Finding a manageable approach to create a culture of continuous quality improvement

Do you remember that patient you saw … ?

If you have worked in an emergency department (ED) for more than a few days you have undoubtedly heard those words, and just as surely you have learned to dread them. While sometimes the punchline is “They dropped off chocolates for you,” more often it is something closer to “I saw him the next day with an MI.” And then you begin the process of reviewing the presentation, the care you provided, and the subsequent events to see whether you missed any opportunities for a better outcome.

In 2015 I co-chaired a panel in the Canadian province of Ontario that reviewed health system funding reform and how well the strategy’s goals aligned with the realities of emergency services. Funding reform uses financial incentives to improve cost and quality. We struck a subcommittee to look at incentivizing quality in emergency care, and we quickly focused on the issue of return visits. However, we faced a dilemma; we knew reviews of return visits could readily identify improvement gaps and opportunities, but we also knew the rate itself is a poor quality indicator.[1]

The signal-to-noise ratio is poor because many return visits are planned for early follow-up, or they occur because of normal disease progression. There were reports of unintended consequences in other jurisdictions where readmission rates have been tied to funding, resulting in some providers avoiding higher-risk cases and hospitals being penalized for serving disadvantaged populations. How could we address these challenges?

A solution took shape when one of our committee members shared a paper by colleagues in Ontario.[2] The authors tried to maximize the efficiency of the review of return visits by focusing on patients discharged from the ED on the first visit and admitted on the second, with the latter occurring within 72 hours of the first. They further simplified reviews by having clinical team members screen cases for any potential concerns, and then senior team members performed more detailed reviews of the selected cases. Approximately 12% of the qualifying cases needed secondary review. This seemed like an approach worth supporting.

Another team member had published findings on a similar approach that focused on specific paired presentations: chest pain on the first visit with an acute Myocardial Infarction (AMI) on the second visit; headache followed by sub-arachnoid hemorrhage; and fever/flu-like illness in children followed by sepsis. For this review the authors called these three presentation pairings “sentinel diagnoses,” as all three are often missed on initial presentation, and they used a seven-day window for return rather than 72 hours. We developed a proposal to have hospitals conduct reviews to identify their own adverse events and quality issues, formulate their own quality improvement (QI) initiatives to address the gaps, and provide summary reports.

We verified that we could provide these data to our hospitals but wondered about the tie to funding. A discussion with an ad hoc group of ED directors suggested incremental funding would not be needed to conduct the reviews and write the reports, and that 50 reviews/year would not be onerous, even for smaller sites. Our team recommended the government adopt this program as a requirement of its pay-for-performance program designed to improve ED wait times, and ensure compliance by asking that the report of the year’s chart reviews be submitted to the hospital’s CEO and quality committee and to Health Quality Ontario. (Health Quality Ontario is an agency that advises the provincial government and health care providers on evidence-based care and supports and monitors quality improvement of health care in the province.) We also recommended that Health Quality Ontario establish a working group to review the reports and mine them for trends and tips that would be of interest to all.

Overall, we felt the program—the Emergency Department Return Visit Quality Program—would encourage a culture of continuous QI in our EDs. Since it did not require new funding, the program was implemented in less than a year from the time of our initial report.[3] In addition to the 73 sites whose participation was mandated, a dozen smaller EDs took part voluntarily. We have now completed year two of the program and generated a lot of academic activity. This month’s guest blog by Dr. Jesse McLaren comes from the review of reports submitted in year two and focuses on the sentinel cases where the patients returned with AMIs within seven days of visits for chest pain.

We hope the Emergency Department Return Visit Quality Program will lead to many more publications and stimulate similar work in other jurisdictions. When it comes to return visits the absolute number of cases tells us very little, but a review of high-risk charts can be a gold mine for QI opportunities.


