Rush University College of NursingExamination of Care in Patients with

Intellectual Disabilities in the Emergency Department:

Creation and Conduction of a Mock Tracer

Keren Talor and Renee Sandusky

Introduction

The management of care of individuals with intellectual disability (ID) can prove a difficult task in healthcare settings, with the emergency department (ED) posing an additional challenge given the critical, time-sensitive nature of care provided.

● Patients with ID are more likely to frequent EDs than patients without ID (Lunsky, 2010)● Patients with ID have difficulty communicating needs (Iacono et al, 2014)● Nurses have expressed non-confidence in their ability to provide adequate treatment

(Iacono et al, 2014; Sowney & Barr, 2006) Tailoring nursing care to manage patients with ID is essential to delivering optimal care and providing appropriate interventions. A tracer, an evaluation tool used to detect gaps in systemic patient care, will be applied to the ED at RUMC.

Mock Tracer

WHAT IS A TRACER?● Surveying tool

● Method used to evaluate gaps in systemic patient care

● Utilized in healthcare organizations to identify compliance and patient safety issues prior to official evaluations by regulatory commissions and agencies

● Highlights deficits in level and consistency of care

● Identifies areas of future focus

● Patients with ID have greater health care needs

● High-end users of EDs in lieu of primary care

● Needs often go unmet

● Increased complexity in provision of primary health care

● Challenges lead to increased difficulty assessing patient’s baseline of functioning vs syptomoatic behaviors

● Patients with ID require increased health care provider time (Iacono, Bigby, Unsworth, Douglas, & Fitzpatrick, 2014; Sowney, Brown, & Barr, 2006)

Review of Literature

cont

Communicative Impairments

● Effective communication - Most challenging aspect in care of patient with ID

● Communicative Impairments - Up to 90% of patients affected

● Difficulty interpreting internal cues

● Difficulty articulating cues and needs

● Impacts

● Assessment● Informing patients of status● Seeking consent (Blair, 2012; Nakken & Vlaskamp, 2007; MENCAP, 2007)

Review of Literature

Microsystem Analysis

● 55,000+ annually● Full range of needs● 60 private rooms ● 3 Pods:

● A: Triage ● B: Critical care ● C: Peds/Obs● Psych rooms

Leadership:

● Unit Director: Patricia Altman

Communication:

● Morning huddle● Direct verbal exchange● Customized Epic

format● Cell phones/pagers● Emergency Severity

Index (ESI)

Interdisciplinary Teamwork:

● Physicians, nurses, and support staff

System:

Problem IdentificationIn the United States, intellectual disability is prevalent in only a small percentage of the

total population.

However, several recent articles have highlighted that this small population

● Reports higher rates of comorbidities

● Engages in a remarkably increased rate of emergency room visits with noted greater difficulties in

■ Communication ■ Comprehension■ Navigation of the health care system

Lack of studies analyzing the quality of care in patients with ID within the ED setting

(Ervin, Hennen, Merrick, & Morad, 2014; Iacono, Bigby, Unsworth, Douglas, & Fitzpatrick, 2014; Lunsky et al., 2011; Merrifield, 2011; Sowney, & Barr, 2007; Williamson, Flowers, & Cooke, 2012)

Logic Model

Administration

Providers

Epic

Committees

Design tracer

Conduction of mock tracer

Obtainment of data

Evaluation of tracer results

Determination of gaps in patient care

Address gaps in care

Achieved via inservices, training, etc.

Improved care of patients with ID in the ED based upon improvements in gaps of care identified

Develop and conduct a mock tracer specific to:● Patients with ID● Patients in RUMC ED

● Care provided ● Gaps in care● Barriers

● Continuity of care● Guardianship● Transfers● Discharge

Evidence-Based Intervention

45 questions● Yes/No and

qualitative

Topics:● Triage ● Decisions of Care● Nursing Care● Transitions of Care● Discharge

Design based on:

● Joint Commission

● Previously conducted tracers

● Current research

● Content expert

Evidence-Based Intervention

Mock Tracer

Mock Tracer

Mock Tracer

Mock Tracer

Data Collection

Conducted on March 12, 2015 at RUMC in the ED

Team consisting of ● GEM students● Dr. Ailey● ED unit director● Social worker● 2 staff RNs

Data Collection

Conducted on March 12, 2015 at RUMC in the ED

Chart audit Interviews

Key Findings

Strengths● Experienced staff

● Excellent care provided to special needs patients

● Excellent crisis management skills

● Impressive understanding on guardianship

● Strong stakeholder support

1stPlace

Key Findings

Areas for Improvement● Ambiguity of diagnosis and terminology

● Lack of confidence in providing care

● Time constraints

● Lack of thorough and consistent documentation

● Lack of post discharge community resources

Cost

The development and conduction of the mock tracer was accomplished at minimal financial cost. Generation of the tracer by nursing students completing a capstone project, with overseeing guidance from faculty, mitigated any potential financial costs associated with the production of salaried work.

Non-financial costs associated with the conduction of the tracer included the allocation of time on the part of staff in the ED at RUMC.

