- Email: [email protected]
The Use of Care Plans in the Emergency Department
CLINICAL
THE USE OF CARE PLANS IN THE EMERGENCY DEPARTMENT Author: Jacqueline Rodricks, RN, ENA ENPC, ENA TNCC, RNAO, BCLS, Mississauga, Ontario, Canada
T
doi: 10.1016/j.jen.2007.05.008
tunity to collaborate in their care because it helps expedite their future ED visits and provides greater consistency in the management of their condition. Patients who have care plans have an electronic flag placed in their record so they are identified easily at the time of ED registration. The care plans are available in the ED electronic file on the hospital internal information system and can be accessed easily by our health care professional. In some circumstances, community resources are consulted to assist with the patient’s long-term plan of care. Examples of patients needing this type of care would be patients with chronic pain issues who are referred to community pain clinics, the hospital’s Drug and Alcohol Drug Program, and home care. Examples of medical care plans in our emergency department are for patients with angioedema, organ transplants, chromosomal disorders, blood dyscrasia, and psychiatric disorders. Currently our department has more than 60 care plans. About 40 of these plans currently are active. Patients with medical care plans call the care plan coordinator with updates on medications and condition treatments. Figure 1 provides an example of a working care plan in our emergency department. Patients with care plans have reported increased satisfaction with their care. Some patients with care plans have expressed feelings of being “cared for” because they have a care plan. They feel secure in the knowledge that we know them and that a lengthy explanation of their health problems will not be necessary. Because of confidentiality legislation, the care plans are unique to our facility and cannot be shared with other agencies. The care plans have been a tremendous assistance to the health care team in our emergency department. Some patients with complex medical conditions now can have their care plans reviewed and orders written without confusion as to what treatment is needed. Length of stay seems to be decreased for this patient population, and their number of visits seems to be decreased as well. We now are evaluating the effectiveness of the care plans by auditing the number of ED visits for these patients, length of stay in the ED during each visit, and patient satisfaction since the implementation of their care plan through telephone survey. In conclusion, ED care plans started out with a single patient requesting consistent care for a child’s hemophilia and has become a valuable resource to ED staff and physicians.
June 2008 34:3
JOURNAL OF EMERGENCY NURSING
he emergency department at Credit Valley Hospital in Mississauga, Ontario, Canada, is using care plans to improve outcomes and help with flow for emergency patients who experience repeat visits for management of their complex health care problems. The individual care plans are for specific patients, including both adult and pediatric patients. Credit Valley Hospital is a 397-bed community hospital. We see approximately 71,000 patients a year, of whom approximately 28% are pediatric patients. We also have a significant psychiatric population. The emergency department has a Care Plan Committee coordinated by an emergency nurse. Other members of the Committee include the nurse manager, an ED physician, and the clinical educator. On an ad hoc basis, a social worker, home care nurse, pediatrician, and medical specialist also participate as Committee members. The patient’s family doctor is consulted if he or she has one. The patient also has reasonable input into the formation of the care plan. A literature search was done and yielded no information with regard to other facilities doing individual care plans for patients. Some remote references have been included.1-3 Patients are referred in different ways to the Care Plan Committee. ED staff members send an E-mail message to the care plan coordinator when they note patterns with patient visits. Family physicians and/or specialists in our community call the care plan coordinator if they believe they have a patient who will benefit by having a standard of care when they come into the emergency department. The care plan coordinator reviews all available electronic data in the computer in relation to the patient’s frequency of visits and usual treatment. The coordinator phones the patient to inform him or her of our intention to create a care plan. Patients generally embrace the opporJacqueline Rodricks is Staff Nurse, Care Plan Coordinator, Emergency Department, Credit Valley Hospital, Mississauga, Ontario, Canada. For correspondence, write: Jacqueline Rodricks, RN, RNAO, BCLS, Credit Valley Hospital, 2200 Eglinton Ave West, Mississauga, Ontario, Canada L5M 2N1; E-mail: [email protected]. J Emerg Nurs 2008;34:227-8. Available online 14 April 2008. 0099-1767/$34.00 Copyright © 2008 by the Emergency Nurses Association.
