Discharge Instructions—Old Process
In our ED, providers, attending physicians, residents and advance practice nurses enter and print their own discharge instructions, which are given to nursing staff to review with patients. Prior to the project, nurses were expected to notify a physician if they thought a vital sign was abnormal. Each nurse made independent decisions on what constituted a vital sign abnormality based on the patient’s condition and could communicate that to the provider at their discretion prior to discharge. This process created inconsistencies in care.
Development of Alert
We created an alert that appears within the provider workflow at the time the provider attempts to print discharge instructions. Based on literature review and operational leadership consensus, we set the parameters for abnormal vital signs ( Table 1 ). We chose parameters to identify abnormalities important to
The alert displays when a user attempts to print discharge instructions on a patient whose last recorded vital signs are not all normal. The display informs that there are abnormal vital signs ( Figure). Upon display of the alert, the user can click on the message, which would take them to the vital sign entry activity in the EMR, or they can proceed with printing by clicking the print button (not visible in the Figure). The alert is not a forcing function; the user can proceed with printing the discharge instructions without addressing the abnormality that triggered the alert.
Pre-Post Evaluation
We would have liked to have determined how often the abnormal vital signs alert triggered, how it was responded to, and whether the patient was subsequently discharged with normal vital signs; however, our system does not record these events. Instead, we used the system to compare the percentage of adult patients who were discharged with abnormal vital signs for 2 time periods: the period prior to our December 2014 implementation (1 Oct to 1 Dec 2014) and the post implementation period (15 Dec 2014 to 15 Feb 2015). Our presumption was that the use of the alert system would reduce the percentage of patients discharged with abnormal vital signs, including an abnormal pulse oximetry.
To conduct our analysis, we identified adult patients seen during the 2 time periods. We eliminated those patients who died, left without being seen, eloped, were admitted or were transferred to other institutions. This resulted in 3664 patients, with 2179 in the pre-implementation group and 1485 in the post-implementation group. The higher volume in the pre group reflects the early occurrence of influenza season in our area during the study period, along with our generally busier time in late fall compared to winter.
The analysis was performed as a likelihood ratio chi-square analysis using SAS (Cary, NC) software.
Results
The analysis demonstrated that physicians were, by and large, following recommendations consistent with policies of the American College of Emergency Physicians regarding the management of elevated blood pressures, which do not mandate that patients with asymptomatic elevations of blood pressure receive medical intervention in the ED [12]. In our analysis, the percentage of patients discharged with elevated blood pressures actually increased from 7.5% to 9.9% following the intervention. Importantly, however, the percentage of patients discharged with low blood pressures decreased from 6.9% to 5.0% ( P < 0.01).Tthe percent of patients discharged with an elevated heart rate, decreased from 58% in the pre alert group to 42% in the post alert group ( P < 0.02).