Quality Improvement Project: Improving the Time Management of the Patients with Suspected PE in the Emergency Department of Leighton Hospital Case History (Research Paper Sample)

Quality Improvement Project: Improving the Time Management of the Patients with Suspected PE in the Emergency Department of Leighton Hospital Student’s Name Institutional Affiliation Course Name Professor’s Name Due Date Quality Improvement Project: Improving the Time Management of the Patients with Suspected PE in the Emergency Department of Leighton Hospital Case History The current project is based on a case study of a patient with suspected pulmonary embolism who self-registered at the emergency department (ED) of Leighton Hospital. At around 8.00 in the morning, a 35-year-old male arrived at the ED department in our facility. The patient was triaged around 11.00 o’clock when the medical practitioners at the front desk of the ED department finished taking his medical history and other related data. The initial oral examination revealed that the patient was suffering from pleuritic chest pain without shortness of breath. Due to the high number of patients in the queue, the patient was seen by a medical doctor at 1.00 PM. The doctor conducted the recommended oral tests to establish the underlying cause of the patient’s chest pains. The results showed that his breathing was within the normal range. Additionally, his clinical examination revealed that the patient was not suffering from any serious condition that required urgent medical attention. The doctor prescribed Ibuprofen and Paracetamol as the needed remedies to resolve the patient’s chest pains. However, when the laboratory tests were concluded, the patient’s blood tests revealed that his D-dimer was significantly higher than the recommended clinical levels. The patient’s electrocardiogram (ECG) results, chest x-ray, and the remaining blood tests were unremarkable. To correct the raised D-dimer, the patient was prescribed a treatment regime of Tinzaparin. The examining doctor recommended that the patient undergo a Computer Tomography Pulmonary Angiogram (CTPA) to rule out any chances of pulmonary embolism. The patient’s CTPA tests were not finalized on that particular day since the ED department was handling two trauma cases and other patients who had serious medical conditions requiring urgent attention. At around 9 PM, the patient was still in the facility waiting for his CTPA results, without any communication from the medical practitioners in the facility. Towards the end of my work shift, the patient approached me, seeking clarification on his proposed care plan, given that his CTPA results were still unavailable. The patient was concerned that he should have been released to go back home instead of staying at the hospital since he was feeling well, and the chest pains had reduced significantly. Unfortunately, the discharge protocol at the hospital at this period required that patients be released to go home only after their CTPA results have been examined by a medical doctor. Therefore, I had no ready answer for the patient, but I assured him that he would know the recommended plan of care once the CTPA results are out. Identification and Analysis of the Problem A careful analysis of the above-discussed case study reveals that patients with suspected pulmonary embolism (PE) end up wasting a lot of time in the hospital waiting to be given directions on the next course of their care plan. The patient arrived at around 8 AM in the hospital but was not triaged until 11 AM. In addition, the patient did not see the medical doctor until 1 PM. Moreover, as of 9 PM, the patient had not yet received his CTPA results nor given directions on the way forward. I found this situation to be undesirable since the facility was wasting a lot of patients’ valuable time. Application of the NICE guidelines for the diagnosis of suspected PEs could drastically reduce the amount of time that patients spend in the ED department. Leighton Hospital is a busy District General Hospital (DGH), whereby during the winter period, the average waiting time for a patient to meet a medical doctor after triage was between 5-6 hours during the day and well over 10 hours at night. Moreover, the trickle-down effect is that the ED department is almost overcrowded all the time owing to the long queues of patients waiting to see a medical practitioner. Furthermore, the situation is worsened by the number of patients waiting to be admitted into the hospital and assigned to their respective medical beds. The exit areas are blocked, significantly posing a danger to both the patients and medical practitioners at the facility. The waiting time alone can be argued as a basis for patients to feel that they are not receiving quality care. I could tell that the majority of the patients who were kept waiting for their CTPA results in the ED were visibly angered and frustrated with the whole ordeal. The particular male patient in the case study became restless after