Engineering Safe Care Journeys for Vulnerable Older Adults

Principal Investigator: Maureen Smith, M.D., M.P.H., Ph.D., University of Wisconsin, Madison, WI; formerly Pascale Carayon, Ph.D., University of Wisconsin, Madison, WI
Co-PI: Nicole E. Werner, Ph.D., Indiana University - Bloomington, Bloomington, IN
AHRQ Grant No.: HS26624
Project Period: 09/30/18-07/31/23
Description: The overall goal of this lab was to provide older adults with a safe journey in the emergency department (ED) by developing a system of care that provides opportunities to detect and recover from errors, anticipate patient safety issues in subsequent steps of the journey, and improve communication and coordination.

The specific aims were to:

1. Analyze, design, develop, implement, and evaluate a system of care (identified as the patient safety passport) that supports the safe journey of older adults after ED presentation.
2. Develop a transdisciplinary PSLL to engineer safe care journeys for vulnerable patients, including older adults.

The lab’s transdisciplinary team of engineers, health services researchers, nurses, physicians, and pharmacists collaborated with a health system composed of academic and community EDs. They process mapped older patients’ journey in the ED and identified barriers and facilitators of these processes, disposition decision making, and care transitions.^1-4 

This research led to the development of a “patient safety passport.” Like a passport to travel between countries, the patient safety passport is “checked” at each transition point and facilitates recognition and anticipation of older adults’ specific safety needs. 

The passport consists of three interventions^1,5: 

• The ED discharge intervention targets the journey from the ED to home and includes four components: medication self-management, patient care plan, followup, and red flags.
• The ED-to-skilled nursing facility (SNF) antibiotic stewardship intervention automatically identifies older adult SNF residents who present to the ED. This intervention triggers a series of actions aimed at increasing communication between the ED and skilled nursing facility to improve antibiotic stewardship for older adults with a suspected urinary tract infection. It includes feedback loops with direct communication to the nurse practitioner regarding culture results and a mechanism for the nurse practitioner to follow up with the health system regarding the outcome of the antibiotic prescribed.
• The patient journey map intervention is designed for patients and caregivers during the ED visit. It is divided into three segments that represent different stages in the patient’s ED experience: intake and triage; assessment, diagnosis, and next steps; and discharge.

Challenges during the COVID-19 pandemic impacted the lab’s data collection and resulting interventions, complicating its ability to interpret comparisons with data collected before the onset of the pandemic.^1,3 However, the ability to continue the project after the height of the pandemic’s social distancing measures meant that the lab could account for system changes in patient safety passport interventions. 

Overall, the lab’s findings from this work have provided a foundation to inform future work on patient safety during the patient ED journey. Efforts include multiple doctoral dissertations, conference panels and presentations, and additional projects from collaborations among patient safety learning lab team members.¹

To date, this PSLL’s work has resulted in at least 16 peer-reviewed publications, with 224 citations in other publications, as well as posters and presentations at conferences across the United States.

Publications

2024

• Wust KL, et al. Older adult patients and care partners as knowledge brokers in fragmented health care. Hum Factors 2024;66(3):701-713. 

2023

• Barton HJ, et al. Evaluating the usability of an emergency department after visit summary: staged heuristic evaluation. JMIR Hum Factors 2023 Mar 9;10(1):e43729.
• Hoonakker PL, et al. Satisfaction of older patients with emergency department care: psychometric properties and construct validity of the consumer emergency care satisfaction scale. J Nurs Care Qual 2023 Jul-Sep;38(3):256-263.
• Rutkowski RA, et al. A scoping review of work system elements that influence emergency department disposition decision-making. Hum Factors Health 2023 Dec;4:100059.
• Wust McBroom K. Collaboration Between Older Adults and Clinicians in the Emergency Department: Role of the Complex Sociotechnical Systems. University of Wisconsin - Madison ProQuest Dissertations & Theses, 2023.  https://www.proquest.com/openview/49a67825fff0bc6c6a2cba129fc1d33e/1?pq-origsite=gscholar&cbl=18750&diss=y.

2022

• Hoonakker PLT, et al. A systematic review of the consumer emergency care satisfaction scale (CECSS). J Nurs Care Qual 2022 Oct-Dec;37(4):349-355.
• Rutkowski RA. A Sociotechnical Systems Approach to Disposition Decision-Making in the Emergency Department for Older Adults. Doctoral dissertation, University of Wisconsin-Madison; 2022.
• Wust K, et al. SEIPS-based patient journey mapping: application to a patient visit in the emergency department. Proc Hum Factors Ergon Soc Annu Meet 2022 Sep;66(1):848:852.
• Xiao Y, et al. Patient safety learning labs: effective collaborations for enhanced patient safety. Proc Hum Factors Ergon Soc Annu Meet 2022 Sep;66(1):1581-1585.

2021

• Li J, Carayon P. Health care 4.0: a vision for smart and connected health care. IISE Trans Healthc Syst Eng 2021;11(3):171-180.
• Werner NE, et al. Disparate perspectives: exploring healthcare professionals’ misaligned mental models of older adults’ transitions of care between the emergency department and skilled nursing facility. Appl Ergon 2021 Oct;96:103509.
• Zhu W, et al. Reducing fall-related revisits for elderly diabetes patients in emergency departments: a transition flow model. IEEE Robot Autom Lett 2021 Jul;6(3):5642-5649. Epub 2021 May 19.

2020

• Rutkowski RA, et al. Physician perceptions of disposition decision-making for older adults in the emergency department: a preliminary analysis. Proc Hum Factors Ergon Soc Annu Meet 2020 Dec;64(1):648-652.
• Salwei ME, et al. Identifying roles in older adults’ emergency department transitions. Proc Hum Factors Ergon Soc Annu Meet 2020 Dec;64(1):685-689.
• Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA 2020; 324(24):2481-2482.
• Zhu W, et al. A Markov chain model for transient analysis of handoff process in emergency departments. IEEE Robot Autom Lett 2020;5(3):4360-4367.

References

1. Smith M. Final Report: Engineering Safe Care Journeys for Vulnerable Older Adults. Bloomington, IN: University of Indiana; 2024, pp. 1-30.
2. Rutkowski RA, et al. Physician perceptions of disposition decision-making for older adults in the emergency department: a preliminary analysis. Proc Hum Factors Ergon Soc Annu Meet 2020 Dec;64(1):648-652.
3. Werner NE. Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults. Madison, WI: Univeristy of Wisconsin-Madison; 2021, pp. 1-55.
4. Werner NE, et al. Disparate perspectives: exploring healthcare professionals’ misaligned mental models of older adults’ transitions of care between the emergency department and skilled nursing facility. Appl Ergon 2021 Oct;96:103509.
5. Wust K, et al. SEIPS-based patient journey mapping: application to a patient visit in the emergency department. Proc Hum Factors Ergon Soc Annu Meet 2022 Sep;66(1):848-852.