Improving transitions of care: a resident-driven approach to address delays in patient care during the direct admission process

Abstract

Background The direct admission process is a complex system that can be aggravated by inherent gaps in communication leading to inefficient continuity of care and patient safety issues. Bypassing the emergency room, triage is often associated with long periods of unmonitored observation and significant delays in patient assessment. We identified significant communication gaps, delays in placement of admission orders and patient assessment during the direct admission process at our institution. To address this issue, we created and implemented a standardised direct admission flow diagram that consists of a step-by-step direct admission process, which includes a communication device and a triage power plan in the Electronic Medical Record. Methods We used the Plan-Do-Study-Act (PDSA) model for Quality improvement to address communication gaps in the direct admission process Baseline measurement confirmed two critical gaps in communication: 1) communication to the Medical Admitting Resident (MAR), the central source of communication of all medicine admissions, and 2) delays in placement of orders and assessment of the patient. Results Two months after implementation of a standardised process that addressed the two major gaps in communication, we found that communication to the MAR increased from 16% (7/42) to 100% (15/15). Additionally, the average time for order placement and assessment of patient decreased from 153 minutes to 53 minutes (n=15). Conclusion In order to improve the safety of direct admissions, the entire process must be carefully analysed and potential delays in patient assessment should be minimised. A standardised flow diagram that identified and targeted specific communication gaps can minimise delays in patient care.

Closing the Gap in Direct Admissions: A Quality Improvement Project

“…Statistical analysis showed that this decrease in mean time was statistically significant for PDSA 2. Although the absolute change in mean time to orders placed is less than that found by Goolsarran et al 3 (100 minutes compared with 27 minutes), this difference is likely due to a markedly different baseline (153 minutes compared with 84.8 minutes). The final mean time to orders placed is similar and within our stated objective.…”

“…The final mean time to orders placed is similar and within our stated objective. 3 The percentage of patients with orders placed within 60 minutes or less improved in the intervention groups but was not statistically significant in either PDSA cycle, which was most likely secondary to low patient numbers.…”

“…With a delayed prompt evaluation, treatment of sick patients is delayed and can result in poor patient outcomes. 3 However, recent trauma literature suggests that in times of ED overcrowding, DAs may be a safe alternative to admission. 11 Although we did not track any specific patient safety outcome measures, we believe that improved communication and increased timeliness of care will allow our teams to care for these patients with less risk of adverse outcomes, and we recommend future studies to examine this specifically.…”

“…Implications of this standardized and streamlined DA process are far reaching, from patient safety to workflow efficiency. With a delayed prompt evaluation, treatment of sick patients is delayed and can result in poor patient outcomes 3. However, recent trauma literature suggests that in times of ED overcrowding, DAs may be a safe alternative to admission 11.…”

Providing a Clear Path to the Direct Admission Process

“…Directly admitting a stable patient to the hospital is appropriate because it bypasses an often-overcrowded ED and can positively impact patient throughput. 7 The transfer of relevant clinical information is a crucial step in ensuring continuity of safe, timely, and adequate patient care. 2 Miscommunication or lack of pertinent patient information is a leading cause of medical errors.…”