Kvalitet og udvikling

Et forbedringsprojekt omhandlende patientsikre overgange, hvor der blandt andet er dokumenteret en behandlingsplan og en TOKS-ordination før overflytning.

Der arbejdes med data ud fra journalaudit. Der iværksættes indsatser.

Et forbedringsprojekt omhandlende etablering af et akut vurderingsspor til rettidig og effektiv behandling af ABC-stabile patienter, som hovedsageligt er selvhjulpne.

Ud fra BI-data arbejdes der med baseline og resultatmål. Der udføres PDSA'er, iværksættes forandringer/indsatser og arbejdes med implementering.

Et forbedringsprojekt om at sikre, at patienten får den korrekte medicin under indlæggelse, og at patienterne får ajourført FMK ved udskrivelse.

Ud fra BI-data arbejdes der med baseline og resultatmål. Der udføres PDSA'er, iværksættes forandringer/indsatser og arbejdes med implementering.

Et forbedringsprojekt omhandlende reduktion af unødvendige laboratorieanalyser rekvireret ved Blodprøver og Biokemi under hensynstagen til, at patienterne i Akutafdelingen stadig får taget de nødvendige og relevante laboratorieanalyser. 

Ud fra BI-data arbejdes der med baseline og resultatsmål. Der udføres PDSA'er, iværksættes forandringer/indsatser og arbejdes med implementering. 

Abstract proposal for ePoster display at:

International Forum on Quality and Safety in Healthcare Copenhagen 2023

Fast assessment track in a Danish Emergency Department

Context:

The Emergency Department, Viborg Regional Hospital, Regional Hospital Central Jutland, Denmark.

The Emergency Department (ED) has 38 beds and approximately 36.000 visits annually. In total about 22.000 of the patients are discharged directly from the ED.

Aproximately 110 nurses and 36 physicians are employed at the ED.

Sponsors: 1 head nurse, 1 chief nurse and 1 chief physician

Resource persons: 1 ED nurse, 1 ED physician and 1 medical secretary

Patientgroup: Acute patients, who are stable and of low complexity. These patients are mainly self-reliant and their triage score are low compared to the triage system, DEPT.

Problem:

This patientgroup were hospitalised for longer despite their low triage score.

Telephone interviews with patients were characterized by frustration and surprise over the waiting                                

time and the length of stay at the ED.

The purpose:

• To give these patients a quick and efficient assessment and treatment, with the aim of reducing the waiting time for patients while increasing patient safety and patient satisfaction            
• To strengthen patient safety for the next acute patient, as there will be both an examination room and staff ready to receive the patient
• To increase the flow in the ED and reduce daily overcrowding

Assessment of problem and analysis of its causes:

The workflow was analysed and the staff group was involved in this description.

We also conducted two focus group interviews with the staff.

Intervention:

Improvements implemented

• Decision making support tool
• Inclusion via hospital referral centre, flow coordinator, ED physician and ED nurse
• Interdisciplinary reception at the ED around the clock, every day of the week
• Actioncards for ED physicians and ED nurses
• The patients are registered as inpatients

Strategy for change:

Performance goal number 1, March 2022:

The patient is discharged within 4 hours. Baseline 6 hours

Performance goal number 2, March 2022:

Patients included increased to 4/day. Baseline 1-2/day

Performance goal number 3, May 2022:

90% of patients are discharged from the track. Baseline: 70%

Feedback from staff: Interviews, emails, meetings with resource persons and sponsors.

Feedback from patients: Interviews and feedback via questionnaire delivered and collected under admission.

Measurement of improvement:

The Model of Improvement is used as the approach to measure the effekt of change.

Therefore, we used PDSA-cycles combined with data (Business Intelligence), flow diagrams and time series charts.

System of profound knowledge is used to understand how appreciation of a system, variation, building knowledge and the human side of change interrelate during the improvement project.

Goal 1 was reached in spring 2022 with the median 2,5. However after testing PDSA number 5 in July 2022 the hours spent in the fast track increased even though 55% of the patients were discharged from the fast track within 4 hours.

Goal 2 was not accomplished as expected in March 2022. This goal was accomplished with the PDSA cycle number 5 in July.

Goal 3 has been accomplished since April 2022.

Effects of changes:

The fast assessment track:

• Reduces waiting time for stable patients of low complexity
• Focuses documentation
• Improves the interdisciplinary cooperation and matching of expectations
• Secures effective utilisation of ressources

The main challenge experienced during the period of evolving the fast assessment track was that the ED went through another major reorganization. This caused some delay and anxiety among the clinicians.

