Enhancing the Flow of Quality Improvements
For emergency department (ED) doctors and nurses who see hundreds of patients a week, the intake procedure can become something of a routine. Get the patient’s heart rate and blood pressure, get them a wristband and a gown, set them up with a bed and a room, hook them up to a urinary catheter…
Wait, what? Since when did catheterizing patients become a routine part of patient intake? Bizarrely, at many EDs, it is.
Studies have suggested urinary catheters, and other devices, are sometimes placed out of reflex, by protocol, or without a good sense of their necessity. Some studies have even suggested a fairly substantial portion of urinary catheters placed in EDs do not have a good medical indication in the first place.
While some might see this as only resulting in some unnecessary discomfort, there are many serious risks of catheterization, not the least of which is infection.
Promoting Quality
What does this have to do with quality improvement in EDs? There are many ways to improve quality in EDs, but I find the first step is simply taking a step back and asking: “Are our protocols and routines promoting quality?”
What does this have to do with quality improvement in EDs? There are many ways to improve quality in EDs, but I find the first step is simply taking a step back and asking: “Are our protocols and routines promoting quality?”
Consider the urinary catheter example. Say we have decided that we want to reduce catheterization-related complications in our ED. The first step is to have staff ask themselves, before catheterizing a patient: “Is there a legitimate clinical need for a urinary catheter in this patient?”
An intervention often implemented to answer this type of question is a checklist of the medical and surgical indications for the placement of a urinary catheter. It is critical to make sure those who meet the criteria are the only ones receiving the catheter. Standardizing care by using this type of process will reduce the number of patients exposed to the risk of catheter-related complications, which in turn will reduce the number of subsequent complications.
Once the legitimate need for catheterization has been determined, we then need to revisit our medical training and examine how we can improve execution and management of the procedure. While I would hope that proper technique is always used when placing a catheter, it is often the case that those who are doing so are not always properly trained. Correcting this is a relatively minor step, but it can have huge quality improvement payoffs.
The same goes for ensuring that catheters are in for no longer than they need to be. The number one predictor of catheter associated urinary tract infection is the amount of time the catheter is left in place. Without a standardized system to regularly assess whether or not a patient has an ongoing need for a catheter, it is easy to leave a catheter in too long, increasing the risk of infection.
Quality Improvement in the Emergency Department
ED improvement is not all about catheterization, obviously. It just serves as an excellent microcosm for our practices in EDs. Catheterization is just one of a multitude of processes routinely carried out at hospitals and in our EDs that are common and accepted but not necessarily well thought out. For these procedures and practices, we need to think about their potential adverse impact on quality in the ED. By taking the time to do this, we can reduce unnecessary complications and ensure patients are receiving care that helps, not hurts them.
We know that in order for any substantial quality improvement effort to succeed, it is essential to have the support of the institution’s senior leadership. Quality improvement efforts require top-down participation and investment to be taken seriously. While the support of front-line staff, especially in the form of “champions” is critical, quality improvement does not get on the agenda unless someone in the C-suite puts it there. Senior administration can allocate resources to an initiative and get the attention of the board of directors’ in ways no one else in the hospital can. I don’t think it is unfair to say that the involvement of senior administration is one of the most important factors in an initiative’s success or failure.
I could go to the board of directors of any hospital and ask them if improving and maintaining quality is one of their top priorities, and they will almost invariably answer it is. Quality is one of those things that a hospital’s leadership tends to assume is a priority, or is being worked on by the front-line staff, even if it is not. To make quality improvement a reality, senior administration must aggressively promote it, not assume that “it is being taken care of” and hold people within the organization accountable for seeing it through.
Only then can we start pulling the plug on bad practices and improving quality in our EDs.
Dr. Dale Bratzler, DO, MPH, Chief Executive Officer, Oklahoma Foundation for Medical Quality, President American Health Quality Association
