New Joint Commission report warns: Sentinel events most likely in the ED
Implement strategies to reduce risks, prepare for survey
If you’re like most emergency department (ED) managers, improving patient flow is one of the biggest challenges you face every day. Now there is a new compelling reason for you to take immediate action to address this problem. A Sentinel Event Alert from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations says that more than half of the sentinel events involving death or permanent injury over a seven-year period beginning in 1995 occurred in the ED, and treatment delays were identified as a significant factor. Of 55 reported sentinel events that resulted from treatment delays, 29 were ED-related.
ED will come under focus for surveys
The ED will become a major area of focus for surveyors, says Marilyn Bromley, RN, director of the emergency medicine practice department for the Dallas-based American College of Emergency Physicians (ACEP). "We have every indication that the ED will remain a focus of intense scrutiny, especially anything you are doing to increase patient safety and prevent medication errors," she says. (For more information on this topic, see "Reports spotlight medication errors: Make changes before tragedy strikes," ED Management, June 2000, p. 61.)
There is a dizzying array of reasons why the ED is at high risk for sentinel events, according to Susan Nedza, MD, FACEP, clinical faculty for the division of emergency medicine at Northwestern Memorial Hospital in Chicago and former chair of the ACEP Patient Safety Task Force. She points to unlimited flow of patients, a high variability of conditions treated and diagnosed, and vulnerable populations including elderly patients with complex medical problems, non-English speaking patients, and patients with substance abuse problems.
"A large percentage of the ED population falls into one of three categories: high-risk, high-volume, and problem-prone," says Cindy Bruns, RN, BSN, CEN, quality management coordinator for the Emergency Center at Tallahassee (FL) Memorial Hospital.
Other problems putting EDs at risk include overcrowding, understaffing, admitted patients being held, and unavailability of on-call specialists, Bromley says. "One patient suffering a medical mishap is one too many," she says. "However, with the above issues, a sentinel event occurring in the ED is certainly possible."
Here are ways to avoid sentinel events in your ED:
• Improve the way providers communicate. The Joint Commission report identified communication as an underlying cause of sentinel events, and recommended the following interventions:
- Implement processes and procedures to improve the timeliness, completeness, and accuracy of staff-to-staff communication, including communication with and between resident and attending physicians.
- Implement face-to-face interdisciplinary change-of-shift debriefings.
- Take steps to reduce reliance on verbal orders, and require a procedure of "read back" or verification when verbal orders are necessary.
• Maintain a high index of suspicion for meningitis. The most frequently missed diagnosis causing a sentinel event was meningitis. The Joint Commission report specifically recommends that EDs implement strategies for this disease. Surveyors will ask about policies related to diagnosis and treatment of this high-risk group, Nedza says. "All children under the age of two months with complaint of irritability or fever should be seen as soon as possible," she stresses. Adequate follow-up for children presenting with fever is mandatory, Nedza adds. "A discharge instruction to call your doctor or the peds clinic’ is insufficient," she says. Stress the need to return for changes in symptoms and to call the child’s pediatrician directly to discuss the case, she advises.
• Identify specific high-risk areas. Bruns advises you to collect data to spot trends for high-risk populations, such as patients with chest pain, female abdominal pain, and headaches. "If you identify a systems problem or a problem with a specific individual, make the needed changes," she says. "Then continue to collect data and trend until you are satisfied with the results."
Nedza recommends tracking statistics for patients who left without being seen. "This is a high-risk group, and a sudden jump in these numbers indicates the need for vigorous interventions," she explains. These may include increasing the number of triage personnel, or putting in place an expedited triage process to shorten waits during busy times, Nedza says. (For more information on this topic, see "Reduce risks of patients who leave too soon," ED Management, November 2001, p. 125.)
