How Nelson Hospital reduced avoidable ED presentations

Nelson Hospital designed a public awareness campaign intended to educate the local population on other available care sites beyond the emergency department. They places notices in locations throughout the area to inform individuals of care options for times when their concern was not truly an emergency. They specifically targeted locations frequented by tourists, who often visit the ED for non-emergency concerns.

Conduct outreach to prevent presentations

Conversations with patients presenting to the emergency department led the emergency department staff to develop a public awareness campaign that provided guidance on when and why to present to the emergency department.

It was evident that many patients did not understand what constituted an emergency or where else they might receive care. Because of this, many presented to the emergency department inappropriately. Using an in-house media advisor, Nelson Hospital created a series of public awareness ads aimed at addressing this knowledge gap.

Engaging potential patients through multiple media

Nelson Health used a wide variety of channels for disseminating this information.

FOR MORE RESOURCES

Please see the supporting artifacts section of the PDF for sample public awareness advertisements.

To address the challenges around general practitioners referring patients unnecessarily to the ED, Nelson Hospital undertook a collaborative approach to pathway development, implementation, and enforcement. Nelson Hospital created referral pathways and established a hotline for general practitioners to use, allowing general practitioners to route their patients to the most appropriate care site. The following pages detail these two steps.

Develop care pathways to move patients to appropriate sites of care

Leaders at Nelson Hospital presented data to a multidisciplinary group of stakeholders that included leaders of local general practitioners. This data highlighted the variance that existed across general practitioners in terms of referrals to the emergency department, indicating the need for care pathways. A working group, which included general practitioners and hospital clinicians, was established to develop clinically-based care pathways. In the end, Nelson Hospital developed some 400 pathways, of which about 250 related to the emergency department.

These pathways were not created to limit how general practitioners practiced medicine, but rather to better support them in ambiguous situations. Room was still left for general practitioners to use their clinical judgement and pursue a different course of treatment. When a general practitioner does opt for something other than the protocol, however, a process also exists that gives them the opportunity to explain this alternative course of treatment.

Create a GP referral assessment line in the ED for consultation

The emergency department staff added an additional resource to help general practitioners navigate the various pathways that included a possible emergency department referral. Using an iPhone, the emergency department opened a direct phone line, connecting general practitioners to the most senior emergency department consultant on duty. The consultant serves as a reference, helping the general practitioner select the best course of care. In other words, this phone line allowed general practitioners to consult with an emergency department specialist before deciding to refer the patient to the emergency department.

They selected an iPhone for its portability. The senior most consultant carries it throughout the shift, making him/her accessible at all times. Because it is assigned to only one person at a time, the responsibility for responding to calls is clear.

Buy-in for this phone line was easily achieved: the direct and timely nature of the guidance resonated with general practitioners, while the ability to curb emergency department demand made garnering support from emergency department consultants straightforward.

Accountability reinforces adherence to guidelines

To ensure all of these new measures—from patient education to pathways support—were successful, Nelson Hospital also established protocols for dealing with patients and care providers who deviated from the expected course of action.

Patients who presented to the emergency department inappropriately were referred back to their GP. These patients were reminded that follow up care and any other low-acuity concerns should be taken to their general practitioners. For patients without a GP, staff requested that they find one and provided support to help with this task. By taking a proactive role in connecting patients to GP, ED staff have the opportunity to reduce demand for emergency services.

Similarly, senior ED consultants took an active role in ensuring GP pathway adherence: when a GP refers a patient in a manner not specified by the pathway, a senior consultant follows up with them to discuss the decision.

Together, these protocols function to decrease reliance on emergency service by routing inappropriate presentations to better sites of care.

Nelson Health brought an allied health team into the emergency department full time, enabling the emergency department to provide the necessary psychosocial support patients were previously lacking.

Addressing inappropriate presentations was a significant part of Nelson Hospital’s emergency department strategy, but they also sought to reduce the number of patients who re-presented to the emergency department. Staff realized that many complex patients were being discharged unsafely, as nurses did not have the time to properly link them to community health resources or to provide health behavior education.

To provide fuller support for these patients, and alleviate the pressure on nurses, Nelson Hospital based an allied health team—physiotherapist and social worker—in the emergency department full-time. The team engaged in falls prevention with frail elderly patients and linked at-risk emergency department patients to community programs and health funding sources in order to reduce the likelihood of addiction relapse, anxiety attacks, and mood disorders, among other psychosocial concerns.

Introducing this team into the emergency department has helped to avoid unnecessary readmissions, further contributing to reducing emergency department demand.