A Quality Improvement Emergency Department Surge Management Platform (SurgeCon): Protocol for a Stepped Wedge Cluster Randomized Trial

Abstract

Background Despite many efforts, long wait times and overcrowding in emergency departments (EDs) have remained a significant health service issue in Canada. For several years, Canada has had one of the longest wait times among the Organisation for Economic Co-operation and Development countries. From a patient’s perspective, this challenge has been described as “patients wait in pain or discomfort for hours before being seen at EDs.” To overcome the challenge of increased wait times, we developed an innovative ED management platform called SurgeCon that was designed based on continuous quality improvement principles to maintain patient flow and mitigate the impact of patient surge on ED efficiency. The SurgeCon quality improvement intervention includes a protocol-driven software platform, restructures ED organization and workflow, and aims to establish a more patient-centric environment. We piloted SurgeCon at an ED in Carbonear, Newfoundland and Labrador, and found that there was a 32% reduction in ED wait times. Objective The primary objective of this trial is to determine the effects of SurgeCon on ED performance by assessing its impact on length of stay, the time to a physician’s initial assessment, and the number of patients leaving the ED without being seen by a physician. The secondary objectives of this study are to evaluate SurgeCon’s effects on patient satisfaction and patient-reported experiences with ED wait times and its ability to create better-value care by reducing the per-patient cost of delivering ED services. Methods The implementation of the intervention will be assessed using a comparative effectiveness-implementation hybrid design. This type of hybrid design is known to shorten the amount of time associated with transitioning interventions from being the focus of research to being used for practice and health care services. All EDs with 24/7 on-site physician support (category A hospitals) will be enrolled in a 31-month, pragmatic, stepped wedge cluster randomized trial. All clusters (hospitals) will start with a baseline period of usual care and will be randomized to determine the order and timing of transitioning to intervention care until all hospitals are using the intervention to manage and operationalize their EDs. Results Data collection for this study is continuing. As of February 2022, a total of 570 randomly selected patients have participated in telephone interviews concerning patient-reported experiences and patient satisfaction with ED wait times. The first of the 4 EDs was randomly selected, and it is currently using SurgeCon’s eHealth platform and applying efficiency principles that have been learned through training since September 2021. The second randomly selected site will begin intervention implementation in winter 2022. Conclusions By assessing the impact of SurgeCon on ED services, we hope to be able to improve wait times and create better-value ED care in this health care context. Trial Registration ClinicalTrials.gov NCT04789902; https://clinicaltrials.gov/ct2/show/NCT04789902 International Registered Report Identifier (IRRID) DERR1-10.2196/30454

Covid-19 and its Impact on Hospitals

“…The main concern among commentators was that the healthcare system has reached its breaking point. Doctors and nurses are overworked and have to work longer hours than any other department in the hospital (Mariathas et al, 2022) because the surplus of patients in the ED waiting room leads to a backlog of patients. This backlog leads to extremely long wait times in the ED, and some patients' symptoms can worsen immensely, resulting in the patient's overall health decreasing.…”

“…SurgeCon aims to improve ED wait times and department efficiency and was piloted in an ED in Carbonear, Newfoundland and Labrador. During the piloting of SurgeCon, the results indicated that despite the increase in ED patient volume, the number of patients had an overall decrease (Mariathas et al, 2022). The pilot study allowed SurgeCon to allot to other EDs and assess how this platform's incorporation affects EDs.…”

Interventions Intended to Alleviate Emergency Department Overcrowding

“…[38][39][40] At sites across Newfoundland and Labrador researchers are using SurgeCon, 41 a home-grown quality improvement initiative using ED and hospital data to apply real-time protocols to manage surges in ED visits before they occur, reducing ED length of stay. 42,43 At Niagara Health -St. Catherine's Site (Ontario) patient flow simulation exercises were used to help an interdisciplinary team decide where to offload ambulance arrivals and transfer patients needing a bed. 44 In Toronto the Hospital for Sick Children and St. Michael's Hospital have both used forms of machine learning and artificial intelligence to understand when surges will happen in their EDs.…”

A Qualitative Study of the Barriers and Facilitators Impacting the Implementation of a Quality Improvement Program for Emergency Departments

“…The typical duration of a visit to an ED is around 3.5 hours, which poses a risk to patients since prolonged waiting times in EDs have been associated with suboptimal patient outcomes (Magid et al, 2009;Bernstein et al, 2008;Pines & Hollander, 2008;Fee et al, 2007;Sprivulis et al, 2006;Richardson, 2006;Derlet & Richards, 2000), and to the increased likelihood of adverse events (Guttmann, 2011). To address this issue, SurgeCon, a quality improvement program, was devised to address the lack of integration, sustainability and logistical issues which negatively impact wait times in EDs (Anaraki et al, 2022, Mariathas et al, 2022Patey, et al, 2019). SurgeCon delivers its quality improvement program through a department level management platform that encompasses three key elements: the installation and con guration of a tailored eHealth system, organizational restructuring, and the establishment of a patient-centric environment.…”