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Abstract

Introduction: Critically ill patients are a growing population in U.S. Emergency Departments (ED),requiring increasing physician time,higher intensity of treatments,and longer boarding times in the ED.The longer boarding times may be associated with increased mortality, as the patients are in a gray zone of uncertainty regarding the responsible physician team,management and communication.Inadequate communication between teams magnifies the potential for serious medical errors.Our project was designed to improve the quality of communication and safety of patient care by instituting a formal evaluation and handoff process between the ED physician/nurse team and the evaluating critical care team. The project goals were completion of an interdepartment handoff which includes identifying the responsible team, delineating exact management plans, and targeting the timeframe for ICU decision.The goal measures were improved time to critical care decision and reduction of ED boarding time. Methods: For this quality improvement project,we assembled an interprofessional team including physicians and nurses from Emergency Medicine,Critical Care Medicine and Internal Medicine to implement a novel policy for evaluation and management of critically ill patients in the ED.An initial survey of ED nurses was performed. Education of Emergency Medicine and Critical Care was initiated and a time frame of 90 minutes from ED call to ICU decision was established.A formal written handoff was implemented:Part A was the initial request for ICU evaluation which required a face-to-face handoff from ED to critical care;following critical care team assessment, Part B documented a huddle with the ED team to articulate the decision and management plans.All written handoff documents were reviewed and the median time to decision was recorded. ED boarding times for the period were obtained and compared to the prior year.An extensive education program included all disciplines. Results: Baseline survey of ED nurses revealed: 56% believed there was thorough transfer of information to critical care team, 29% believed the responsible physician was clearly identified and 24% believed a clear plan of care was communicated to the nurse. Baseline median time from ED call for ICU evaluation to ICU decision was 130 minutes. Following implementation of the handoff policy: for the 4 month period, 475 ED-critical care team handoff/huddles were completed and documented, comprising 90% of critical care evaluations in the ED. Median time to ICU decision decreased from 130 to 86 minutes. Compared to year 2012, during the intervention period, median ED boarding time from ICU decision to discharge to ICU decreased from 238 to 181 minutes. Conclusions: This interprofessional and interdepartment quality and safety project was successful in implementing a formal in-person written handoff and team huddle for all critically ill patients in the ED.Our initial survey of nurses indicated deficits in communication. The education and handoff process resulted in a reduction in time to ICU decision and reduced ED boarding times. This project led to improved communication among physicians and nurses,improved communication between Emergency Department and ICU staff, and improved staff satisfaction. We believe that this model helped to build relationships and improve accountability and responsibility for critically ill patients in the ED.