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CLINICAL/Rodricks
Credit Valley Hospital ED Care Plan Patient: Patient X Unit number: 00000 PATIENT PROFILE HISTORY Patient X is a woman diagnosed with chronic pancreatitis due to congenital small pancreatic ducts. She has had stents implanted approximately 12 to 13 times previously and has had difficulty retaining the stents. She currently is seeing a pancreatic surgeon at X hospital to see if a surgical solution (pancreatectomy) is possible. This condition probably is incurable and it is likely it eventually will lead to her demise. An aunt with the same problem died in her 40s. Until recently Patient X was taking Hydromorph Contin and methadone along with Dilaudid for breakthrough pain. Recently (April 4, 2007) she started a process to switch her to the fentanyl patch because of her severe vomiting. She takes pancreatic enzymes (Viokase 16) with meals and takes Ensure and Resource on a regular basis when she can get it covered. She uses Stemetil for vomiting and Pariet to reduce stomach acidity. She comes to the hospital frequently for flares of her abdominal pain. Her amylase and lipase levels frequently (but not always) are elevated. She vomits quite frequently because of the pain and possibly because of her opioid therapy. Another contributor to her vomiting is her recently diagnosed pregnancy (March 2007). She has 2 other children, and both pregnancies were complicated with hyperemesis. Further details of her history and blood tests are available on PCI. Other past medical problems include migraine headaches and renal colic. Patient X sees Dr X for chronic pain management, and her visits to CVH drastically decreased until the fall of 2006, when her condition seemed to worsen. She also has been seen in the past at Hospital X emergency department and occasionally has been admitted to this facility. She is known by all of the gastroenterologists there and Dr. X at CVH. In spite of being “interviewed” by a number of family practitioners in the community, no one has agreed to take on her medical care, even though Dr. X has agreed to continue to prescribe her opioids. ALLERGIES Chlorpromazine Seafood Alcohol Liquid morphine The patient states that morphine previously may have caused seizures. This is not objectively documented. Dr X has documented that patient X became sweaty and shaky between doses of morphine. He believes this may have been related to interdose withdrawal rather than seizure. ASSESSMENT 1. Patient X is aware of her active care plan in the emergency department of the Credit Valley Hospital. 2. Assess patient X in a nonjudgmental manner. Include a full assessment, subjective and objective data. A full set of vital signs needs to be done at triage. 3. A lipase and amylase level will be evaluated at each visit. 4. Patient X may come to Credit Valley Hospital to see the crisis worker. Assess whether her visit is to see the crisis worker or for pain management and assess accordingly. PLANNING 1. If her condition stabilizes in our emergency department, patient X should be discharged home with advice to return if she gets worse. Remember she does not have a family doctor. If she has persistent vomiting, she may require intravenous fluids, Stemetil, and intravenous opioids until she settles. IMPLEMENTATION 1. Triage patient X as quickly as possible. 2. Visits with the crisis worker can be managed in the quiet room and blood work is not required. 3. If the wait for a room will be lengthy, draw blood for routine tests and to determine amylase and lipase levels at triage. 4. Medicate as needed with hydromorphone, 1 to 2 mg intravenous every 15 to 30 minutes until she is settled and Gravol, 50 mg intravenous or Stemetil, 10 mg intravenous every 6 hours prn. 5. Document and observe for vomiting, induced and noninduced. 6. Admission is recommended if she does not settle with intravenous fluids, opioids, and antinauseants, if she has high elevations of her pancreatic enzymes, or if any complication of chronic pancreatitis is found clinically. 7. Do not prescribe any opioids for pain medication on discharge. Dr. X should be the only person to prescribe opioids. If there are extenuating circumstances, then prescribe the smallest amount of opioid that will manage her symptoms until the next available weekday. Please fax a copy of the ED chart to Dr. X’s office: XXXXXX-XXXX upon discharge. 8. If there is ever any question about her pain medications, Dr. X can be paged through locating. EVALUATION 1. The care plan team will re-evaluate this care plan every 3 months. 2. Compliance by staff to follow the care plan as written will be evaluated approximately every three months. First draft: May 16, 2000 Revised: June 1, 2000 Revised: August 22, 2000 Reviewed: March 11, 2001 Revised: September 28, 2001 Revised: November 1, 2001 Reviewed: February 28, 2002 Revised: July 24, 2002 Revised: January 27, 2003 Reviewed and revised: October 22, 2006 Reviewed and revised: April 7, 2007 **** NOTE: The care plan is NOT a permanent part of the patient’s record. ****
FIGURE 1 Credit Valley Hospital ED care plan for an individual patient.
1. Brice M, Lenehan GP. Care plans for patients with frequent ED visits for such chief complaints as back pain, migraine, and abdominal pain. J Emerg Nurs 2004;30:150-3, 193-8. 2. Boulet L, Belenger M, Lajoie P. Characteristics of subjects with
high frequency of emergency visits for asthma. Ann Emerg Med 1996;48:623-8. 3. Schenk F. Care plans/care tracks. How are other departments developing a plan of care for the ED patients they see frequently? J Emerg Nurs 1999;25:313-4.