Recommendations

● List of community resources● Enhance knowledge and education about this population

■ Annual Competency■ Effective Communication■ Documentation

● Additional time● Clarify definition● Caregiver Familiarity● Seek additional assistance

■ Utilization of social worker, child-life therapist, interpreter

Conclusion

Findings at RUMC - ED aligned with current literature

Implementation of suggested interventions can result in: Improved level of provided care

Increased patient safety

Enhanced provider confidence

Increased patient satisfaction

Rush University College of Nursing

Content Expert Dr. Sarah Ailey

Questions?

ReferencesBlair, J. (2012). Caring for people who have intellectual disabilities. Emergency Nurse, 20 (6), 15-19.

Bradbury-Jones, C., Rattray, J., Jones, M., & MacGillivray, S. (2013). Promoting the health, safety and welfare of adults with learning disabilities in acute care settings: a structured literature review. Journal of Clinical Nursing, 22, 1497–1509.Ervin, D. A., Hennen, B., Merrick, J., & Morad, M. (2014). Healthcare for persons with intellectual and developmental disability in the community. Frontiers in Public Health, 2 (83), 1-8.Gaskell, S., & Nightingale, S. (2010). Supporting people with learning disabilities in acute care. Nursing Standard, 24(18), 42-48.Hirschman, K.B., Paik, H.H., Pines, J.B., McCusker, C., Naylor, M.D., Hollander, J.E. (2011). Cognitive impairment among older adults in the Emergency Department. Western Journal of Emergency Medicine (12), 56–62.Iacono, T., Bigby, C., Unsworth, C., Douglas, J., & Fitzpatrick, P. (2014). A systematic review of hospital experiences of people with intellectual disability. BMC Health Services Research, 14, 1-8.Lin, J., Yen, C., Loh, C., Hsu, S., Huang, H., Tang, C., et al. (2006). A cross-sectional study of the characteristics and determinants of emergency care utilization among people with intellectual disabilities in Taiwan. Research in Developmental Disabilities, 27, 657-667.Lunsky, Y., & Elserafi, J. (2011). Life events and emergency department visits in response to crisis in individuals with intellectual disabilities. Journal Of Intellectual Disability Research, 55 (7), 714-718.Lunsky, Y., & Gracey, C. (2009). The reported experience of four women with intellectual disabilities receiving emergency psychiatric services in Canada. Journal of Intellectual Disabilities, 13 (2), 87‒98.Lunsky, Y., Gracey, C., & Gelfand, S. (2008). Emergency Psychiatric Services for Individuals With Intellectual Disabilities: Perspectives of Hospital Staff. American Association on Intellectual and Developmental Disabilities, 46 (6), 446-455.Lunsky, Y., Lin, E., Balogh, R., Klein-Geltink, J., Bennie, J., & Wilton, A. (2011). Are adults with developmental disabilities more likely to visit EDs? The American Journal of Emergency Medicine, 29 (4), 463 - 465.Lunsky, Y., Lin, E., Balogh, R., Klein-Geltink, J., Wilton, A., & Kurdyak, P. (2012). Emergency Department Visits and Use of Outpatient Physician Services by Adults With Developmental Disability and Psychiatric Disorder. Canadian Journal of Psychiatry, 57 (10), 601-607.

References

MENCAP. (2007). Death by indifference. Retrieved from: https://www.mencap.org.uk/death-by-indifferenceMerrifield, J. (2011). Meeting the needs of people with a learning disability in the emergency department. International Emergency Nursing, 19 (3), 146-151.Rush University Medical Center (n.d.a). Emergency department. Retrieved from: https://www.rush.edu/services/emergency-departmentSowney, M., & Barr, O. (2006). Caring for adults with intellectual disabilities: perceived challenges for nurses in accident and emergency units. Journal of Advanced Nursing, 55 (1), 36-45.Sowney, M., & Barr, O. (2007). The challenges for nurses communicating with and gaining valid consent from adults with intellectual disabilities within the accident and emergency care service. Journal Of Clinical Nursing, 16 (9), 1678-1686.Sowney, M., Brown, M., & Barr, O. (2006). Caring for people with learning disabilities in emergency care. Emergency Nurse, 14 (2), 23-30.The Arc. (2015). Intellectual disability. Retrieved from: http://www.thearc.org/learn-about/intellectual-disabilityThe Joint Commission. (2010). The Joint Commission: Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals. Retrieved from: http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdfThe Joint Commission. (2012). The Joint Commission Survey (Part 1): Maximizing Tracer Activities – A Dialogue with Surveyors. Joint Commission Resources Quality & Safety Network Resource Guide. Retrieved from: http://www.jcrqsn.com/docs/resource_guide/demorgjune2012.pdfVenkat, A., Pastin, R., Hegde, G., Shea, J., Cook, J., & Culig, C. (2011). An analysis of ED utilization by adults with intellectual disability. American Journal of Emergency Medicine, 29, 401–411.Williamson, T., Flowers, J., & Cooke, M. (2012). Quantifying emergency department admission rates for people with a learning disability. Emergency Medicine Journal, 29 (9), 771-772.