Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative

What about physician wellness? Impact of a quality improvement intervention

BACKGROUND

Emergency department (ED) consultations with general internal medicine (GIM) are required when patients need admission, assistance with safe disposition or evaluation and management of complex or acute medical needs. GIM physicians often balance responsibilities between hospital wards and the ED, which can lead to delayed ED consultations, difficulty balancing workload and potential burn-out. To address this issue, a quality improvement (QI) initiative was trialled, establishing a dedicated GIM ED consultation service to manage these duties independently. This study aimed to evaluate the impact of this intervention on physician wellness.

METHODS

A pre-post design was used, with two questionnaires adapted from the validated Mini Z version 2.0 (Zero Burnout Program) Worklife measure for clinicians. These were distributed via Google Forms to collect feedback from participating GIM physicians before and after the intervention. Data were analysed using descriptive statistics and the Mini Z outcome measurement scale.

RESULTS

13 physicians completed the surveys. Applying the Mini Z scale, the GIM ED consultation service had no impact on physician well-being or burn-out. There was a minor increase in satisfaction (1 point) and stress levels (2 points), and the working environment worsened slightly (1 point). Comparing preintervention and postintervention survey responses, job satisfaction improved (36%), while reports of 'burn-out' (23%) and 'beginning to burn out' (8%) decreased. Postintervention, physicians reported decreased time for documentation (23%), a perception of a more chaotic work environment (23%) and an increase in work encroaching on personal time (15%) when on the ED consultation service. Additionally, there was a 23% reduction in the likelihood of needing to reduce clinical teaching unit service weeks.

CONCLUSION

When conducting QI initiatives, consider measuring the wellness of physicians and other healthcare providers. Proactively integrating wellness strategies into interventions requires further exploration which may enhance participant experience and initiative sustainability.

Quality and Patient Safety Metrics: Developing a Structured Program for Improving Patient Care in the Department of Medicine at The Ottawa Hospital

PROBLEM

Despite increasing recognition of the importance of quality and patient safety in academic medicine, challenges remain with ensuring physician participation in quality assurance and quality improvement efforts, such as lack of compensation and enabling resources. An organizational culture that includes physician leadership and a supportive infrastructure is needed to encourage physician backing of quality and patient safety initiatives.

APPROACH

The authors describe the development of a robust quality and patient safety program in the Department of Medicine at The Ottawa Hospital over the past 7 years and highlight how the department changed its organizational culture by prioritizing quality and patient safety and establishing the necessary infrastructure to support this program. Program development was characterized by 4 overarching themes: incentives, administrative structure and physician leadership, training and support, and system enhancements.

OUTCOMES

As a result of the program, the department broadly implemented a standardized framework for conducting quality committee meetings and morbidity and mortality rounds and reviewing patient safety incidents and patient experience across its 16 divisions. This has led to 100% departmental compliance on corporate quality assurance metrics each year (e.g., regular multidisciplinary divisional quality committee meetings), along with physician participation in formal quality improvement initiatives that align with larger corporate goals.

NEXT STEPS

The authors reflect on lessons learned during the implementation of the program and the essential elements that contributed to its success. Next steps for the program include using a centralized repository of quality and patient safety data, including patient safety incident dashboards, to encourage greater divisional collaboration on quality improvement initiatives and continuous institutional learning over time. Another important avenue will be to create an academic hub for excellence in quality and a formal approach to reward and promote physicians for their quality work.

Interventions to improve consultations in the emergency department: A systematic review

OBJECTIVES

Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process.

METHODS

Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted.

RESULTS

Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I²  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied.

CONCLUSIONS

The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.