—Dr. Howard Ovens, August 2018



Ten QI opportunities for reducing missed AMIs: Lessons from Ontario’s Emergency Department Return Visit Quality Program

Patients presenting with AMIs are discharged from the ED with a misdiagnosis rate as high as 2%. While this is a relatively small number, AMIs are a leading cause of death, making them a major medico-legal concern. With 20,000 cases of AMI in Ontario in a given year, a 2% miss rate translates into 400 missed cases of AMI, or slightly more than one per day.[4] Rather than dismiss return visits as inevitable or as evidence of individual negligence, a QI framework encourages learning from them—not only to enhance provider education, but also to improve system issues at the local level.

The Emergency Department Return Visit Quality Program (RVQP), which launched in April 2016, aims to foster and enhance a culture of continuous QI in Ontario EDs. In partnership with Health Quality Ontario, the Ministry of Health and Long-Term Care, Access to Care (Cancer Care Ontario), the Institute for Clinical Evaluative Sciences, the Ontario Hospital Association, and Ontario ED physician and nursing leaders, the program creates an efficient way for clinicians to receive data, reflect on their practices, work collaboratively, and find improvement opportunities systematically.

The RVQP’s 2017 evaluation included 175 cases of AMI, of which 85 (49%) resulted in the identification of a quality issue/adverse event as judged by the staff of the facility where the care was provided.[3] These included general themes and AMI–related themes—including education about high-risk patient profiles, protocols for repeating troponins, follow-up protocols, and education and follow-up for patients who leave against medical advice (LAMA).[3] The report on the program’s second year has just been released and explores in greater detail the program’s three sentinel diagnoses (revisits due to AMI, subarachnoid hemorrhage, and sepsis in children following initial visits due to chest pain, headache, and fever or flu-like illness, respectively) and how hospitals are learning from return visits to promote QI.

As a member of the provincial evaluation team I had an opportunity to analyze approximately 240 chart reviews of AMI sentinel cases. In this article I will summarize 10 QI opportunities identified during the RVQP analysis—ranging from education initiatives to protocols to system issues—that local EDs could apply to their specific contexts.


  1. Strategies to minimize Leaving Without Being Seen (LWBS) and Leaving Against Medical Advice (LAMA)

A number of patients with possible AMIs discharge themselves—either leaving without being seen (LWBS) or LAMA part way through their assessments. Contributing factors may include system issues such as ED overcrowding and long wait times to be seen or to receive results. There are opportunities to improve wait times, access to beds, and triage processes to enable the early identification and treatment of AMI.[5]

Many EDs reported they are working to decrease their physician initial assessment times and improve access to monitored beds as strategies to reduce LAMA rates for patients with AMIs. Others said they are working to improve communication with patients, such as explaining wait times, providing a risk/benefit document about LAMA, or identifying patients before they LAMA.


  1. Triage ECG protocol including patients with epigastric discomfort

When a patient presents to the ED with chest pain it is standard protocol for a nurse or ECG technician to perform an ECG and in many cases to draw blood to assess troponin levels. But with the recognition of “atypical” presentations of AMI, especially epigastric pain, some EDs are expanding their medical directives for ECGs to include certain patients with epigastric discomfort (e.g., older patients, those with risk factors).


  1. Physician education on atypical presentations and electronic reminders for high risk patients

AMI has classically been described as exertional chest pressure, and cases that don’t conform to this have been labelled “atypical.” But there is a growing literature questioning this false dichotomy. Large studies have found that one-third of AMI patients experience no chest pain and one in 20 has atypical pain (e.g., pleuritic or reproducible).[6,7] So-called atypical AMI is neither rare nor benign; because AMI without chest pain is more common with age and with comorbidities such as diabetes and congestive heart failure, and because of delays in recognition and treatment, it carries a higher mortality rate.[8] Women have often been described as presenting with atypical symptoms because they are more likely to experience non-chest pain AMI symptoms such as shortness of breath, fatigue, weakness, dizziness, epigastric pain/nausea, or muscle aches—and this likelihood rises and converges among men and women with age. As one author concluded, “our goal should be to standardize ACS symptom presentation and to elucidate the full range of ACS and myocardial infarction symptoms considering the substantial overlap of symptoms among women and men rather than use conventional terms such as ‘typical’ and ‘atypical’ angina.”[9]

