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Lightbody T, Thull-Freedman J, Freedman SB, Wright B, Finseth N, Coulombe A, Morrissette M, DeGuerre A, McConnell S, Bozocea K, Groves-Johnston S, Woods J, Newton A. Use of quality improvement methods to enhance implementation of a mental health care bundle in a pediatric emergency department. CAN J EMERG MED 2023; 25:326-334. [PMID: 36964857 PMCID: PMC10039676 DOI: 10.1007/s43678-023-00476-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 02/24/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES We used quality improvement methods to implement a care bundle for children presenting to a pediatric emergency department (ED) with mental health concerns. A bundle novelty was that it included an option for assessment in a partnered clinic, not in the ED, to families of children assessed as having no medical or safety concerns. The primary aim of this study was to establish successful implementation of the bundle prior to studying its impact. METHODS The bundle included the Ask Suicide-Screening Questions to standardize risk assessment at triage, the HEADS-ED (Home, Education, Activities/Peers, Drug/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources) tool for brief, scored mental health assessments, and offering an urgent appointment within 96 h for low-risk children as an alternative to ED-based assessment or as a follow-up option for patients assessed in the ED. We developed aims, driver diagrams, and outcome measures for each bundle element. Each element was introduced with small tests of change using iterative plan-do-study-act cycles. Run charts were used to determine successful completion of aims. RESULTS Rules for special cause were met through detection of shifts in performance 5 months after bundle implementation for the Ask Suicide-Screening Questions and HEADS-ED. These bundle elements were consistently used with ≥ 80% of eligible patients, representing aim achievement. During the 6 months of providing urgent appointments, 89.3% of 159 referred families received an appointment within 96 h. CONCLUSIONS Using quality improvement methods, we were able to successfully ensure reliable implementation of a new care bundle for pediatric patients presenting to the ED with mental health concerns and allow eligible low-risk patients to receive full assessments in a partnered clinic instead of the ED.
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Affiliation(s)
- Teresa Lightbody
- Children, Youth, and Families, Addiction and Mental Health-Edmonton Zone, Edmonton, AB, Canada.
- Northgate Health Centre, Alberta Health Services-Edmonton Zone, Edmonton, AB, Canada.
| | - Jennifer Thull-Freedman
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Stephen B Freedman
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Bruce Wright
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Faculty of Medicine and Dentistry, Stollery Children's Hospital University of Alberta, Women and Children's Research Institute, Edmonton, AB, Canada
| | - Nicole Finseth
- University of Alberta Hospital and Stollery Emergency Department, Edmonton, AB, Canada
| | - Angela Coulombe
- Children, Youth, and Families, Addiction and Mental Health-Edmonton Zone, Edmonton, AB, Canada
| | - Matthew Morrissette
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Amanda DeGuerre
- Children, Youth, and Families, Addiction and Mental Health-Edmonton Zone, Edmonton, AB, Canada
| | - Stephanie McConnell
- Children, Youth, and Families, Addiction and Mental Health-Edmonton Zone, Edmonton, AB, Canada
| | - Karen Bozocea
- Children, Youth, and Families, Addiction and Mental Health-Edmonton Zone, Edmonton, AB, Canada
| | | | - Jennifer Woods
- University of Alberta Hospital and Stollery Emergency Department, Edmonton, AB, Canada
| | - Amanda Newton
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Morreel S, Verhoeven V, Philips H, Meysman J, Homburg I, De Graeve D, Monsieurs KG. Differences in emergency nurse triage between a simulated setting and the real world, post hoc analysis of a cluster randomised trial. BMJ Open 2022; 12:e059173. [PMID: 35777880 PMCID: PMC9252194 DOI: 10.1136/bmjopen-2021-059173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES In the TRIAGE trial, a cluster randomised trial about diverting emergency department (ED) patients to a general practice cooperative (GPC) using a new extension to the Manchester Triage System, the difference in the proportion of patients assigned to the GPC was striking: 13.3% in the intervention group (patients were encouraged to comply to an ED or GPC assignment, real-world setting) and 24.7% in the control group (the assignment was not communicated, all remained at the ED, simulated setting). In this secondary analysis, we assess the differences in the use of the triage tool between intervention and control group and differences in costs and hospitalisations for patients assigned to the GPC. SETTING ED of a general hospital and the adjacent GPC. PARTICIPANTS 8038 patients (6294 intervention and 1744 control).Primary and secondary outcome measures proportion of patients with triage parameters (reason for encounter, discriminator and urgency category) leading to an assignment to the ED, proportion of patients for which the computer-generated GPC assignment was overruled, motivations for choosing certain parameters, costs (invoices) and hospitalisations. RESULTS An additional 3.1% (p<0.01) of the patients in the intervention group were classified as urgent. Discriminators leading to the ED were registered for an additional 16.2% (p<0.01), mainly because of a perceived need for imaging. Nurses equally chose flow charts leading to the ED (p=0.41) and equally overruled the protocol (p=0.91). In the intervention group, the mean cost for patients assigned to the GPC was €23 (p<0.01) lower and less patients with an assignment to the GPC were hospitalised (1.0% vs 1.6%, p<0.01). CONCLUSION Nurses used a triage tool more risk averse when it was used to divert patients to primary care as compared with a theoretical assignment to primary care. Outcomes from a simulated setting should not be extrapolated to real patients. TRIAL REGISTRATION NUMBER NCT03793972.
