Connected care: How a health science centre is using evidence to improve patient transitions from primary to secondary care

Number 18, April 2008

Making the transition between primary and secondary healthcare can be like driving between cell phone coverage areas — disconnects happen. These disconnects are frustrating for everyone involved, especially patients and caregivers, and can be costly to healthcare systems. Nova Scotia’s Capital Health District is improving the transition from primary to secondary care, starting with a project on deepvein thrombosis (DVT).

DVT is the formation of a blood clot — commonly in leg veins — that can break off and cause severe complications. It’s a serious condition, but suspected cases often have more simple underlying causes. To investigate each case, family physicians follow various methods involving several medical disciplines, which adds to the potential for gaps in care and communications. Moreover, since doctors don’t want to take chances, they often refer patients directly to emergency departments, although this is frequently unnecessary.

“It’s been a chaotic process,” says Dr. Sam Campbell, director of continuous quality improvement in the department of emergency medicine at Queen Elizabeth II Health Sciences Centre and a fellow of the Executive Training for Research Application (EXTRA) program. As part of EXTRA, Dr. Campbell investigated DVT referrals. “I wanted to help strengthen the capacity of family physicians to manage their patients and make care management easier for all caregivers. But I also wanted to take practitioners out of their primary or secondary care silos and put them in the patient’s silo, organizing care with the patient as the focus.”

The project adapted a scoring tool, based on new evidence-based protocols for DVT diagnosis and treatment, to allow family physicians to determine a patient’s clinical probability of disease and the appropriate diagnostic strategy. With this step-by-step process, most patients can be diagnosed and treated by their family doctors as outpatients. For those whose diagnosis requires referral to the emergency department, Dr. Campbell’s team developed a diagnostic pathway involving advanced care paramedics to avoid taking resources from other emergency cases.

Research evidence guided the development of the investigation and treatment protocol, as well as the strategy to introduce the new process. Dr. Campbell’s review of the literature on change management and quality improvement revealed several useful strategies. One was the discovery of the “productivity of resistance” concept, which suggests that resistance can be used constructively. “Resistance is usually viewed as preventing change,” says Dr. Campbell, “but the resisters pointed out problems and we adjusted the process accordingly. It was hugely valuable.”

Dr. Campbell’s multidisciplinary team, which included not only healthcare providers and decision makers, but also an industrial process engineer, believed that a pathway designed to improve care and make life easier for caregivers would have a better chance of success than one focused solely on improving patient care. With this in mind, they sought input from each stakeholder group on how the process should work.

“We wanted something that would be easier to follow than to ignore,” says Dr. Campbell. “That meant we needed a ‘win’ in it for everyone — patients, family and emergency physicians, advanced care paramedics, and radiology and haematology staff.”

The team was careful not to be prescriptive or defensive about the process. “We had no sacred cows to defend,” says Dr. Campbell. “We stressed that physicians could override the protocol if they felt it necessary and acknowledged that problems with the process itself might emerge once it was in use.”

The team also decided that user feedback was needed to improve the process, and it gathered and used this feedback in a very visible way. For example, since many found the progression of care confusing, a poster was hung in the emergency department to spell it out. The team encouraged staff to write their suggestions directly on the poster.

“This was a master stroke,” says Dr. Campbell. “It not only helped us clarify the process, but also, by visibly incorporating people’s suggestions via new versions of the poster, the caregivers began to own the project, which really fostered buy-in.”

After one year, family physicians who had used the pathway rated it 8.99 out of 10, and 95 percent of emergency physicians were satisfied or very satisfied with it, as were 89 percent of the advanced care paramedics. In addition, 95 percent of patients contacted were satisfied or very satisfied with their experience. Patients referred to emergency saw their length of stay decrease by more than an hour and a half.

The pathway is now considered the standard of care for DVT. “But more importantly,” says Dr. Campbell, “we are now developing similar approaches in other areas, such as anticoagulation management, where the processes and primaryto-secondary interfaces are not well defined.”

For more information, contact Dr. Sam Campbell at sgcampbe@dal.ca.