The RVQP’s chart review corroborates this view. There were many missed AMI cases that presented with so-called atypical symptoms that fall within the well-documented spectrum of AMI: shortness of breath, epigastric pain/nausea/reflux, weakness/dizziness, and musculoskeletal pain. With this in mind, a number of EDs identified the need to educate their staff around the full spectrum of AMI symptoms, or to issue electronic reminders to patients with coronary artery disease at risk for AMI.


  1. Serial ECG protocol and physician education in ECG interpretation

The ECG is central to the diagnosis of AMI, but it is only a brief snapshot of a dynamic process of ischemia. For this reason the initial ECG is diagnostic only in slightly more than half of AMI cases, making serial ECGs essential.[10] Even if ECGs detect ischemia, they must be properly interpreted—and a significant number of patients discharged from the ED with AMI have abnormal ECGs in retrospect.[11,12]

The RVQP reflects the literature, with a number of cases having only one ECG performed and a few having new abnormalities identified in retrospect—including mild ST elevation, ST depression, inverted T waves, and Wellen’s sign.[13] As a consequence, some EDs are implementing serial ECG protocols to detect dynamic changes, while others are organizing educational opportunities to improve physician interpretation skills.


  1. Repeat troponin protocol including troponins that rise but remain below the diagnostic threshold for AMI

Troponin is also central in the diagnosis of AMI, and like the ECG it is a dynamic marker that can change over time. A number of chart reviews identified the lack of a repeat troponin measurement, and a couple identified challenges in interpreting levels that were rising but remained within the normal range. Some EDs are developing protocols for repeat troponin measurement, while others are revisiting their protocols to include troponins that rise but remain below the diagnostic threshold for AMI.


  1. HEART Score protocol to risk stratify patients for disposition decisions

After a non-diagnostic ECG and negative troponin, most patients presenting with possible AMI are discharged from the ED—some with follow-up in outpatient cardiology clinics. But this practice can miss some patients with unstable angina who are at high risk of AMI and would benefit from expedited tests and inpatient monitoring and management. There are numerous risk stratification tools such as the HEART Score [14] (recently validated in a Canadian ED [15]), which helps stratify patients with chest pain into those at low risk who can safely be discharged and those at moderate or high-risk who would benefit from inpatient consultation.

Similarly, this chart review identified a number of sentinel cases of unstable angina with a moderate or high HEART Score who may have benefited from admission on the index visit. As a result, some EDs are standardizing the HEART Score to risk stratify patients into inpatient or outpatient follow-up.


  1. Improving outpatient clinic access

Not all patients being worked up for cardiac disease can or should be admitted to hospital, and those stratified as low risk for AMI are better managed with timely outpatient follow-up. But this is easier said than done, as some patients are given appointments too far in the future, are lost to follow-up, and/or may be inadequately educated about when to return to the ER. The chart review reflected many EDs at different stages of fine-tuning outpatient follow-up; some are developing urgent cardiology follow-up clinics, clarifying their protocols to confirm appointment time on discharge, improving their clinics to guarantee rapid follow-up, or developing advice sheets to educate patients about when to return if their conditions worsen.


  1. Call-back protocols for ECG discrepancies and LWBS/LAMA patients

While most efforts to reduce missed AMI focus on the index visit prior to discharge, opportunities also exist after discharge. Some EDs have implemented protocols to follow up with LWBS or LAMA patients by telephone—which may identify patients with missed AMI—while others are developing ECG discrepancy protocols and call-backs similar to radiology re-reads.