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Affiliation(s)
- Stefan Morreel
- Department of Family and Population Health, University of Antwerp Faculty of Medicine and Health Sciences, Antwerpen, Belgium
| | - Veronique Verhoeven
- Department of Family and Population Health, University of Antwerp Faculty of Medicine and Health Sciences, Antwerpen, Belgium
| | - Hilde Philips
- Department of Family and Population Health, University of Antwerp Faculty of Medicine and Health Sciences, Antwerpen, Belgium
| | - Jasmine Meysman
- Department of Economics, University of Antwerp, Antwerpen, Belgium
| | - Ines Homburg
- Department of Economics, University of Antwerp, Antwerpen, Belgium
| | - Diana De Graeve
- Department of Economics, University of Antwerp, Antwerpen, Belgium
| | - K G Monsieurs
- Emergency Department, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
- ASTARC, University of Antwerp, Antwerpen, Belgium
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Meysman J, Morreel S, Lefevere E, Verhoeven V, De Graeve D, Monsieurs KG, Philips H. Triaging and referring in adjacent general and emergency departments (the TRIAGE-trial): A process evaluation of medical staff experiences in a nurse-led triage system. Int Emerg Nurs 2022; 63:101191. [PMID: 35810679 DOI: 10.1016/j.ienj.2022.101191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/23/2022] [Accepted: 06/04/2022] [Indexed: 11/26/2022]
Abstract
AIMS This process evaluation aims at identifying the facilitators and inhibitors that influenced the successful uptake of a nurse-led triage system streaming low-risk patients from an emergency department (ED) to the general practitioner (GP). DESIGN & METHODS Semi-structured interviews with ED nurses (n = 12), ED doctors (n = 6) from the ED of a Belgian general hospital and GPs (n = 5) affiliated with the adjacent GP cooperative (GPC). The process evaluation ran in parallel with the TRIAGE trial that started in March 2019 and ended 31st of December 2019. The first set of interviews was conducted in June 2019 and the second set in January 2020. Data were analysed based on grounded theory. RESULTS Through a deductive framework, facilitators and inhibitors could be identified on three levels: the organisational, group and individual level. Main inhibitors are the degree of risk aversion of individual nurses, possible language barriers during delivery of the triage advice and the non-adapted ED infrastructure. Training on both the use of the triage protocol and effective delivery of the triage advice, in combination with periodical feedback from the GPC were the most important facilitators. CONCLUSION Based on the process evaluation we can conclude that a consensus exists among stakeholders that the ED Nurses are considered ideally positioned to perform the triage of walk-in patients, although a certain degree of experience is necessary. Although the extended triage protocol and GPC referral increases the complexity and duration of triage and entails a higher workload for the triage nurses, ED nurses found it did lead to a lower (perceived) workload for the ED in general.
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Affiliation(s)
- Jasmine Meysman
- Faculty of Business and Economics, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium.
| | - Stefan Morreel
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Eva Lefevere
- Faculty of Business and Economics, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium
| | - Veronique Verhoeven
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Diana De Graeve
- Faculty of Business and Economics, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium
| | - Koenraad G Monsieurs
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; Department of emergency medicine, Antwerp University Hospital, University of Antwerp, Belgium
| | - Hilde Philips
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
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Homburg I, Morreel S, Verhoeven V, Monsieurs KG, Meysman J, Philips H, De Graeve D. Non-compliance with a nurse's advice to visit the primary care provider: an exploratory secondary analysis of the TRIAGE-trial. BMC Health Serv Res 2022; 22:463. [PMID: 35395840 PMCID: PMC8994354 DOI: 10.1186/s12913-022-07904-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 03/28/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND During the cluster randomised TRIAGE-trial, a nurse advised 13% of low-risk patients presenting at an emergency department in Belgium to visit the adjacent general practitioner cooperative. Patients had the right to refuse this advice. This exploratory study examines the characteristics of refusers by uncovering the determinants of non-compliance and its impact on costs, as charged on the patient's invoice. METHODS Bivariate analyses with logistic regressions and T-tests were used to test the differences in patient characteristics, patient status, timing characteristics, and costs between refusers and non-refusers. A chi-square automatic interaction detection analysis was used to find the predictors of non-compliance. RESULTS 23.50% of the patients refused the advice to visit the general practitioner cooperative. This proportion was mainly influenced by the nurse on duty (non-compliance rates per nurse ranging from 2.9% to 52.8%) and the patients' socio-economic status (receiving increased reimbursement versus not OR 1.37, 95%CI: 0.96 to 1.95). Additionally, non-compliance was associated (at the 0.10 significance level) with being male, not living nearby and certain reasons for encounter. Fewer patients refused when the nurse perceived crowding level as quiet relative to normal, and more patients refused during the evening. The mean cost was significantly higher for patients who refused, which was a result of more extensive examination and higher out-of-pocket expenses at the ED. CONCLUSIONS The nurse providing the advice to visit the general practitioner cooperative has a central role in the likelihood of patients' refusal. Interventions to reduce non-compliance should aim at improving nurse-patient communication. Special attention may be required when managing patients with a lower socio-economic status. The overall mean cost was higher for refusers, illustrating the importance of compliance. TRIAL REGISTRATION The trial was registered on registration number NCT03793972 on 04/01/2019.
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Affiliation(s)
- Ines Homburg
- Department of Economics, University of Antwerp, Antwerp, Belgium.
| | - Stefan Morreel
- Department of Family and Population Health, University of Antwerp, Antwerp, Belgium
| | - Veronique Verhoeven
- Department of Family and Population Health, University of Antwerp, Antwerp, Belgium
| | - Koenraad G Monsieurs
- Department ASTARC, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Jasmine Meysman
- Department of Economics, University of Antwerp, Antwerp, Belgium
| | - Hilde Philips
- Department of Family and Population Health, University of Antwerp, Antwerp, Belgium
| | - Diana De Graeve
- Department of Economics, University of Antwerp, Antwerp, Belgium
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