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Expert panel issues report to help EDs improve safety

Most everyone who has spent time in an emergency department (ED) is familiar with the daily challenge to consistently deliver safe, timely care in such a busy, fast-paced setting.

A new report from an expert panel of Massachusetts emergency department physicians, nurses and patients offers recommendations to aid and bolster safety improvement efforts in EDs, with particular focus on three areas of risk: crowding, cognitive overload and post-ED care coordination.


The panel’s work stemmed from concerns raised by frontline care providers that, despite high marks in national rankings for ED safety and quality, the day-to-day environment in Massachusetts emergency facilities is not as safe as it could be for patients or staff.

The 14-member panel, organized by the Betsy Lehman Center in partnership with the Massachusetts College of Emergency Medicine Physicians (MACEP), Massachusetts Emergency Nurses Association (MENA) and Massachusetts Association of Physician Assistants (MAPA), shaped its work and deliberations around overarching areas of risk that could be addressed “within the four walls of the ED.”

I am hopeful that the best practices, case studies and tools presented in this report assist by providing some constructive solutions to the day-to-day struggles.

Gerald (Wook) Beltran, D.O.

“Emergency departments across Massachusetts face challenges, but often, challenges can inspire innovation, change and improvement,” says Gerald (Wook) Beltran, D.O., one of the expert panel’s three co-chairs and Chief of the Division of Prehospital and Disaster Medicine at Baystate Health. “I am hopeful that the best practices, case studies and tools presented in this report assist by providing some constructive solutions to the day-to-day struggles faced by frontline emergency department teams."

In brief, the panel found that:

  1. While crowded conditions in EDs can’t be ameliorated by ED staff working alone, patient flow within the ED can often be better optimized and risks lessened with changes to resource and personnel management, especially during peak periods of patient volume in the ED.
  2. Cognitive overload of health care practitioners practicing in EDs is a significant concern that can be addressed with a variety of different strategies, including increased use of cognitive decision aids, limiting interruptions, and a team-based approach to situational awareness and shared responsibility for patient safety.
  3. Coordination of care for patients leaving the ED can be managed through standardized discharge processes, renewed attention to and communication about medication changes, and follow-up with patients after discharge.
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Peter Smulowitz, M.D., co-chair of the expert panel and Chief of Emergency Medicine at Beth Israel-Lahey Needham, says cognitive overload is a particular challenge in the fast-paced environment of a busy ED. "Clinicians are expected to manage multiple patients at once while also handling frequent interruptions and incoming information." He adds, "Using simple tools to offload some cognitive tasks, ED clinicians can free up their working memory to focus on the key tasks at hand and ensure the delivery of safe patient care."

Using simple tools to offload some cognitive tasks, ED clinicians can free up their working memory to focus on the key tasks at hand and ensure the delivery of safe patient care.

Peter Smulowitz, M.D.

Using the three areas of concern as a framework, the panel developed and released 16 recommendations with a series of tools and successful strategies from Massachusetts emergency departments to help with implementation. Read the full report, executive summary and more here.

Case studies highlight safety strategies

Among the resources included with the report are case studies that demonstrate safety strategies implemented by Massachusetts EDs, such as:

The panel also reviewed the results of informal surveys of members of MACEP, MENA and MAPA designed to collect frontline providers’ perceptions of key risks to safety in the ED. Asked what keeps them up at night when they think about delivering safe care in the emergency facilities in which they work, answers included “Delays in patient care,” “Not enough time,” and “Fear of being hurt by my patients.” One respondent wrote: “Not getting to spend enough time with patients because work load is too severe. Makes me think, ‘What have I missed or forgotten?’”

“Crowding in the emergency department is a big concern for patients, clinicians and hospital administrators across Massachusetts,” says Emily Aaronson, M.D., expert panel co-chair and emergency physician at Massachusetts General Hospital. “While the most effective solutions to crowding are aimed at the whole system, there are ways within the ED to mitigate some of the risks posed by crowding.”

While the most effective solutions to crowding are aimed at the whole system, there are ways within the ED to mitigate some of the risks posed by crowding.

Emily Aaronson, M.D.

Patient safety is a common concern

The ED expert panel’s work is tied to other efforts to improve the safety of care in Massachusetts and elsewhere. Almost 20 percent of adults in the United States visit an emergency department at least once a year, accounting for 145 million visits in 2016, according to data from the U.S. Center for Disease Control and Prevention. More than three million ED visits are logged in Massachusetts annually.

Data from the American College of Emergency Medicine Physicians suggest that more than 90 percent of emergency departments in the U.S. experience overcrowded conditions. Limitations to inpatient and outpatient capacity to care for patients, particularly those with behavioral health and other complex needs, are key drivers.

“Massachusetts is not alone in facing challenges to patient safety in emergency settings,” says Barbara Fain, executive director of the Betsy Lehman Center. “We’re happy to be part of this effort with so many thoughtful professionals and staff from EDs across the state. At some point in time, we are all emergency department patients. Safe, reliable emergency care is in everyone’s best interest.”

To learn more, visit BetsyLehmanCenterMA.gov/EDsafety

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