  1. Collaborative education: Learning from return visits

After an AMI has been missed it is too late to go back in time to prevent it, but it is not too late to learn from the case and try to prevent future misses. Many EDs are working to normalize the discussion of these return visits, remove the associated stigma, and promote a culture of QI in order to learn from return visits and improve, including inter-disciplinary collaboration. Some EDs are using their morbidity and mortality rounds to review missed AMI cases, while others are increasing feedback with internal medicine or cardiology services that jointly managed the patients.


  1. QI dissemination

Missed AMI will continue to be a permanent feature of emergency medicine, but not all cases should be dismissed as inevitable or a consequence of individual negligence. As this review has demonstrated, there are numerous QI approaches that can be used to reduce missed AMI. While each needs to be tailored and implemented locally, lessons from one ED can be shared to inspire others. The RVQP has identified a number of opportunities to improve the care of patients presenting with AMI—from wait times for nursing assessment to physician assessment and follow-up. By analyzing what multiple EDs across the province are doing to examine this specific sentinel diagnosis, we can learn from each other and the broader medical literature to improve patient care.


—Dr. Jesse McLaren is an emergency physician at the University Health Network in Toronto, Ontario, and an assistant professor at the University of Toronto. Follow him on Twitter: @avoidingERrors.


Dr. McLaren and Dr. Ovens have no conflicts of interest to declare.



  1. Barnett ML, Hsu J, McWilliams M. Patient characteristics and differences in hospital readmission rates. JAMA Intern Med. 2015;175(11):1803-1812.
  2. Calder L, Pozgay A, Riff S, Rothwell D, Youngson E, Mojaverian N, et al. Adverse events in patients with return emergency department visits. BMJ Qual Saf. 2015;24(2):142-148.
  3. Health Quality Ontario. The Emergency Department Return Visit Quality Program: Results from the first year. Toronto, ON: Health Quality Ontario; 2017. Available at Accessed 2018 Aug 19.
  4. Schull MJ, Vermeulen MJ, Stukel TA. The risk of missed diagnosis of acute myocardial infarction associated with emergency department volume. Ann Emerg Med. 2006;48(6):647-655.
    Sayah A, Rogers L, Devarajan K, Kingsley-Rocker L, Lobon LF. Minimizing ED waiting times and improving patient flow and experience of care. Emerg Med Int. 2014; article ID 981472.
  5. Sayah A, Rogers L, Devarajan K, Kingsley-Rocker L, Lobon LF. Minimizing ED waiting times and improving patient flow and experience of care. Emerg Med Int. 2014; article ID 981472.
  6. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283(24):3223-3229.
  7. El-Manyar A, Zubaid M, Sulaiman K, AlMahmeed W, Singh R, Alsheikh-Ali AA, et al. Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality. J Cardiol. 2011;57(2):165-171.
  8. Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, et al. Acute coronary syndrome without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2):461-469.
  9. Canto JG, Canto EA, Goldberg RJ. Time to standardize and broaden the criteria of acute coronary syndrome symptom presentations in women. Can J Cardiol. 2014;30(7):721-728.
  10. Welch RD, Zalenski RJ, Frederick PD, Malmgren JA, Compton S, Grzybowski M, et al. Prognostic value of a normal or non-specific initial electrocardiogram in acute myocardial infarction. JAMA. 2001;286(16):1977-1984.
  11. McCarthy BD, Beshansky JR, D’Agostino RB, Selker HP. Missed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study. Ann Emerg Med. 1993;22(3):579-582.
  12. Christenson J, Innes G, McKnight D, Boychuk B, Grafstein E, Thompson CR, et al. Safety and efficiency of emergency department assessment of chest discomfort. CMAJ. 2004;170(12):1803-1807.
  13. Mead NE, O’Keefe KP. Wellen’s syndrome: An ominous EKG pattern. J Emerg Trauma Shock. 2009;2(3):206-208.
  14. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158.
  15. Andruchow J, McRae A, Abedin T, Wang D, Innes G, Lang E. Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay. CJEM. 2017;19(S1):S61-S62.