It's Sunday morning; a blood culture on an 8-monthold

CLINICAL FACILITATING A SAFE TRANSITION FROM THE PEDIATRIC EMERGENCY DEPARTMENT TO HOME WITH A POST-DISCHARGE PHONE CALL: A QUALITY-IMPROVEMENT INITIATIVE TO IMPROVE PATIENT SAFETY Authors: Pamela J. Bucaro, MS, BSN, RN, PCNS-BC, CPEN, and Erin Black, BSN, RN, CPEN, Dayton, OH It's Sunday morning; a blood culture on an 8-monthold infant seen in the urgent care facility yesterday is now growing gram-positive cocci. Because the urgent care facility is closed, the laboratory is calling the busy emergency department in search of someone to follow up with this result. Who is available to make sure this parent is contacted and additional follow-up is completed? A mother of a toddler diagnosed with acute gastroenteritis late last evening calls the emergency department asking for additional advice. She has misplaced her discharge instructions, has not slept since she left the emergency department with her child, and is unable to remember what the emergency department provider told her. The nursing staff is very busy with patients who are currently in the emergency department, so who will have time to review discharge instructions and answer this mother's concerns? The ED provider from the previous night awakens from sleep with a concern about a child he cared for that night. He would like to obtain an update on this patient's abdominal pain and to remind the family to have the child checked by the primary care physician. Who can he ask to call the family? Pamela J. Bucaro, Member, Greater Cincinnati Chapter, is Clinical Nurse Specialist, Soin Pediatric Trauma and Emergency Department, Dayton Children's Medical Center, Dayton, OH. Erin Black, Member, Greater Cincinnati Chapter, is Outreach Nurse, Soin Pediatric Trauma and Emergency Department, Dayton Children's Medical Center, Dayton, OH. For correspondence, write: Erin Black, BSN, RN, CPEN, Soin Trauma and Emergency Department, Dayton Children's Medical Center, One Children's Plaza, Dayton, OH 45404-1815; E-mail: blacke@childrensdayton.org. J Emerg Nurs 2014;40:245-52. Available online 26 March 2013. 0099-1767/$36.00 Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.02.003 In our pediatric emergency department, these are 3 of the situations that may be encountered on a daily basis. Staff is busy with the current ED patients, and these former patients, who are now home, are in need of additional education, intervention, or perhaps a simple follow-up phone call to facilitate appropriate and safe care at home. In addition, health care providers (HCPs) may have concerns about the family's understanding of discharge information, the patient's symptoms worsening, or the patient not arranging needed follow-up. During an ED visit, parents experience stressors that can impede their understanding of discharge information and, ultimately, their ability to appropriately care for their child at home 1 (Table 1). Because of our concerns about the effect of these stressors on post-discharge care and patient safety, we asked the following questions: How can we involve patients and families in the discharge process? How can we offer a resource for families that will facilitate continuity of care? How can we give accurate nursing advice related to a child's specific visit to the emergency department? How do we offer families reinforcement of their child's ED discharge plan? How can we best support families in caring for their child at home? Our Outreach Nurse Program was developed as an answer to these questions. Our primary goal was to increase parental understanding of ED discharge instructions so that parents can successfully and safely manage their child's care at home. An additional goal of the project was to decrease HCP anxiety by developing a standardized process for patient follow-up care. Methods Our Midwest children's hospital is a Level II Trauma Center that provided care for over 72,000 patients last May 2014 VOLUME 40 ISSUE 3 WWW.JENONLINE.ORG 245

CLINICAL/Bucaro and Black TABLE 1 Stressors that impede parental understanding and their consequences Stressors that impede understanding Medical terminology Staff level of training Family anxiety Time of day in emergency department Complex written instructions Lack of time for questions Language barriers 1 Consequences of impeded understanding Returning for rechecks because of uncertainty Calling about discharge instructions no one available to answer questions Not filling prescriptions in a timely manner Not administering medications appropriately Not scheduling follow-up appointments Not recognizing deterioration Anxiety, confusion, and frustration year. We developed a nurse-facilitated post-discharge callback program, the ED Outreach Nurse Program, to promote family understanding and relieve parental anxiety. Our ED Outreach Nurse Program is managed by experienced pediatric emergency nurses, and it operates daily. Although the outreach nurse is a valuable member of the ED care team, this nurse is not included in daily staffing numbers. We modeled our program after a successful program at another Midwest pediatric emergency department. Our ED medical director and pediatric clinical nurse specialist formulated a proposal for the Outreach Nurse Program and sought ED management support for creation and implementation. The management team was enthusiastic and encouraging. The outreach nurse position was developed, and applications were submitted from experienced emergency nurses. These nurses work some staff nurse shifts and some outreach shifts. The outreach nurse is not routinely pulled to direct patient care. We determined that the outreach nurse would work between the hours of 9:00 AM and 7:00 PM, 7 days a week. As we developed our program, we identified the importance of having a registered nurse initiate the phone contact and use established protocols to optimize the telephone contact. 