ED Accreditation Update: Quality, timely care: An ED’s keys to compliance

Staffing, overcrowding make it difficult

It sounds simple enough: When surveyors look at key accreditation areas, the performance of an emergency department (ED) boils down to whether the ED gives patients quality care in a timely manner. But when patient load and staffing don’t mesh, or when concentration on the disease means the individual is ignored, the simple expectation of quality care in a timely manner may be a challenge.

Under the Joint Commission’s Shared Visions — New Pathways accreditation process, which will be implemented in the majority of accredited programs in January 2004, ensuring patient confidentiality while providing quality, timely care are key points surveyors will be examining, says Leslie Furlow, PhD, RN, C-FNP, president of AchieveMentors, an operations and management consulting firm. "Because of the hectic pace and turnaround time [in the ED], records on patients who leave against medical advice and leave without being seen also will be monitored more closely. Efforts to track and follow up on these patients will be needed."

Furlow suggests EDs employ the tracer method of spot-checking cases.

"Pull a chart, trace it retrospectively, and also, trace a chart concurrently with the patient [while he or she is in the ED]," she says. "Or, do the secret shopper.’ Have someone who has been prepped on what to look for come into the ED with a patient — maybe a family member or a friend they’re accompanying into the ED — and watch to see that they’re treated appropriately."

Compliance with Joint Commission requirements can call for different actions in the ED compared to other hospital departments, Furlow says. Most EDs can stand to improve in the areas of staffing and individualization of patient care, she says.

"Most of us treat the patients based on their disease process rather than their individual needs," Furlow says. "Assessing developmental level, culture, and socioeconomic status is as important as vital signs and diagnosis for some patients."

For example, in one ED, a patient was provided written instructions and asked to sign that he had received them, she says. "He returned in 48 hours and was labeled noncompliant,’" Furlow says. "The patient was functionally illiterate."

Another ED had a policy that all women of child-bearing age would be tested for pregnancy prior to being treated with pharmaceuticals, she says. "This became and issue when a lesbian refused the pregnancy test and was told she would not be treated," Furlow says. The patient subsequently filed a complaint and received a formal, public apology from the facility, she says.

Individualized care important

Few EDs do a good job of individualizing care for their patients, Furlow says. Pediatric EDs, she states, are the exception.

"Pediatric hospitals are so aware of development and cultural issues that they gear their care to patient and family needs," says Furlow. "Mixed and adult departments could learn a lot from peds."

A medical plan that doesn’t integrate a child’s culture, socioeconomic status, and development "will be potentially nonfunctional," says pediatrician Ann Dietrich, MD, FAAP, FACEP, attending physician at Columbus (OH) Children’s Hospital.

"For example, if the family does not have insurance and is paying for the care themselves, writing a prescription that costs $80 to $100 is potentially a therapy that won’t be completed, not because the family doesn’t want to, but because they can’t," Dietrich says. "In this situation we may choose an alternative therapy that may be administered within the department and provide close follow-up."

There also are several cultural medical therapies that easily may be confused with abuse, and simply questioning the family in a nonthreatening way will help determine their practices and therapies that have been instituted at home, Dietrich says.

Monitor staffing levels vs. patient wait times

Staffing can pose compliance problems because patient numbers can change drastically in a very short time. One solution is for each patient to be assigned to a nurse, Furlow says. A charge or lead nurse can keep abreast of the patient flow and be alert to wait times that might be negatively affected if, for example, a patient’s primary nurse becomes unavailable due to a more serious case, she says.

Management should be monitoring patient care and comparing that to staffing to determine if there is a correlation between staffing levels and periods of extended wait times for patients, says Furlow. Overcrowding changes a department’s ability to comply in several areas, she adds.

"Over the years, we have decreased the number of available beds, and now we have a nursing shortage on top of that, and this means that EDs are . . . holding patients longer than they should have to," Furlow says. Having patients backed up in the ED while waiting for admission is an example of an ED problem that actually stems from elsewhere in the hospital, she says.

Resources

For more information on individualizing care in the pediatric ED, contact:

  • Ann Dietrich, MD, FAAP, FACEP, Attending Physician, Columbus (OH) Children’s Hospital. Phone: (614) 722-4385.