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JOURNAL OF EMERGENCY NURSING
REFERENCES
34:3 June 2008
THE USE OF CARE PLANS IN THE EMERGENCY DEPARTMENT Author: Jacqueline Rodricks, RN, ENA ENPC, ENA TNCC, RNAO, BCLS, Mississauga, Ontario, Canada
T
doi: 10.1016/j.jen.2007.05.008
tunity to collaborate in their care because it helps expedite their future ED visits and provides greater consistency in the management of their condition. Patients who have care plans have an electronic flag placed in their record so they are identified easily at the time of ED registration. The care plans are available in the ED electronic file on the hospital internal information system and can be accessed easily by our health care professional. In some circumstances, community resources are consulted to assist with the patient’s long-term plan of care. Examples of patients needing this type of care would be patients with chronic pain issues who are referred to community pain clinics, the hospital’s Drug and Alcohol Drug Program, and home care. Examples of medical care plans in our emergency department are for patients with angioedema, organ transplants, chromosomal disorders, blood dyscrasia, and psychiatric disorders. Currently our department has more than 60 care plans. About 40 of these plans currently are active. Patients with medical care plans call the care plan coordinator with updates on medications and condition treatments. Figure 1 provides an example of a working care plan in our emergency department. Patients with care plans have reported increased satisfaction with their care. Some patients with care plans have expressed feelings of being “cared for” because they have a care plan. They feel secure in the knowledge that we know them and that a lengthy explanation of their health problems will not be necessary. Because of confidentiality legislation, the care plans are unique to our facility and cannot be shared with other agencies. The care plans have been a tremendous assistance to the health care team in our emergency department. Some patients with complex medical conditions now can have their care plans reviewed and orders written without confusion as to what treatment is needed. Length of stay seems to be decreased for this patient population, and their number of visits seems to be decreased as well. We now are evaluating the effectiveness of the care plans by auditing the number of ED visits for these patients, length of stay in the ED during each visit, and patient satisfaction since the implementation of their care plan through telephone survey. In conclusion, ED care plans started out with a single patient requesting consistent care for a child’s hemophilia and has become a valuable resource to ED staff and physicians.
June 2008 34:3
JOURNAL OF EMERGENCY NURSING
he emergency department at Credit Valley Hospital in Mississauga, Ontario, Canada, is using care plans to improve outcomes and help with flow for emergency patients who experience repeat visits for management of their complex health care problems. The individual care plans are for specific patients, including both adult and pediatric patients. Credit Valley Hospital is a 397-bed community hospital. We see approximately 71,000 patients a year, of whom approximately 28% are pediatric patients. We also have a significant psychiatric population. The emergency department has a Care Plan Committee coordinated by an emergency nurse. Other members of the Committee include the nurse manager, an ED physician, and the clinical educator. On an ad hoc basis, a social worker, home care nurse, pediatrician, and medical specialist also participate as Committee members. The patient’s family doctor is consulted if he or she has one. The patient also has reasonable input into the formation of the care plan. A literature search was done and yielded no information with regard to other facilities doing individual care plans for patients. Some remote references have been included.1-3 Patients are referred in different ways to the Care Plan Committee. ED staff members send an E-mail message to the care plan coordinator when they note patterns with patient visits. Family physicians and/or specialists in our community call the care plan coordinator if they believe they have a patient who will benefit by having a standard of care when they come into the emergency department. The care plan coordinator reviews all available electronic data in the computer in relation to the patient’s frequency of visits and usual treatment. The coordinator phones the patient to inform him or her of our intention to create a care plan. Patients generally embrace the opporJacqueline Rodricks is Staff Nurse, Care Plan Coordinator, Emergency Department, Credit Valley Hospital, Mississauga, Ontario, Canada. For correspondence, write: Jacqueline Rodricks, RN, RNAO, BCLS, Credit Valley Hospital, 2200 Eglinton Ave West, Mississauga, Ontario, Canada L5M 2N1; E-mail: [email protected]. J Emerg Nurs 2008;34:227-8. Available online 14 April 2008. 0099-1767/$34.00 Copyright © 2008 by the Emergency Nurses Association.