2 Initially, we determined which patients would receive a callback. This high-risk patient population was identified through information from the collaborating hospital and our own 48-hour return data from the ED Quality Improvement Committee. We labeled this group of patients our priority patient list (Table 2). We also formulated an outreach nurse committee to develop the details of the Outreach Nurse Program. The committee determined the daily tasks, expectations, and required documentation. We discussed guidelines for the outreach nurse's routine for callbacks, established parameters for evaluating radiographic discrepancies and TABLE 2 Outreach priority patients requiring callbacks Tier I: Highest risk Tier II: Higher risk Tier III: High risk Staff concerns LWBS/AMA Burns Radiographic Neonates with fever Age discrepancies Positive cultures/ Bronchiolitis in Fractures laboratory tests patients aged b1 y Abdominal pain Seizures AMA, Against medical advice; LWBS, left without being seen. abnormal laboratory results, and decided when to collaborate with an emergency attending physician for an appropriate plan of care. A daily list of outreach nurse responsibilities was developed (Table 3), and priorities of care were specified. A form for the medical record was developed in order for the outreach nurse to provide pertinent documentation from the calls. An outreach daily log to document all outreach calls and interventions was created. We determined that the log would be completed daily so that we would have statistical data to track as our program developed. In addition, we used information gleaned from a Child Health Corporation of America (CHCA) 2009 Webcast, Left Without Being Seen, 3 to validate our inclusion of all patients who left without being seen in our high-risk callback population. We used some of the Webcast information to provide education to outreach nurses and staff nurses about the importance of follow-up with this high-risk population. Furthermore, we participated in the Press Ganey Partners in Improvement Webinar in 2008 called Dialing for Outcomes: Closing the Loop With Post-Visit Phone Calls. 4 246 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 3 May 2014

Bucaro and Black/CLINICAL TABLE 3 Daily emergency outreach nurse responsibilities Reviews medical imaging reports from the previous 24 h to identify any discrepancies Reviews abnormal laboratory reports resulting after discharge Collaborates with the attending physician to arrange appropriate follow-up Calls/faxes prescriptions Calls families to discuss any additional care as required Makes follow-up calls to patients seen the previous day Calls are made first to a specified list of priority patients (high-risk patients) Discharge instructions are reinforced and questions answered Documents the call on the patient's permanent medical record Answers incoming calls from patients/families with concerns (if patients were seen and treated in the emergency department within the last 72 hours) Facilitates follow-up visits to the emergency department for scheduled appointments Provides information about community resources to families Refers patient/family to social services when indicated Assists in obtaining precertification and prior authorization for additional procedures or medications when needed Evaluation and Analysis To determine whether our goal for improving parental understanding of discharge instructions was met, we conducted a survey of a random sample of parents to determine whether the outreach nurse's phone call was perceived as being beneficial. We also surveyed the staff to determine whether they perceived the role of the outreach nurse as valuable for patient care. In an effort to analyze the ongoing effectiveness of our quality-improvement project, we collected and have continued to collect data from our daily outreach log to show productivity and maintain accountability. Figure 1 shows survey results from February 2008 to February 2009. The outreach nurse obtained this information from parents after a telephone call during which they provided reinforcement of discharge instructions. During this year-long period, the outreach nurses reinforced discharge instructions for 2,122 patients, and 630 of them participated in the survey. This type of follow-up service enhances both patient satisfaction and the evaluation of nursing care that is perceived by patients. 