Lessons learned:

System: Several concurrent changes at the same time is a challenge

Variation: A good and close collaboration with dataexperts is essential

Building knowledge: Learn from experiences in other ED´s

The human side of change: Involving clinicians to secure meaningfulness and motivation for change. 

Messages for others:

• Involve colleagues in the progress of the project and in all tests
• Engage with resource persons to test PDSA cycles
• Attention and backing of the leader is essential
• Dashboard for information and communication of data and PDSA cycles
• It is possible to change even in holidays as long as both clinicians and leadership agree

How we have involved patients and carers in the project:

Through the project we have involved both patients and clinicians via qualitative feedback, interviews and meetings.

Akutmedicinsk Forskningssymposium

Indstilling til SMART-prisen 2023

Akut vurderingsspor. 

Indstillet:
Vicky Bredkjær Larsen og Inge Trelborg Møller, Akutafdelingen, Hospitalsenhed Midt 

Kort beskrivelse af løsningen:
Etablering af et akut vurderingsspor i Akutafdelingen
til rettidig og effektiv behandling af ABC-stabile patienter, som hovedsageligt er selvhjulpne.

Baggrunden er, at disse patienter, grundet deres lave triageringsgrad, oplevede ventetid og fik timelange forløb i Akutafdelingen. Tilbagemeldinger fra interviews med nogle af disse patienter var præget af frustration og overraskelse over ventetiden og forløbenes længde. 

Formål:

• At give disse patienter en hurtig og effektiv vurdering og behandling, med henblik på at reducere ventetiden for patienterne samtidig med at øge patientsikkerheden og patienttilfredsheden
• At styrke patientsikkerheden for den næste akutte patient, idet der dermed kan være både stue og personale til at modtage denne
• At øge flowet i Akutafdelingen og reducere daglig overbelægning

Forbedringsarbejdet er blevet monitoreret med data fra BI-portalen og kvalitative metoder i forhold til patienter og klinikere (læger, sygeplejersker og lægesekretærer). I hele forløbet tæt tværfagligt samarbejde omkring inklusion af patienter til sporet på tværs af specialer i Akutafdelingen.

De kvalitative tilbagemeldinger fra interviews med både patienter og klinikere har vist, at det giver mening med et akut vurderingsspor, da det:

• Nedbringer ventetid for ikke komplekse ABC stabile patienter, hvilket bl.a. øger patienttilfredsheden
• Giver færre dokumentationskrav for såvel lægesekretærer, sygeplejersker og læger
• Giver bedre udnyttelse af kapacitet
• Resulterer i et hurtigere forløb for patienten og dermed et bedre flow i afdelingen

Iværksatte forandringer:

• Funktionsbeskrivelse for akutlæger (akut vurderingssporet er skrevet ind)
• HU og AP læger er tilføjet som modtagende læger
• Klinisk Logistik understøtter synlighed (akut vurderingsspor som speciale)
• Actioncards udarbejdet til læger og sygeplejersker

Forbedringer implementeret:

• Beslutningsstøtteværktøj på baggrund af DEPT kontaktårsagskort
• Inklusion via Hospitalsvisitation, flowkoordinator, akutlæge og modtagesygeplejerske
• Tværfaglig modtagelse i modtageområdet døgnet rundt alle ugens dage
• Patienterne registreres som indlagte
• HE Midts tværfaglige dokumentationsstrategi ift. at dokumentere det nødvendige og undgå dobbeltdokumentation
• Digitale spørgeskemaer til patienternes evaluering af forløbet

01.03.2023, Abstract til mundtligt oplæg

Akutafdelingen ønsker at sikre, at ABC-stabile patienter, som hovedsageligt er selvhjulpne og uden komplekse, behandlingskrævende problemstillinger bliver modtaget, behandlet og afsluttet inden for få timer.

Baggrund for Forbedringsprojektet:

Baggrunden er, at disse patienter, grundet deres lave triageringsgrad, oplevede ventetid og fik timelange forløb i Akutafdelingen.

Tilbagemeldinger fra interviews med nogle af disse patienter var præget af frustration og overraskelse over ventetiden og forløbenes længde.

