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Service Delivery Innovation Profile

Dedicated Emergency Department Team Follows Up With Discharged Patients, Easing Physician Workload and Enhancing Quality of Care


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Snapshot

Summary

Stony Brook University Medical Center's emergency department has a dedicated followup team of registered nurses and support staff to address issues that arise after patient discharge from the emergency department, with the goal of improving care transitions and communication with patients and primary care providers. The team's key responsibilities include reviewing patient charts and test results, phoning patients to give them test results and go over relevant postdischarge care issues, contacting primary care providers, reporting relevant health data to government agencies, and monitoring patients who leave before being discharged. Anecdotal reports and surveys suggest the program has improved the quality of patient care, generated high levels of satisfaction among patients and primary care providers, and reduced the patient walkout rate.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation anecdotal reports and surveys of emergency department (ED) physicians, discharged patients, and community-based primary care providers (PCPs).
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Developing Organizations

Stony Brook University Medical Center
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Use By Other Organizations

  • The Emory University Hospital ED in Atlanta, GA, has a similar program called aftERcare. 

Date First Implemented

1992

Problem Addressed

EDs by nature emphasize quick care and resolution of patients' immediate health needs. ED physicians and staff tend to focus less on followup, which sometimes leads to treatment gaps that put patients at risk of adverse outcomes.
  • Focus on immediate care needs: ED physicians, nurses, and support staff typically work under extreme time pressure, attempting to keep pace with large numbers of patients with diverse and often serious health problems. At many EDs, patient discharge and followup responsibilities are spread out informally among staff, creating the potential for patients to receive incomplete information. Most efforts to improve ED operations focus on patient—staff interactions during the ED visit, with little attention to patients' experiences in the days and weeks afterward.
  • Leading to treatment gaps that can jeopardize health: The failure to focus on postdischarge care creates the potential for diagnostic errors and missed communications that put patients at risk of adverse outcomes. For example, busy ED physicians may give patients incorrect information or overlook test results not directly tied to the reason for the patient's ED visit. ED staff may also have trouble contacting patients for followup (e.g., to give them test results and/or review postdischarge care instructions) once they leave the hospital.

What They Did

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Description of the Innovative Activity