2 A staff survey was conducted after the second year of our outreach program's initiation. The purpose of this qualitative survey was to determine the staff's perception of the outreach nurse. ED providers, nurses, and support staff participated in this survey, and the results showed a consistent appreciation for the role of the outreach nurse in the emergency department (Figure 2). In addition, we obtained feedback that we have used to improve our processes. The ED staff has continued to be very supportive of the Outreach Nurse Program. Figure 3 illustrates data collected from the outreach daily log. This graph shows a consistent increase in the volume of patients/families assisted by our outreach nurses. For example, the outreach nurses talked with 7,316 patients the first year and 12,862 patients the fifth year. During this time, the patient volume increased from 57,592 patients treated in the first year to 72,635 patients in the fifth year. In addition, the outreach nurses have consistently increased the number of services provided for patients. Results We have encountered roadblocks to our process and have made some changes and improvements as a result. For example, many staff members were initially skeptical about the new role, and some had the perception that the outreach nurse was not helpful. In addition, some staff nurses believed that the outreach nurse should be available for direct patient care. As a result of these misperceptions, we have added outreach information sessions for newly hired providers and nurses to educate them about the role of the outreach nurse in the emergency department. This has increased their understanding and appreciation of the outreach nurse's role (Table 4). During our first year, one of our outreach nurses performed job shadowing at another Midwest children's hospital that had a successful post-discharge callback May 2014 VOLUME 40 ISSUE 3 WWW.JENONLINE.ORG 247

CLINICAL/Bucaro and Black Patient Caregiver Survey Results Survey Question: After talking with me today, would you say your understanding on how to care for your child's illness/injury has improved a great deal, somewhat or not at all? 6.8% 0.2% For the period of 02/24/08 to 02/23/09, the outreach nurse reinforced d/c instructions with 2,122 patient caregivers. Of those 2,122, there were 630 that responded to the survey question. Great Deal Somewhat Not at all 93.0% FIGURE 1 Patient caregiver survey results. d/c, Discharge. program. After her visit, the outreach nurse was able to help refine our processes and forms to better streamline our calls and increase our call volume. Our implementation of an electronic medical record system has assisted the outreach nurses in faster and more standardized documentation and has given them the ability to run reports that provide additional information about their patients. One of the important things we have discovered as our program has grown is the need for communication within our outreach team. We meet bimonthly with our medical director and clinical nurse specialist to evaluate and modify our processes. Examples of agenda items include handling parent complaints, facilitating follow-up appointments, interpreting laboratory and medical imaging results, and triaging incoming calls. Sharing ideas and troubleshooting from specific patient examples have assisted us in making numerous changes that have helped to make our postdischarge callback process more efficient and allowed us to increase our call volume. Communication, accountability, flexibility, and teamwork are essential components for an effective post-discharge callback program. Our medical director helped develop our outreach program and continues to function as a medical resource for our team. We routinely involve the social work and patient relations departments as needed in complicated family situations. Our computer information system staff has been vital in our transition to electronic charting, and their expertise has provided us with the tools needed for accurate and efficient documentation. Our hospital's performance analyst has assisted us in analyzing and interpreting our data. To ensure continued quality improvement, we routinely audit a random sample of patient medical records. For example, we review patient encounters for high-risk patient groups to confirm that outreach nurse contact was made. Our current audits for this purpose include patients with a chief complaint or discharge disposition of abdominal pain, patients for whom staff requested a callback, patients who left without being seen by a provider or against medical advice, 248 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 3 May 2014