waiting for several hours without any communication and decided to approach me for help. When I looked and listened to him carefully, I could feel that he was tired and resigned to spend the entire night at the facility waiting for the results. My lack of decision-making powers only exacerbated the issue since I could not provide him with clear information to calm him down. It was the same case with the majority of patients with suspected PE, but in a stable condition, either waiting for a medical examination by their doctor, or for their CTPA results, or to be admitted in the emergency ward. These patients contributed to the high human traffic that is usually experienced in the ED department in the Leighton Hospital. Literature Review According to NICE (2020), “venous thromboembolism (VTE) is a condition in which a blood clot (a thrombus) forms in a vein and then dislodges to travel in the blood (an embolus)” (p. 12). When a venous thrombus occurs in the deep veins of the legs or pelvis, the situation is known as a deep vein thrombosis (DVT) (NICE, 2020). Pulmonary embolism (PE) occurs when a blood clot is displaced from the deep veins and transported to the pulmonary artery. PE can be fatal if not managed by using the recommended procedure. Nonfatal VTE should be appropriately managed since “it can cause serious longer-term conditions such as post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH)” (NICE, 2020, p. 12). The damage to the deep veins and their valves caused by DVT leads to PTS, which is a chronic medical condition. NICE Guideline On Diagnosis of Pulmonary Embolism PE is a treatable condition where its adverse effects, such as collapse and/or sudden death, make its effective diagnosis a critical process in the medical field. Recent studies have shown that the category of rapid PEs leading to fatal cases is rarely diagnosed clinically before the patient dies (NICE, 2020). According to NICE (2020), "in patients where PE is diagnosed, the mortality rate is lower in those who are hemodynamically stable and higher in those who present in cardiorespiratory arrest” (p. 68). The symptoms and signs associated with PE include pleuritic chest pain, cough, dyspnoea, retrosternal chest pain, and hemoptysis (NICE, 2020). Patients with severe PE might experience dizziness and/or syncope due to right ventricle failure. NICE (2020) states the signs to include “tachypnoea, tachycardia, hypoxia, pyrexia, elevated jugular venous pressure, a gallop rhythm, a widely split second heart sound, tricuspid regurgitant murmur, pleural rub, systemic hypotension and cardiogenic shock” (p. 68). Medical practitioners conduct an objective diagnosis of PE through either CT pulmonary angiogram (CTPA) or ventilation-perfusion (V/Q). Diagnostic imaging procedures are associated with high costs necessitating the need to adopt more cost-effective strategies to diagnose PE. The need for cheaper but efficient PE diagnostic pathways has been made all more important by the increasing number of negative tests. The strategies incorporate the use of clinical history and examination and assays to detect D-dimers. Anticoagulation side effects call for medical practitioners to conduct an accurate diagnosis to tailor the PE management plan correctly. BTS Guidelines for the Initial Outpatient Management of Pulmonary Embolism Modern technological advancements and research in the medical field have made it possible to have a deep understanding of therisks associated with various conditions, making it possible to reduce the amount of time elective and non-elective patients spend in the hospital (Howard, 2018). The British Thoracic Society (BTS) Guidelines enable clinicians around the country to categorize suspected and confirmed PE patients depending on their risk index to manage them either in ambulatory care or outpatient (OP) settings (Howard et al., 2018). The guidelines cover Haemodynamically stable adults aged 16 years and above with suspected and confirmed acute PE (Howard et al., 2018). The use of single direct oral anticoagulant (DOAC) to manage suspected PE patients in the OP category and classifying patients into different groups based on their risk scores to identify those suited for the OP management or early discharge (Howard et al., 2018). Included in the guidelines are special groups such as cancer, pregnant, and intravenous drug abuser patients. Grade B patients should be assessed to determine if they are suitable to be managed as OPs (Howard et al., 2018). Management strategies for confirmed PE patients in the low-risk mortality and morbidity category are influenced by the accurate risk identification and stratification to determine whether to place patients under OP or for early discharge. Research Studies According to Zondag et al. (2013), “traditionally, patients with pulmonary embolism (PE) are initially treated with anticoagulants in a hospital setting, with a mean length of hospital stay of 6 days” (p. 135). The American College of Chest Physicians (ACCP) recommend...