Article Title

Lessons Learned in Developing and Implementing the ED-PACT Tool: An Innovation Supporting Communication of Care Needs After Emergency Department Visits

Publication Date



technology adoption and diffusion, VA health system, dissemination and implementation of innovations, technology assessment, quality improvement


Background: Communication failures between providers represent a threat to patient safety. Despite the importance of timely receipt of recommended post-emergency department (ED) care, up to two-thirds of patients discharged from EDs do not receive recommended post-ED care. The ED-PACT tool uses the electronic health record to send messages from Veterans Health Administration ED providers to nurse care managers of patients’ VA Patient-Aligned Care Team (PACT) when patients are discharged home from the ED with an urgent or specific follow-up need. We developed, piloted and formatively evaluated the spread of this tool at VA Greater Los Angeles Healthcare System (VAGLAHS).

Methods: Before implementation, we assessed readiness to participate in the innovation with leadership interviews and nurse care manager questionnaires. During deployment, we used audit and feedback to monitor adherence with correct use of the tool. We logged all user feedback, tracked all failures (ie, PACT nurse not acting on message) and their causes, and used run charts to assess for weekly variations in failures. We audited a random sample of 150 messages to capture types of care needs for which messages were sent. We interviewed leaders in three clinics about perceptions of usability and value, and implementation facilitators and barriers.

Results: Between November 1, 2015, and May 31, 2016, the ED-PACT tool was used to send 1,350 messages from the VAGLAHS ED to 35 PACT teamlets across 5 primary care clinics. Care needs included: symptom recheck (55%), care coordination (16%), wound care (5%), medication adjustment (5%), laboratory recheck (5%), radiology follow-up (3%), and blood pressure recheck (3%). On average, nurses successfully acted on 91% of messages (weekly range: 72%–100%). Reasons for failure included human error, staffing shortages and technical errors. Interviews with clinic leaders revealed that the ED-PACT tool is perceived to provide substantial benefit for coordinating post-ED care by effectively communicating with patients’ PACT nurses. Leaders also reported nurse training and “buy-in” facilitated implementation, whereas insufficient staff posed a barrier.

Conclusion: The ED-PACT tool facilitates communication between providers during a vulnerable care transition. Deployment of similar tools should include attention to the organizational, human and technical factors revealed by our evaluation.




June 28th, 2017


August 10th, 2017