Advocate Sherman Hospital

Presentation Notes

Quality Improvement poster presented at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: Sherman Emergency Department (ED) is seeing a change in population that includes larger volumes of patients over the age of 65 who suffer falls while being treated with a medication that impacts coagulation (Coumadin, Brilanta, Xaralto, Aspirin etc.). This patient population is required to be reported on at a State level during regional trauma meetings that are held quarterly.

Sherman ED had been underperforming in meeting target of 120 minutes from arrival to reversal. An RCA was conducted, and it was found that a well identified process was not in place resulting in inconsistent reversal times and gaps in care. It was decided that a streamline process needed to be created to better serve these patients with early identification and intervention with reversal agents to decrease risk of morbidity and mortality.

Local problem: Data collection from the first 3 months of 2021 supported inconsistences in reversals times average reversal was 164 min. with longest >200 min.

Data collection continued monthly with continued review of process and interventions put into place. Department now supersedes target with last quarter (Q1 2022) data 93 min. from arrival to reversal.

Method: PDSA was the methodology used to initiate the QI project and ensure sustainability. Data was collected using internal daily audits of ACT alert initiation. Team members included, Trauma Coordinator, bedside nursing, ED Physician, Trauma Surgeon. Partnership included radiology, telecom, and pharmacy.

Results/Conclusions: Since the initiation of the ACT Alert process at Sherman Hospital we have seen continued improvement in reversal times. Since Q2 2021 we have decreased our time from arrival to reversal agent administration by 70 min. which is a 40% decrease.

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