Quality Improvement Strategies for the Senior-Friendly ED

Implementing new ideas, protocols, and tools is great. And if every member of the team is on board 100% of the time, it is even better. But the reality is not so always so rosy:  that is why a quality improvement program is important.

A Quality Improvement program includes the following:

• Data collection;
• Evaluation of success rate (after you have defined what success is);
• Encouragement and reinforcement for your team;
• Enhancement of communication;
• Evaluation of the process (where it works, where it does not);
• Attention to sustainability of the project;
• Evidence of success which can be assessed both by management and by participants.

To illustrate the importance of a quality improvement, I will use a hypothetical situation:

You are the geriatric nurse specialist of your institution. In agreement with the medical director, the nursing staff and the administration, you decide to implement a screening tool for frailty at triage called the ISAR (Identifying Seniors at Risk) . The plan is simple. In every patient over 75 years old, the 6-question screen is to be done by the primary nurse. If the patient scores 2 or more, a Geriatric Emerency Management (GEM) nurse referralis triggered. The ultimate goal is to decrease the admission rate.

In order to monitor your progress, you decide to collect these data:

• Geriatric volume (75 years and older)
• % completion of ISAR screening for this population by primary nurse
• % triggered GEM nurse consult in the of 2+ positive answer
• Admission rate in the 75 years and older

You do weekly data gathering for a month and post the results as run charts for all to see.  One month later, you realize that the ISAR is done only 30% of the time; 90% of 2+ have triggered a GEM consult; admission rate and geriatric volume remain unchanged.

You approach several of the front-line nursing staff to enquire about their attitudes and learn that they do not know what value will be added for the patient or for them by a GEM consult.  You realize that you have to increase education and reinforcement among the nursing staff.  You institute a series of huddles and postering campaign to illustrate the interventions that are implemented in those patients for whom a GEM consult is initiated.  You also feed back several success stories, for example, highlighing that the return to ED rate is lower among those patients seen by the GEM nurse (better for the patient; less work for the nurse).

Six months later, 90% of completion, 95% of GEM nurse consult triggered at triage, 1% decrease rate of admission, 7% decrease in 72-hour return rate.

In addition, the Geriatric Emergency Department Guidelines suggest monitoring a few other items:

1. Falls (prevalence, polypharmacy screening after a fall, referral for follow up, head injury, hip fractures, death, etc.)
2. Urinary catheter (days of use, indications, UTI caused by an ED catheter, etc.)
3. Medication reconciliation (high risk medication use documentation, ED visit for an adverse effect of a medication, etc.)
4. Restraint use (Documentation of physical and chemical restraints)

Here is a dashboard sample of quality improvement monitoring. Click on the image to view the PDF for download.

Sample Quality Improvement Assessment Instrument

In conclusion, a quality improvement program in a senior-friendly ED is essential for performance and sustainability.

To read more about, or view the complete Geriatric Emergency Department Guidelines please visit: https://www.acep.org/geriedguidelines/