Quality Improvement initiative leads to new positions at Dartmouth General Hospital emergency department

Patient safety and quality care have always been at the forefront for Nova Scotia Health teams. These past few years have strained our health care system and have challenged our health care teams. Some teams have been affected more than others—but all are feeling the impact.

Patient visits to emergency departments are at an all-time high. Last year, the Dartmouth General Hospital emergency department (ED) saw almost 45,000 patients—the highest number in the past five years.

Rachel Nalepa is the health services manager at the Dartmouth General Hospital ED. In June 2022 she began a quality improvement initiative with the overall goal of increasing the safety of patients in the ED waiting room.

Through the Enhancing Care-Implementation of a Waiting Room Care Provider initiative, a position called the waiting room care provider was created. This position’s main responsibility is the reassessment of patients in the ED waiting room.

“When patients come to the ED, they are triaged and assigned an acuity score,” explained Nalepa. “The acuity score is used to determine how frequently a patient should be reassessed. Prior to this role being present the busy triage RN had to try to complete all these assessments along with triaging new patients arriving. The waiting room care provider is now responsible for reassessment. This could be anything from repeating vitals on somebody or checking in to see if the patient has experienced any changes.”

Since rolling out this pilot project at the Dartmouth General ED the waiting room care provider

has had a dramatic impact on improving health outcomes. The reassessment rate has improved by more than 500 per cent, increasing patient safety, the quality of care provided, and overall patient satisfaction.

In addition, having the waiting room care provider conduct early interventions (blood work, ECGs, etc.) has enhanced decision-making for the clinical team, improving perception of care provided and anecdotally has avoided negative patient outcomes.

This position differs from the new patient advocate role who is there to provide non-clinical support to patients, including directing patients and helping make them a bit more comfortable by getting them a blanket or water.

The waiting room care provider is a trained health care professional. They could be a Registered Nurse, Advanced Care Paramedic or Licensed Practical Nurse.

At the Dartmouth General ED, the waiting room care provider position is staffed for 12 hours a day with the intention of expanding this position to 24 hours a day, seven days a week.

This initiative started as a pilot program at the Dartmouth General ED with plans to be spread to other facilities. However, it didn’t happen overnight.

Nalepa and her team were part of the Nova Scotia Health Quality Improvement (QI) collaborative - which is designed to help staff, physicians, leaders, and patient family advisors lead quality improvement initiatives, giving them all the tools, resources and supports they need for every step of the QI process.

“When you are in operations in health care—especially lately—you can be so overwhelmed with operations that it can become very difficult to try to move things forward,” said Nalepa. “What the collaborative helped with was setting deadlines and creating dedicated time for this work because you were focused and there were defined timelines. The support and expertise from the QI coaches was also extremely valuable.”

The team included a variety of ED staff and a patient family advisor, Judy Porter.

“I was thrilled to be part of this project,” said Porter. “As a patient, I have seen how anxiety builds up in the waiting room as time passes and I was able to share my experiences and those that I have witnessed with the team.  I am deeply appreciative of how much they involved me in planning and discussions, including a decision that the waiting room care provider should be situated in the ED waiting room where patients could see them and they could see patients, hoping this would reduce some patient and essential care partner's anxieties during their waiting time.” 

Nalepa and the team were the recipients of the excellence in patient safety quality award from Nova Scotia Health. This award recognizes individuals/teams committed to improving patient safety within health care, through leadership, culture, best practices, innovation, or change management.