Hostname: page-component-586b7cd67f-l7hp2 Total loading time: 0 Render date: 2024-11-22T15:42:35.260Z Has data issue: false hasContentIssue false
  • English
  • Français

Barriers and facilitators to the implementation of Ontario's emergency department clinical decision unit pilot program: a qualitative study

Published online by Cambridge University Press:  11 May 2015

Erin Salkeld ,
Chad A. Leaver ,
Astrid Guttmann ,
Marian J. Vermeulen ,
Brian H. Rowe ,
Anne Sales  and
Michael J. Schull
Erin Salkeld
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON
Chad A. Leaver
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON
Astrid Guttmann
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Department of Paediatrics, University of Toronto, Toronto, ON Division of Paediatric and Emergency Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, ON
Marian J. Vermeulen
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON
Brian H. Rowe
Affiliation:
Department of Emergency Medicine, University of Alberta, Edmonton, AB School of Public Health, University of Alberta, Edmonton, AB
Anne Sales
Affiliation:
Faculty of Nursing, University of Alberta, Edmonton, AB
Michael J. Schull*
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON
*
Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, G-Wing, Toronto, ON M4N 3M5; [email protected]

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

In Ontario, clinical decision units (CDUs) were implemented as a pilot project in 2008 by the Ministry of Health and Long-Term Care as part of its strategy to reduce emergency department (ED) waiting times. Our objective was to describe general characteristics of the program at each of the participating sites and to examine barriers and facilitators to integrating CDUs into practice.

Methods:

On-site small-group interviews were conducted in two phases with ED and hospital staff at participating sites, first at 8 to 12 weeks and again at 12 months postimplementation. Interview data were analyzed using the framework approach. Unstructured field notes and CDU clinical care protocols and documentation were also reviewed.

Results:

The qualitative analysis identified 10 key themes related to integrating CDUs into EDs: shift in clinical and operational practice; administrative aspects of implementation; team building and stakeholder involvement; use of clinical care protocols; physical or virtual model of care; responsive ancillary services; involvement of specialist services; coordination with hospital and community supports; appropriate use of the CDU; and ongoing evaluation and monitoring. Each theme represents an important insight from the perspective of clinical and administrative staff at participating sites.

Conclusion:

The implementation of CDUs is a complex process, with no single preferred clinical care or operational model. This study identifies a number of key considerations relevant to the future implementation of CDUs.

Keywords

clinical decision unitemergency servicesevaluationqualitative research
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 13 , Issue 6 , November 2011 , pp. 363 - 371
Copyright
Copyright © Canadian Association of Emergency Physicians 2011

References

REFERENCES

1.Ontario Ministry of Health and Long-Term Care. Understanding emergency room performance. 2009. Available at: http://www.health.gov.on.ca/transformation/length_of_stay/ pro/index.html (accessed January 21, 2010).Google Scholar
2.Vancouver Coastal Health. Innovation reduces ER congestion in Lower Mainland. 2009. Available at: http://www.vch. ca/about_us/news/media_contacts/news_releases/innovation_ reduces_er_congestion_in_lower_mainland (accessed January 21, 2010).Google Scholar
3.Alberta Health Services. Edmonton EMS, Capital Health hopeful changes will improve ambulance access. 2007. Available at: http://www.capitalhealth.ca/NewsAndEvents/NewsReleases/2007/Ambulance_access.htm (accessed January 21, 2010).Google Scholar
4.Bell, R, Willett, J, Oliver, J. Improving access to emergency care: addressing system issues. Toronto: Ontario Hospital Association, Ontario Medical Association, Ontario Ministry of Health and Long-Term Care; 2006.Google Scholar
5.Martinez, E, Reilly, BM, Evans, AT, et al. The observation unit: a new interface between inpatient and outpatient care. Am J Med 2001;110:274–7, doi:10.1016/S0002-9343(00) 00710-5.CrossRefGoogle ScholarPubMed
6.Roberts, MV, Baird, W, Kerr, P, et al. Can an emergency department-based clinical decision unit successfully utilize alternatives to emergency hospitalization? Eur J Emerg Med 2010;17:89–96, doi:10.1097/MEJ.0b013e32832f05bf.CrossRefGoogle ScholarPubMed
7.Ritchie, J, Spencer, E. Qualitative data analysis for applied policy research. In: Bryman, A, Burgess, RG, editors. Analysing qualitative data. London: Routledge, 1994. p. 173–94.CrossRefGoogle Scholar
8.Hassan, TB. Clinical decision units in the emergency department: old concepts, new paradigms, and refined gate keeping. Emerg Med J 2003;20:123–5, doi:10.1136/emj. 20.2.123.CrossRefGoogle ScholarPubMed
9.Runy, LA. Clinical observation units: building a bridge between outpatient and inpatient services. Hospitals & Health Networks Magazine 2006. Available at: http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG (accessed March 2, 2010).Google Scholar
10.McGowan, A, Hassan, TB. Clinical decision units: a new development for emergency medicine in the United Kingdom. Emerg Med 2003;15:18–21, doi: 10.1046/j.1442-2026.2003.00402.x.CrossRefGoogle ScholarPubMed
11.Brillman, J, Mathers-Dunbar, L, Graff, L, et al. Management of observation units. Ann Emerg Med 1995;25:823–30, doi:10.1016/S0196-0644(95)70215-6.CrossRefGoogle ScholarPubMed
12.Cooke, MW, Higgins, J, Kidd, P. Use of emergency observation and assessment wards: a systematic literature review. Emerg Med J 2003;20:138–42, doi: 10.1136/ emj.20.2.138.CrossRefGoogle ScholarPubMed
13.State of Victoria. Observation medicine guidelines 2009. Melbourne: Victorian Government Department of Human Services; 2009.Google Scholar
14.The College of Emergency Medicine. The way ahead 2008–2012: strategy and guidance for emergency medicine in the United Kingdom and the Republic of Ireland. London UK: The College of Emergency Medicine; 2008.Google Scholar
15.Pearson, SD, Goulart-Fisher, D, Lee, TH. Critical pathways as a strategy for improving care: problems and potential. Ann Intern Med 1995;123:941–8.CrossRefGoogle ScholarPubMed
16.Graff, L. The textbook of observation medicine: The healthcare system’s tincture of time. 2010. Available at: http://www.acep.org/pressroom.aspx?LinkIdentifier=id&id=46142&fid=3496&Mo=No (accessed May 4, 2010).Google Scholar
17.Graff, L, Zun, LS, Leikin, J, et al. Emergency department observation beds improve patient care: Society for Academic Emergency Medicine debate. Ann Emerg Med 1992;21:967–75, doi:10.1016/S0196-0644(05)82937-3.CrossRefGoogle ScholarPubMed
18.Landers, GA, Waeckerle, JF, McNabey, WK. Observation ward utilization. JACEP 1975;4:123–5.CrossRefGoogle Scholar
19.Johnson, WH. Pros and cons of emergency department observation wards. JACEP 1976;5:45.CrossRefGoogle ScholarPubMed
20.Krome, RL. Observation care units. Ann Emerg Med 1989;18: 705, doi:10.1016/S0196-0644(89)80535-9.CrossRefGoogle ScholarPubMed