Bucaro and Black/CLINICAL Staff Survey Questions and Responses Do you feel the ED Outreach Nurse is a valuable member of the ED team? Yes No Do you believe the Outreach program has had an effect on the number of patients who return to our ED within 48 hours? Yes No Not sure What do you perceive are the benefits of the Outreach Nurse Program? Answering family calls Calling in prescriptions Reinforcing d/c instructions Handling concerns Provider Nurse Support Staff Checking on patients 0 5 10 15 20 25 # answered FIGURE 2 Staff survey questions and responses. d/c, Discharge. and patients with an radiographic discrepancy discovered after discharge. These data are shared with our ED Quality Improvement Committee and the outreach team, and changes are recommended and implemented as needed. Initially, we hypothesized that the addition of the outreach nurse would decrease our 48-hour return rate. Our definition of a 48-hour return is a patient who returns within 48 hours of discharge from the emergency department with the same diagnosis and is admitted. Our 48-hour return rate decreased after implementation of the outreach nurse role, but in subsequent years, the rate has often increased. As we evaluated this information, we realized that there are circumstances when the outreach nurse appropriately encourages patients to return to the emergency department for re-evaluation. For example, the outreach nurse routinely calls patients with a chief complaint of abdominal pain and reviews their discharge instructions with them. If the patient has worsening pain, any sign of dehydration, or a new concerning symptom, the outreach nurse recommends re-evaluation either by the patient's primary care physician or in the emergency department. Therefore we determined that the 48-hour return data do not constitute a reliable measure of the success of our program. Discussion One goal of the 2013 Nursing Patient Safety Goals (NPSG) for hospitals is to improve communication. NPSG.02.03.01 states, Get test results to the right person on time. 5 A primary daily responsibility of the outreach nurse is to review all tests that result after a patient's discharge from the emergency department. All laboratory and electrocardiographic reports, resulting after discharge, are automatically directed to the outreach nurse's in-basket. These are May 2014 VOLUME 40 ISSUE 3 WWW.JENONLINE.ORG 249

CLINICAL/Bucaro and Black 20% 18% Outreach Statistics FY07-08 to FY12-13 101% increase in volume from 2007 to 2013 Patient volume increased by 30% from the 2007-2008 period to the 2012-2013 period 16% 14% Percentage by Year 12% 10% 8% 489% increase in volume from 2007 to 2013 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 6% 2012-2013 4% 112% increase in volume from 2007 to 2013 73% increase in volume from 2007 to2013 20% increase in volume from 2007 to 2013 2% 0% Parent called in Nurse talked with parent Prescription called Return to ED Referral made Percentage Change Year-to-Year FIGURE 3 Outreach statistics. FY, Fiscal year. reviewed by the outreach nurse and are discussed with an ED attending when indicated. All significant and critical laboratory values for discharged patients are directly communicated to the outreach nurse by telephone. The outreach nurse also evaluates the final medical imaging reports, which were reviewed by the radiologist after the patient's discharge, and follows up on any discrepancies. Guidelines for the review of all laboratory and imaging results are established by the ED medical director. Test results and any possible follow-up care needed are then communicated to the patient or to the primary care provider as needed. The patient is educated appropriately when indicated and his or her recommended treatment clarified. Another 2013 NPSG for hospitals refers to using medication correctly. NPSG.03.06.01 states, Make sure the patient knows which medicines to take when they are at home. 5 Many factors during an ED visit can hinder the patient's and family's ability to recall explanations and instructions once the patient has been discharged. Fatigue, anxiety, and distraction are only a few of these factors. Proper administration, possible side effects, and correct dosing can be reviewed on the phone. Family dynamics can further complicate patient/family understanding because there may be multiple family members involved in the patient's care at home. Having access to the outreach nurse promotes continuity of care. Our outreach program promotes safety for patients by enabling us to contact many families after discharge to clarify discharge instructions, assist with follow- 250 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 3 May 2014

Bucaro and Black/CLINICAL TABLE 4 Roadblocks leading to process improvements Encountering roadblocks Removing obstacles Staff perception of program Staff meetings to clarify Distractions related to physical space Dedicated area in ED renovation plan Call volume fluctuations because of census Consideration of additional staff during high census Inaccurate contact information for families Communication with unit clerks New nursing/medical staff Implementation of 1-on-1 orientation Communication between outreach nurses Staff meetings for outreach team Transition from paper to electronic records Specialized training for outreach team Lack of standardized process for outreach Implementation of process improvements up care, and promote success in caring for patients at home. supplying families with a consistent, knowledgeable nurse to discuss concerns and answer questions about their child's care. giving staff a consistent method for follow-up with high-risk patients. creating a standardized process for follow-up when laboratory tests or radiographic findings result after discharge. formulating