Formål for Forbedringsprojektet:

• At give disse patienter en hurtig og effektiv vurdering og behandling, med henblik på at reducere ventetiden for patienterne samtidig med at øge patientsikkerheden og patienttilfredsheden
• At styrke patientsikkerheden for den næste akutte patient, idet der dermed kan være både stue og personale til at modtage denne
• At øge flowet i Akutafdelingen

Forbedringsarbejdet er blevet monitoreret med data fra BI-portalen og kvalitative metoder i forhold til patienter og klinikere (læger, sygeplejersker og lægesekretærer). De kvalitative tilbagemeldinger fra interviews med både patienter og klinikere har vist, at det giver mening med et akut vurderingsspor, da det:

• Nedbringer ventetid for ikke komplekse ABC stabile patienter, hvilket bl.a. øger patienttilfredsheden
• Giver færre dokumentationskrav for såvel lægesekretærer, sygeplejersker og læger
• Giver bedre udnyttelse af kapacitet
• Resulterer i et hurtigere forløb for patienten og dermed et bedre flow i afdelingen

Abstract proposal for poster display at DEMC 10, 2023:

Fast assessment track in the Emergency Department 

Background
Acute patients, who are mainly self-reliant, stable and of low complexity, were hospitalized for a long time despite their low triage score.

Telephone interviews showed that patients were frustrated and surprised over the waiting time and

the length of stay at the Emergency Department (ED).

The purpose:

• To give these patients a quick and efficient assessment and treatment, with the aim of reducing waiting time for patients while increasing patient safety and patient satisfaction
• To strengthen patient safety for all acute patients by ensuring available staff and examination rooms by quicker assessment of the patients with low triage score
• To increase flow

Methods

In this improvement project we conducted 7 PDSA (Plan Do Study Act) combined with data, flow diagrams and time series charts.

System of profound knowledge were used. 

The workflow was analyzed and the staff was involved in this description.

Improvements implemented:

• Decision making support tool based on DEPT triage
• Inclusion via hospital referral centre, flow coordinator, ED physician and ED nurse
• Interdisciplinary reception at the ED around the clock, every day of the week
• Actioncards for ED physicians and ED nurses
• Targeted documentation without double documentation
• Digital questionnaires for patients to evaluate the patient care

Results

Performance goal 1:

The patient is discharged within 4 hours.

Baseline 6 hours.

Average number of hours has been reduced to 2,5 hours. Due to the rescent PDSA the average number of hours has increased to 6 hours.

Performance goal 2:

Patients included increased to 4 patients a day.

Baseline 1-2 patients a day.

Number of patients in the fast assessment track is now 6 a day.

Performance goal 3:

90% of the patients are discharged from the track.

Baseline: 70%.

The average discharged directly from the fast assessment track is now 100%.

Conclusion

The fast assessment track reduces waiting time for stable patients of low complexity and almost all of the patients are discharged from the track.

The organization experiences a more appropriate utilization of ressources due to interdisciplinary reception and targeted documentation.

Questionnaires indicate that these patients are satisfied with waiting time, information and involvement compared to LUP (nationwide surveys of patient experiences).

Tværfaglig implementering af kompetencekonceptet for medarbejdere på HE Midt i Akutafdelingen med beskrivelse af kompetenceområder og -niveauer for sygeplejersker, social- og sundhedsassistenter og lægesekretærer.

Undervisning på morgenmøder for såvel læger som sygeplejersker.

Undervisning i forbindelse med nyansatte lægers introduktion.

Udarbejdelse af introduktionsprogram for nyansatte sygeplejersker.

Implementering af Fundamentals of Care i en akutmedicinsk sammenhæng blandt andre gennem:

• Udarbejdelse og implementering af skabeloner for cases som læring med afsæt i FoC
• Deltagelse i lokale, nationale og internationale netværk
• Udarbejdelse af en regional forståelse af FoC i samarbejde med kliniske specialister fra akutafdelingerne i Region Midt

Udarbejdelse af problemorienterede planer for patienter med særlige udfordringer på tværs af fagligheder, specialer og sektorer i samarbejde med patienten, hvor det er muligt.

Udarbejdelse og revidering af patientforløbsbeskrivelser og instrukser i E-Dok samt implementering af anbefalinger fra kliniske retningslinjer.

Udvikling af kompetencer og integration af diverse digitale løsninger, blandt andet med afsæt i LUP-resultater.

Implementering af Brøset Violence Score (BVC) og beskrivelse af mulige handleplaner relateret til BVC-score.

Instruks: Traumatiserende hændelser, forebyggelse og håndtering, Akutafdelingen