Stony Brook University Medical Center's ED has a followup team of registered nurses (RNs) and support staff exclusively dedicated to addressing issues that arise after patient discharge from the ED, with the goal of improving care transitions and communication with patients and PCPs. The team's key responsibilities include reviewing patient charts and diagnostic test results, phoning patients to give them test results and go over relevant postdischarge care issues, contacting PCPs, reporting relevant health data to government agencies, and monitoring patients who leave before being discharged. Key program elements include the following:
  • Center logistics and workload: The team works out of the followup center, located in an office near the ED. The center operates from 5 a.m. to 5 p.m. every day (365 days a year).
  • Review of patient charts and test results: RNs review all relevant medical records for each ED visit, with attention to these areas:
    • Test results: Nurses verify that all laboratory values, diagnostic test results, and radiology readings have been recorded in the patient's record, including those results available immediately during the ED visit (e.g., x-rays) and those that take several days to process (e.g., throat and blood cultures). Nurses review these results to detect any serious conditions unrelated to the patient's ED visit, such as an x-ray for a broken bone revealing a suspicious mass, a culture revealing a patient is resistant to a particular antibiotic, or a finding suggesting that a patient treated for asthma has pneumonia. Nurses create a progress note for all abnormal results, which becomes part of the patient's medical record, and use a worksheet to guarantee that all results are followed through to completion.
    • Followup care: Nurses identify particular patients who need followup care, such as those with chronic health conditions, infants experiencing dehydration, and victims of domestic violence.
  • Followup phone calls: Approximately 250 to 300 patients are seen every 24 hours in the ED. Team members contact a select group of these ED patients identified as having a need for a clinical check or requiring education related to testing done in the ED. ED physicians can also specifically request followup by the team if they have concerns related to a patient's safety or ability to identify serious complications or symptoms that may require education or urgent intervention. Topics covered during these calls include the following:
    • Communicating test results: During the call, a nurse provides the test results and discusses the appropriate course of action for any abnormal results. If the nurse cannot reach the patient in two attempts, he or she sends a letter via regular mail for nonurgent situations and via overnight mail for nonemergent situations where treatment should not be delayed. Police officers go to the home of patients who cannot be reached by phone who need to return to the ED emergently, such as when a CT scan finds a cerebral hemorrhage or appendicitis. In cases in which culture tests are positive and the patient is not currently receiving antibiotic therapy, a staff member also calls the prescription in to the patient's pharmacy.
    • Discussion of relevant health issues: As part of the call, the RN checks on the patient's current health status, reviews the treatment plan, and answers any questions. For example, if a patient has Lyme disease, the nurse explains the potential causes and reviews treatment options. For patients with chronic health problems such as hypertension and diabetes, the nurse talks about the role of diet, exercise, and medication in managing the condition. If a patient appears to be the victim of domestic violence, the nurse initiates a victims service referral. Team members can consult with ED physicians as needed for additional medical advice.
    • Incoming phone calls: Discharged patients receive the followup program's phone number, and all calls to the ED from discharged patients are forwarded to the program office. Inquiries cover a wide range of issues, such as concerns about infections and new symptoms, requests for proof of an ED visit to satisfy an employer, and questions about financial issues or access to medical care. Nurses can address most health questions, either with advice or by counseling the patient to see their primary care doctor or, if needed, return to the ED. Staff can also put patients in touch with the hospital's financial aid office or refer them to a clinical social worker or health clinic as necessary.
  • Contacting PCPs: In most cases, program staff get in touch with the patient's PCP, typically contacting dozens each day to update them on their patient's condition. If the hospital admits the patient, the followup office informs the PCP by fax of the admission and diagnosis. If the ED discharges the patient and he or she consents to the release of information, staff send all chart forms to the PCP, including electrocardiograms, consults, physician notes, discharge instructions, and laboratory/radiology results. Results not available within 24 hours are sent when they do become available. To speed these communications, the office uses a computerized fax machine with ED forms and fax numbers of most PCPs programmed into it.
  • Meeting health reporting requirements: Nurses fax or mail daily and episodic reports to the state department of health, which mandates the reporting of events such as animal bites, Lyme disease, pesticide ingestion, certain burns, sexually transmitted diseases, possible rabies exposures, diagnostic clusters (e.g., foodborne illnesses), and evidence of pandemic viruses. In addition, the county department of health calls each day to log how many patients visited the ED the day before.
  • Monitoring walkouts: The office calls every patient who walks out before discharge, leaves without being seen, or leaves against medical advice to determine why they left and make sure they have the resources that they need. Such comprehensive monitoring helps the ED identify and correct problems that lead to these scenarios.
  • Training and education for ED staff: The office serves as a training site for ED staff to learn about followup care issues. All third-year ED residents and new ED nurses are required to work in the followup office, observing its processes and speaking with patients about aftercare issues.

Context of the Innovation

Stony Brook University Medical Center, located in Stony Brook, NY, is a 542-bed teaching hospital and general medical and surgical facility. The hospital's ED treats about 90,000 patients a year. The followup program began in the early 1990s as an initiative to systematically ensure that ED patients received the results of laboratory and radiology tests not available before discharge. Since that time, it has gradually expanded to address other patient care issues.

Did It Work?

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Results

Anecdotal reports and surveys suggest the program has improved the quality of patient care, generated high levels of satisfaction among patients and PCPs, and reduced the ED walkout rate.
  • Improved patient care: Anecdotal reports from ED physicians and patients suggest the program has enhanced the quality of patient care by allowing ED staff to devote more time and uninterrupted attention to current patients, reducing any errors or omissions in reading test results (e.g., missed fractures, amended imaging reports, abnormal laboratory values), monitoring discharged patients' health, and providing guidance that improves patient adherence to recommend followup care (e.g., proper wound care, finishing medication regimens, finding the right specialist).
  • High patient and PCP satisfaction: Discharged patients consistently give the program positive ratings in surveys, singling out benefits such as the ease of having their records and test results sent to one or multiple providers and getting answers to their medical questions. PCPs also give the program high marks in surveys, noting its ability to provide timely reporting of test results (thus preventing duplicated tests) and to better organize referrals, thus enabling primary care clinics to more easily adapt their schedules.
  • Fewer ED walkouts: Information from followup calls and patient surveys has helped the ED reduce its walkout rate significantly, from roughly 3 to 1 percent.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation anecdotal reports and surveys of emergency department (ED) physicians, discharged patients, and community-based primary care providers (PCPs).

