Emergency Department, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Sinai Health System, Toronto, Ontario, Canada.
Ann Emerg Med. 2021 Feb;77(2):193-202. doi: 10.1016/j.annemergmed.2020.09.449. Epub 2020 Nov 13.
The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.
加拿大安大略省启动了急诊复诊质量项目，以倡导质量文化。该项目要求该省最大容量的急诊部（ED）对导致住院的复诊患者的图表进行审核，包括他们的一些 72 小时全因复诊并入院的患者，以及他们所有的 7 天有哨兵诊断（即急性心肌梗死、蛛网膜下腔出血和小儿败血症）的患者，并将他们的发现提交给政府机构。这为识别可能的不良事件和质量问题提供了机会，医院可以通过质量改进措施来解决这些问题。一组具有质量改进专业知识的急诊医生使用一般归纳方法分析了提交的审核和随附的叙述模板，开发了一种新的复发性质量主题分类方法。自 2016 年复诊质量项目启动以来，已确定 125698 例入院复诊，占参与的 86 家 ED 的 13559664 次就诊的 0.93%。总体而言，参与医院共进行了 12852 次详细的图表审核，发现了 3010 例（23.4%）不良事件/质量问题，并因此在全省范围内开展了数百项质量改进项目。归纳分析揭示了 11 个反复出现的主题，分为 3 个分组：患者特征（即患者风险状况和老年护理）、ED 团队的行动或流程（即医生认知失误、记录、提供者之间的交接/沟通、放射科、生命体征和高危药物或药物相互作用）和医疗保健系统问题（即出院计划/社区随访、未经医嘱离开/未得到诊治以及影像/检测可用性）。复诊质量项目是对 ED 进行的最大强制性审核项目，为识别当地不良事件/质量问题提供了一种新方法，以提高患者安全和护理质量。它为卫生系统领导者提供了一个蓝图，使临床医生能够采用一种组织质量的方法，以及为团队构建一个能够产生可改善的明确问题的审核系统。