new child health information sheets for specific patient populations. developing educational/resource information for our adolescent patients. identifying deterioration or social concerns and making appropriate referrals. The future goals of our program include developing outreach nurse competencies, providing additional education about telephone triage, and conducting another parent caregiver survey. We recognize that the outreach nurse job is ever-changing because of the needs of our specific patient population, the changing economic environment, and way in which we deliver health care. Through the use of the electronic medical record, comprehensive patient reports are more readily available, which assists us with audits that help guide our improvement projects. Conclusions One of the most important lessons we have learned through the implementation and initial evaluation of our program is that post-discharge phone calls are necessary and valuable to both patients/families and the ED staff. Closing the loop on a patient contact is facilitated by the education provided in a follow-up telephone call. 1 When a patient is being discharged from the emergency department, a transition of care occurs. HCPs in the emergency department complete their interventions, and the patient's care is then transferred to family members. This transition of care after leaving the emergency department must be done properly to promote patient safety. This transition should be coordinated to provide a smooth transition to these new caregivers the family. Patient safety should always be the focus of our actions as HCPs when caring for the patient in the emergency department and during their transition to home. 6 Our Outreach Nurse Program provides support to the patients caregivers during this transition, as they begin to care for their child at home. Having a nurse call back to check on a discharged patient allows the parent to ask questions, clarify instructions, seek help with follow-up care, and obtain resources. Being able to request phone calls to specific patients provides HCPs an avenue to consistently follow up with patients who are concerning. We also believe that having a consistent, experienced pediatric emergency nurse make and receive post-discharge calls is essential, because the registered nurse has the skill set and abilities to best assist the families. Having dedicated full-time equivalents for the outreach nurses is important so that she or he can focus on post-discharge phone calls and provide a standardized process for receiving and making phone calls each day. In addition, follow-up phone calls from an emergency department can make a significant impact on parent's compliance with discharge instructions. 7 With the increasing numbers of ED patients and the concerns about health care cost containment, there is an May 2014 VOLUME 40 ISSUE 3 WWW.JENONLINE.ORG 251

CLINICAL/Bucaro and Black emphasis on outpatient management for patients. Adequate follow-up, which is enhanced by efficient telephone communication, has become more important in the care of ED patients. 8 Because of our successful Outreach Nurse Program, we now have a dedicated nurse available to ensure that follow-up is completed for the infant with the positive blood culture. A nurse is available by phone who can take the needed time to review discharge instructions and answer a concerned parent's phone call. In addition, a system is in place for an HCP to request a follow-up phone call to a patient about whom he is concerned. As a result, the pediatric patient is able to make a safer transition from our emergency department to the home. Dayton Children s Outreach Nurse Program won first place in the category of quality and safety at Children s Hospital Association s Creating Connections Conference in 2013. In addition, Dayton Children s Hospital was granted status as a Magnet recognized organization in the fall of 2013. REFERENCES 1. Waisman Y, Siegal N, Chemo M. Do parents understand emergency department discharge instructions? A survey analysis Isr Med Assoc J. 2003;5(8):567-9. 2. Barnes S. Not a social event: The follow-up phone call. J Perianesth Nurs. 2000;15(4):253-5. 3. Child Health Corporation of America. Left Without Being Seen [Webinar]. 2009. Available at: http://chca.com/index_flash.html. Accessed October 13, 2009. 4. Press Ganey Partners in Improvement. Dialing for Outcomes: Closing the Loop with Post-visit Phone Calls [Webinar]. 2008. Available at: http:// www.pressganey.com/index.aspx. Accessed March 17, 2009. 5. The 2013 Joint Commission National Patient Safety Goals (NPSG) for Hospitals. Available at: http://www.jointcommission.org. Accessed January 16, 2013. 6. Carr DD. Care managers optimize patient safety by facilitating effective care transitions. Prof Case Manag. 2007;12(2):70-80. 7. Chande VT, Exum V. Follow-up phone calls after an emergency department visit. Pediatrics. 1994;93(3):513-4. 8. Kim IK, Lanni KA, Collazo E, Gracely EJ, Belfer R. Pagers combined with telephones improve successful follow-up from a pediatric emergency department. Pediatrics. 2002;110(1 pt 1):e1. 252 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 3 May 2014