It’s also important to create a system to ensure that waiting patients are re-assessed at regular intervals, she says. She recommends re-checking patients according to these intervals: 15 minutes for emergent complaints, 30 minutes for urgent, and one hour for less urgent. "All patients should also be instructed to talk to a designated individual if their symptoms worsen or they are contemplating leaving," she says.
• Implement an effective system to manage abnormal findings. Have a system to deal with call-backs for all abnormal labs and X-rays, and vigorously monitor this system, Nedza advises.
"Your system should not be the triage nurse doing this in his or her spare time. This needs to be given resources and made a priority," she stresses. The data should be collected and analyzed monthly, Nedza says, and action plans to improve the handling of these cases should be put in place and then reevaluated.
• Use clearly defined protocols for high-risk situations. Surveyors will want to see clearly defined protocols for your high-risk patients and situations, says Pam Moore, RN, CPHQ, performance improvement coordinator at Shawnee Mission (KS) Medical Center. "Then, you need to make sure a system is in place to allow the protocols to be followed," she says. For example, Moore says if your protocol calls for reassessment of patients at certain time frames based on acuity, then you must have the appropriate staffing level to allow this to happen.
Create triage protocols stipulating that high-risk cases such as infants with high fever, elderly individuals with abdominal and back pain, and patients with chest pain symptoms be brought back immediately, Nedza recommends. "The fact that you have six patients with chest pain in the ED should not impact the decision regarding the 47-year-old with chest pain in triage," she warns.
• Ensure appropriate follow-up for abnormal findings. One high-risk area that receives little attention involves abnormal findings that appear after the patient leaves to be discharged or admitted, Nedza says. "This might be a second set of troponins or cardiac enzymes on a patient who was admitted to telemetry but now rules in for a myocardial infarction or cardiac ischemia," she says. You need specific policies for dealing with these laboratory results, especially when the treating physician is now off-duty, the patient was transferred, or the ED record is closed out, Nedza advises.
• Take steps to reduce treatment delays. Because treatment delays are a major cause of sentinel events, these should be monitored closely, Bruns says. "One of our major patient complaints is waiting time to be seen by a physician. Delays are primarily caused by lack of ED beds." Bruns reports that her facility is building a new ED with double the current space. In the interim, plans are being made to open new monitored inpatient beds so fewer patients are held in the ED, she says.
Delays often are caused by inpatients not getting discharged on a timely basis, so the patient is tying up the ED bed, Moore notes. "Looking at the entire system of patient flow may be necessary to reduce treatment delays," she says.
For more information on sentinel events, contact:
• Marilyn Bromley, RN, Director, Emergency Medicine Practice Department, American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038-2522. Telephone: (972) 550-0911. Fax: (972) 580-2816. E-mail: [email protected].
• Cindy Bruns, RN, BSN, CEN, Quality Management Coordinator, Emergency Center, Tallahassee Memorial Hospital, 1300 Miccosukee Road, Tallahassee, FL 32308. Telephone: (850) 431-5079. Fax: (850) 431-6537. E-mail: [email protected].
• Pam Moore, RN, CPHQ, Performance Improvement Coordinator, Shawnee Mission Medical Center, 9100 W. 74th St, Shawnee Mission, KS 66201. Telephone: (913) 676-2681. Fax: (913) 789-3184. E-mail: [email protected].
• Susan Nedza, MD, FACEP, American College of Emergency Physicians, PO Box 619911, Dallas, TX 75261-991. Telephone: (800) 798-1822. E-mail: [email protected].
The Joint Commission’s Sentinel Event Alert on Delays in Treatment can be accessed at the Joint Commission web site (www.jcaho.org). Under "Newsletters," click on "Sentinel Event Alert," "See Past Issues of Sentinel Event Alert," and "Issue 26 — June 17, 2002."
The Joint Commission on Accreditation of Healthcare Organizations says that more than half of the sentinel events involving death or permanent injury over a seven-year period beginning in 1995 occurred in the ED, and treatment delays were identified as a significant factor.
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