Evaluation of Interventions Targeting Follow-up Appointment Scheduling After Emergency Department Referral to Ophthalmology Clinics Using A3 Problem Solving

Abstract

Importance: Many patients seen for eye-related issues in the emergency department do not receive recommended follow-up care. Prior evidence supports that scheduling appointments is a barrier to accomplishing the transition to outpatient ophthalmology care. Objective: To evaluate time until appointment scheduling following emergency department discharge with urgent outpatient ophthalmology referral. Design, Setting, and Participants: The A3 problem solving process was implemented by a multidisciplinary team as part of a structured quality improvement program with the goal of reducing the mean time between urgent referral placement in the emergency department and outpatient ophthalmology appointment scheduling. The study was conducted at Stanford Health Care, an academic medical center in Palo Alto, California, affiliated with Stanford University School of Medicine. Using medical center administrative records, all patients discharged from the adult emergency department with an urgent outpatient referral to the Stanford Department of Ophthalmology from August 9 to September 19, 2020 (baseline; n = 43), and from October 26 to November 29, 2020 (after implementation of all interventions; n = 21), were included. Interventions: Interventions developed to target the workflow of the ophthalmology resident, emergency department, ophthalmology clinic, and health system schedulers to address key drivers of the referral-scheduling process included medical record documentation guidelines, identification of responsible parties, preidentified appointment slots, patient education materials, and education of stakeholders, and were implemented by October 25, 2020. Main Outcomes and Measures: Mean time between urgent referral placement (ie, emergency department discharge) and appointment scheduling with outpatient ophthalmology at baseline vs postintervention. Results: At baseline, appointments were scheduled a mean (range) 2.8 (0-7) days after referral placement. In the 5 weeks following implementation of interventions, the mean (range) decreased to 1.3 (0-4) days, a difference of 1.5 days (95% CI, 0.20-2.74; P =.02). This corresponds to 642 (95% CI, 86-1173) days of reduced patient wait time annually. In addition, there was less variability in the number of days between referral and appointment scheduling after intervention compared with baseline. Conclusions and Relevance: The results suggest improvement in efficiency of outpatient ophthalmology appointment scheduling of urgent emergency department referrals could be achieved through application of a quality improvement methodology by a multidisciplinary team representing key stakeholders in the process.