How They Did It

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Planning and Development Process

Key steps included the following:
  • Initial launch to communicate test results: In the early 1990s, ED leaders became aware that physicians sometimes did not call discharged patients with the results of their laboratory and radiology tests. A registered nurse agreed to take on this responsibility.
  • Gradual expansion over time: In subsequent years, as the number of ED visits increased, the workload of communicating test results became more than one nurse could handle. At the same time, ED leaders recognized the need for more comprehensive followup services, such as patient education and contacting patients' PCPs. Accordingly, the hospital hired an additional nurse and support staff to handle the demand and set up a separate office for the program in a trailer.
  • Keeping pace with technology: Over the years, a number of technological advances have helped the program enhance services and keep pace with continued increases in ED visits. For example, clerks now scan all ED charts when patients are discharged, allowing staff to access all forms electronically and eliminating the need for staff to search paper charts. In addition, PCP fax numbers and ED forms were preprogrammed into the office fax machine to make it easier to send test results.
  • Making program a training site: The hospital formalized the training arrangement, requiring third-year ED residents and new RNs to work in the followup office to learn about the issues that typically arise after patient discharge.
  • Moving to new office space: In 2005, the followup program relocated to an office near the ED.

Resources Used and Skills Needed

  • Staffing: The program employs 4 RNs (2 full-time and 2 part-time) and 3 clerks (1 full-time and 2 part-time), all of whom work overlapping 10-hour shifts. Typically two RNs and one or two clerks work in the office each day.
  • Costs: Program costs are not available but consist primarily of staff salary and benefits, office space, and equipment (e.g., computers, phones, printers fax machine).
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Funding Sources

The hospital funds the program out of the ED's operating budget.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Analyze demand for program: Evaluate if adequate demand for the program exists, including whether enough patients visit the ED and if ED physicians and staff currently spend a lot of time on followup issues. Stony Brook officials believe that EDs with 75 to 100 patients per day may benefit from such a program.
  • Hire staff with ED experience: Nurses and support staff with at least 5 years of emergency medical experience will likely be familiar with the many health issues that can arise with ED patients and also will be adept at dealing with ED paperwork. In addition, staff should have a professional and reassuring phone demeanor.

Sustaining This Innovation

  • Systematically collect and analyze data: Followup program staff review the medical records of every patient who enters the ED, and hence are ideally positioned to identify problems and/or trends that need to be addressed (e.g., an increase in a particular type of diagnosis, a physician who consistently misreads a particular test, a rise in patient walkouts).
  • Communicate with ED and hospital leaders: Followup program staff should meet regularly with ED physicians and hospital administrators to discuss how well the program is working, identify unmet patient needs, and look for opportunities for improvement or expansion.

Use By Other Organizations

  • The Emory University Hospital ED in Atlanta, GA, has a similar program called aftERcare. 

Additional Considerations

  • Program developers note that the followup program acts as a safety net for patients and physicians. Because all ED activity is monitored a second time, issues not addressed by the ED staff are detected and followed through appropriately. ED physicians have expressed an appreciation for and recognition of the value of having a safeguard system to review ED encounters.

More Information

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Contact the Innovator

Eileen M. Dowdy, RN T&R III
Quality Coordinator
Emergency Department
Stony Brook University Hospital
Nicholls Road
Stony Brook, NY 11794
Phone: 631-444-6972
Email: Eileen.Dowdy@stonybrookmedicine.edu

Innovator Disclosures

Ms. Dowdy has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Specht J. Best Practices: Emergency Department Follow-Up Office. Urgent Matters E-newsletter. July/August 2010. Vol. 7, No. 4. Available at: http://smhs.gwu.edu/urgentmatters/news/best-practices-emergency-department-follow-office.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 11, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 14, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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