Research Emergency Department - Adult Clinical Escalation (RED-ACE)

The project is funded by Health Research Board (HRB) and led by Dr. Conor Deasy, Cork University Hospital (CUH), with collaborators from CUH ED, UCC, National Emergency Medicine programme and UCD (Prof. Eilish McAuliffe).

Programme: Research Collaborative for Quality and Patient Safety Award.

Droject's duration: 01-Dec-14 to 28-Feb-17

Project's description:

Implementation of ED escalation protocol in Cork University Hospital

The Emergency Department Monitoring and Clinical Escalation Protocol for Adult Patients (ED-ACE) has been designed to meet the recommendation of Ireland’s health and social care regulator, the Health Information Quality Authority (HIQA) for a system of physiological and triggered escalation responses across all Emergency Departments (EDs) in Ireland (1). It comprises clinical tools to facilitate early recognition and responses to physiological deterioration in patients in the ED setting.  It is an innovative, pragmatic solution developed by a multidisciplinary ED clinician group to mitigate safety risks for patients demonstrating physiological derangement during their ED stay. Prolonged ED patient experience times (PETs) associated with delays in assessment and treatment frequently occurs in many EDs, primarily due to the situation where patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame (‘access block’ or ‘exit block’).  Such delays may arise from resource constraints, and lead to ED crowding which is associated with increased patient morbidity and mortality (Ellen J. Weber et al 2012). The ED-ACE system is proposed as a safety intervention; it does not address the underlying causes of patient delays but is an attempt to reduce associated clinical risks. ED-ACE includes tools adapted from other healthcare settings and new processes for ED patient monitoring and clinical escalation. The development and implementation of longitudinal patient monitoring systems (early warning score [EWS] systems) for the clinically differentiated patients in the ward environment has helped catalyse the development and implementation of a longitudinal patient monitoring system for the ED setting that incorporates the ED triage system, recognises the density of clinical support in that environment, and links relatively seamlessly with an inpatient EWS tool.

Longitudinal patient monitoring systems are recommended to detect the deteriorating patient in many countries. However, evidence is still mixed regarding their success at reducing patient harm and death. The evidence may be mixed because of issues to do with implementation, for example failure to take account of socio-cultural and organisational issues or implementation in a ‘piecemeal’ manner without acknowledging the complexity of such an intervention. This study is concerned with the implementation evaluation of a longitudinal patient monitoring system specifically designed for the unique environment emergency department (ED) setting.

A novel approach, participatory action research (PAR), is taken to the implementation in this study where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of ‘Plan Do Study Act’ (PDSA). Conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation. Taking a PAR approach and doing this in collaboration with the ED staff who work the system should ensure that these challenges can be faced in a meaningful way that will enable both a process and an outcome evaluation of the implementation. Process evaluations can help distinguish between interventions that are inherently faulty (failure of intervention concept or theory) and those that are badly delivered (implementation failure). This will help to overcome limitations of previous studies and allow us to answer the question of whether longitudinal patient monitoring systems significantly contribute to the early detection and treatment of patients at risk of clinical deterioration.