Improving transitions of care: a resident-driven approach to address delays in patient care during the direct admission process

BACKGROUND: The direct admission process is a complex system that can be aggravated by inherent gaps in communication leading to inefficient continuity of care and patient safety issues. Bypassing the emergency room, triage is often associated with long periods of unmonitored observation and significant delays in patient assessment. We identified significant communication gaps, delays in placement of admission orders and patient assessment during the direct admission process at our institution. To address this issue, we created and implemented a standardised direct admission flow diagram that consists of a step-by- step direct admission process, which includes a communication device and a triage power plan in the Electronic Medical Record. METHODS: We used the Plan-Do-Study-Act (PDSA) model for Quality improvement to address communication gaps in the direct admission process Baseline measurement confirmed two critical gaps in communication: 1) communication to the Medical Admitting Resident (MAR), the central source of communication of all medicine admissions, and 2) delays in placement of orders and assessment of the patient. RESULTS: Two months after implementation of a standardised process that addressed the two major gaps in communication, we found that communication to the MAR increased from 16% (7/42) to 100% (15/15). Additionally, the average time for order placement and assessment of patient decreased from 153 minutes to 53 minutes (n=15). CONCLUSION: In order to improve the safety of direct admissions, the entire process must be carefully analysed and potential delays in patient assessment should be minimised. A standardised flow diagram that identified and targeted specific communication gaps can minimise delays in patient care.