This researching implementation and change while improving quality project will re-design the process of emergency department (ED) management for adults with sickle cell disease (SCD). The project will use the Failure Modes, Effects, and Criticality Analysis (FMECA)-- to identify the vulnerabilities, risks, and weak points (failures) in the systems and processes involved in using the Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS), (a decision support tool developed to improve the quality of care for adults with SCD). The root causes of each failure will be identified, then re-designed.
The aims for the proposed project are to (1) Conduct a proactive risk assessment, Failure Modes Effects and Criticality Analysis (FMECA) of the workflow and operational systems and processes involved in four key decisions of the EDSCANS regarding evaluation and management of SCD patients by;applying a FMECA at two academic medical centers to examine four key ED-SCANS decisions;(2) Develop and implement standardized processes and interventions for each of the four decisions of the ED-SCANS;(3) Conduct a formal program evaluation of the quality improvement implementation at each site by;(3.1) reporting process evaluation measures including implementation success, associated facilitators and barriers of process improvement interventions;and (3.2) reporting preliminary data for selected patient and clinician outcome measures to be effected by the quality improvement interventions;and (4) Develop a toolbox for dissemination and implementation of effective systems and processes to support use of the ED-SCANS in EDs at additional low resource US hospitals. Two centers will form quality improvement teams and design interventions targeted to assign correct triage scores, improve rapid, aggressive analgesic management, identify patients at high risk for severe disease or those with frequent ED management or hospitalizations, and identify medical and psychosocial referral needs for adults with SCD during an ED visit. The plan, do, study, act, rapid cycle quality improvement process will be used to rapidly assess the affect of interventions on study outcomes and allow for modifications in the interventions. A formal program evaluation will be conducted using mixed methods to evaluate the affect of the program. Clinicians will participate in semi- annual surveys to evaluate success of program implementation bi-annually, and two focus groups will be conducted at each site toward the end of the project to evaluate program success. Structured medical record review and patient interviews will be conducted to measure the affect of interventions on patient outcomes. A toolbox of protocols, educational tools, and other materials will be developed to help disseminate to other emergency departments.

Public Health Relevance

Sickle cell disease (SCD) is a chronic disease with significant morbidity and mortality as reflected by the median age of death;42 for males, and 48 for females. Persons with SCD often require care in an emergency department and this experience is often frustrating for both the patient and emergency department (ED) clinician. The proposed project will apply an investigator developed, NIH supported, emergency department decision support tool, to guide a formal quality improvement process at two emergency departments, and re- design the process of ED care.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Health Care Quality and Effectiveness Research (HQER)
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Hogan, Eileen
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Duke University
Schools of Nursing
United States
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