The combination of a brief education-based intervention and a computerized FF was more effective than education alone in reducing solitary BC collection in our ED in this time series study. FFs can be a powerful tool in modifying behaviors and processes in the clinical setting.

Introduction: Treat and Release (T&R) patients are seen and discharged home from the emergency department (ED), and asked to return within 12-72 hours for follow-up care (e.g., ultrasound, repeat blood work). Our two academic teaching hospitals see approximately 2,000 T&R patients per year. Handover of care for T&R patientsdone through charting only and therefore dependent on the charts adequacy and completenessis crucial to the safety and quality of care they receive. An 18-month retrospective chart audit at our sites identified quality gaps, including suboptimal documentation that ultimately impedes patient disposition. Our projects aim was to reduce the time-to-disposition (TTD; time spent by patients between provider initial assessment and discharge from the ED) by a third (from 70min) in 6-months time (March 2017), a target felt to be both meaningful and realistic by our stakeholder team. Methods: Our primary outcome measure was the TTD (in minutes). Our process measure was the quality of documentation, using a modified version of QNOTE, a validated tool used to assess the quality of health-care documentation. PDSA cycles included: 1) Involvement of stakeholders for the creation and refinement of an improved T&R handover tool to cue more specific documentation; 2) Education of health-care providers (HCPs) about T&R patients; 3) Replacement of the previous T&R handover tool with a newly designed and mandatory tool (i.e. a forcing function); 4) Refinement of the process for T&R patients and chart hold-over. Results: Run charts for both the median TTD and median modified QNOTE scores over time demonstrate a shift (i.e., run chart rule) associated with the second and third clustered PDSA cycles. After the first three clusters of PDSA cycles (i.e., before-and-after), mean TTD was reduced by 40% (70min to 42min, p=0.005). The quality of documentation (mean modified QNOTE scores) was also significantly improved (all results p<0.0001): patient assessment from 81% to 92%, plan of care from 58% to 85% and follow-up plan from 67% to 90%. Conclusion: We reduced the time-to-disposition for T&R patients by identifying gaps in the quality of documentation of their chart. Using iterative PDSA cycles, we improved their time-to-disposition through improved communication between health-care providers and a new T&R handover tool working as a forcing function. Other centers could use similar assessment methods and interventions to improve the care of T&R patients.

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BackgroundBlood cultures (BCs) are commonly performed in the emergency department (ED). Proper collection is paramount for accurate results, which includes obtaining at least two sets of BCs. In our EDs, an unacceptably high proportion of patients had solitary sets of BCs sent for analysis.ObjectivesTo reduce the rate of solitary sets of BCs being sent to the lab on patients discharged from the ED.MethodsUsing PDSA cycles, we evaluated two sequential interventions. The first intervention included didactic educational sessions and reminders in ED staff huddles. The second intervention added a forcing function (FF) at the point of computer order entry that automatically printed sticker labels for two sets of BCs, instead of the previous default of one. Providers could still send single sets by discarding unused labels. The bi-weekly solitary BC rates were analyzed using statistical process control charts and segmented regression analyses.ResultsThe baseline rate of solitary BCs was 41.1%. The education intervention reduced this rate to 30.3%, and the FF reduced it further to 11.6% (total absolute reduction of 29.5% from baseline). With segmental regression analyses, education alone did not produce a statistically significant change when factoring time-related trends (P=0.071). However, the FF produced a statistically significant improvement (P<0.0005), which was sustained for 6 months.ConclusionsThe combination of an education intervention and a computerized FF was more effective than education alone in reducing solitary BCs in our ED. FFs can be a powerful tool in modifying behaviours and processes in the clinical setting. Table 1Visit data during the duration of the study period (November 2014 to July 2016)MetricSite 1Site 2CombinedTotal ED Visits During Study Period83 747111 621195 368Total ED Ambulatory Visits During Study Period67 04097 538164 578Number of Visits That Had ANY Blood Cultures Sent3 1841 8395 023Blood Cultures (any number of sets) ordered per 100 ambulatory patients4.741.883.05 Table 2Rates of solitary blood cultures sent for patients discharged from the EDTime PeriodSite 1 RateSite 2 RateCombined RateBaseline (November 2014-March 2015)39.3%43.4%41.1%Post Education Intervention (March 2015 – January 2016)32.5%26.3%30.3%Post EPR Intervention (January 2016 – July 2016)12.5%10.2%11.6% Table 3Segmented regression analysisVariableCoefficientP-valueTime-Effect (duration of entire period)−0.00740.132Education Intervention−0.05210.071Time-Effect (post-education)0.00530.294Forcing Function−0.1537<0.0005Time-Effect (post-forcing function)0.00080.778Figure 4