience of care, and health care utilization. We are also interested in determining the feasibility of wider adoption of the ED-PACT Tool.

The ED-PACT Tool is unique in leveraging the care management skills of the PACT RN care manager to receive and triage electronic care coordination communications. As asynchronous electronic communications become more widespread, the optimal role of nurses when interfacing with these communications is an area ripe for future research.

  1. Kripilani S, et al. "Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists," Journal of Hospital Medicine 2007; 2(5):314-23.
  2. Nunez S, Hexdall A, Aguirre-Jaime A. "Unscheduled Returns to the Emergency Department: An Outcome of Medical Errors?" Quality & Safety in Health Care 2006; 15:102-8.
  3. Joint Commission Center for Transforming Healthcare. "Hand-Off Communications Targeted Solutions Tool: Implementation Guide for Health Care Organizations." Retrieved from Center for Transforming Healthcare Website.


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