227
CLINICAL/Rodricks
Credit Valley Hospital ED Care Plan Patient: Patient X Unit number: 00000 PATIENT PROFILE HISTORY Patient X is a woman diagnosed with chronic pancreatitis due to congenital small pancreatic ducts. She has had stents implanted approximately 12 to 13 times previously and has had difficulty retaining the stents. She currently is seeing a pancreatic surgeon at X hospital to see if a surgical solution (pancreatectomy) is possible. This condition probably is incurable and it is likely it eventually will lead to her demise. An aunt with the same problem died in her 40s. Until recently Patient X was taking Hydromorph Contin and methadone along with Dilaudid for breakthrough pain. Recently (April 4, 2007) she started a process to switch her to the fentanyl patch because of her severe vomiting. She takes pancreatic enzymes (Viokase 16) with meals and takes Ensure and Resource on a regular basis when she can get it covered. She uses Stemetil for vomiting and Pariet to reduce stomach acidity. She comes to the hospital frequently for flares of her abdominal pain. Her amylase and lipase levels frequently (but not always) are elevated. She vomits quite frequently because of the pain and possibly because of her opioid therapy. Another contributor to her vomiting is her recently diagnosed pregnancy (March 2007). She has 2 other children, and both pregnancies were complicated with hyperemesis. Further details of her history and blood tests are available on PCI. Other past medical problems include migraine headaches and renal colic. Patient X sees Dr X for chronic pain management, and her visits to CVH drastically decreased until the fall of 2006, when her condition seemed to worsen. She also has been seen in the past at Hospital X emergency department and occasionally has been admitted to this facility. She is known by all of the gastroenterologists there and Dr. X at CVH. In spite of being “interviewed” by a number of family practitioners in the community, no one has agreed to take on her medical care, even though Dr. X has agreed to continue to prescribe her opioids. ALLERGIES Chlorpromazine Seafood Alcohol Liquid morphine The patient states that morphine previously may have caused seizures. This is not objectively documented. Dr X has documented that patient X became sweaty and shaky between doses of morphine. He believes this may have been related to interdose withdrawal rather than seizure. ASSESSMENT 1. Patient X is aware of her active care plan in the emergency department of the Credit Valley Hospital. 2. Assess patient X in a nonjudgmental manner. Include a full assessment, subjective and objective data. A full set of vital signs needs to be done at triage. 3. A lipase and amylase level will be evaluated at each visit. 4. Patient X may come to Credit Valley Hospital to see the crisis worker. Assess whether her visit is to see the crisis worker or for pain management and assess accordingly. PLANNING 1. If her condition stabilizes in our emergency department, patient X should be discharged home with advice to return if she gets worse. Remember she does not have a family doctor. If she has persistent vomiting, she may require intravenous fluids, Stemetil, and intravenous opioids until she settles. IMPLEMENTATION 1. Triage patient X as quickly as possible. 2. Visits with the crisis worker can be managed in the quiet room and blood work is not required. 3. If the wait for a room will be lengthy, draw blood for routine tests and to determine amylase and lipase levels at triage. 4. Medicate as needed with hydromorphone, 1 to 2 mg intravenous every 15 to 30 minutes until she is settled and Gravol, 50 mg intravenous or Stemetil, 10 mg intravenous every 6 hours prn. 5. Document and observe for vomiting, induced and noninduced. 6. Admission is recommended if she does not settle with intravenous fluids, opioids, and antinauseants, if she has high elevations of her pancreatic enzymes, or if any complication of chronic pancreatitis is found clinically. 7. Do not prescribe any opioids for pain medication on discharge. Dr. X should be the only person to prescribe opioids. If there are extenuating circumstances, then prescribe the smallest amount of opioid that will manage her symptoms until the next available weekday. Please fax a copy of the ED chart to Dr. X’s office: XXXXXX-XXXX upon discharge. 8. If there is ever any question about her pain medications, Dr. X can be paged through locating. EVALUATION 1. The care plan team will re-evaluate this care plan every 3 months. 2. Compliance by staff to follow the care plan as written will be evaluated approximately every three months. First draft: May 16, 2000 Revised: June 1, 2000 Revised: August 22, 2000 Reviewed: March 11, 2001 Revised: September 28, 2001 Revised: November 1, 2001 Reviewed: February 28, 2002 Revised: July 24, 2002 Revised: January 27, 2003 Reviewed and revised: October 22, 2006 Reviewed and revised: April 7, 2007 **** NOTE: The care plan is NOT a permanent part of the patient’s record. ****
FIGURE 1 Credit Valley Hospital ED care plan for an individual patient.
1. Brice M, Lenehan GP. Care plans for patients with frequent ED visits for such chief complaints as back pain, migraine, and abdominal pain. J Emerg Nurs 2004;30:150-3, 193-8. 2. Boulet L, Belenger M, Lajoie P. Characteristics of subjects with
high frequency of emergency visits for asthma. Ann Emerg Med 1996;48:623-8. 3. Schenk F. Care plans/care tracks. How are other departments developing a plan of care for the ED patients they see frequently? J Emerg Nurs 1999;25:313-4.
228
JOURNAL OF EMERGENCY NURSING
REFERENCES
34:3 June 2008