Emergency Strategic Clinical Network

• The Emergency Strategic Clinical Network (ESCN) connects patients, staff and physicians at Alberta’s 103 emergency departments and 6 urgent care centres.

• The ESCN works to align care with patient needs, translate evidence into practice and develop new evidence where none exists.

• Since 2012, the ESCN has engaged in projects such as standardized training, integrated care pathways and research to improve care for vulnerable populations.

• Challenges encountered so far include time and resource pressures within emergency departments, change fatigue at the front lines and lack of authority to change clinician practice.

Alberta’s population is aging,1 and this increases the need for complex emergency care. Since 2005–2006, emergency department spending in Alberta has grown by an average of 7.5% per year, with a lower percentage change of 4% over the last 5 years.2 Continued growth in spending is not sustainable, but opportunities for continued improvement exist. Greater efficiencies may be gained by aligning clinical practice across the province with best evidence. Alberta Health Services (AHS) established the Emergency Strategic Clinical Network (ESCN; www.ahs.ca/escn) in 2013 to advance health system innovation and improvement in emergency care.

The ECSN identifies gaps, prioritizes areas for improvement, strategically aligns care with the needs of patients and front-line providers, translates evidence into practice and develops new evidence where none exists.3 To achieve these goals, the network connects with patients, staff and physicians in the 103 emergency departments and 6 urgent care centres across Alberta.

To facilitate collaboration on a provincial scale, the network is guided by a core committee comprising patient and family advisors, government representatives, nurses, pharmacists, physicians, paramedics, administrators, researchers and planners. The network’s priorities, projects and products are developed with the input of the committee and working groups that support specific areas of work. For example, the Operations Working Group meets monthly and brings together emergency department clinicians, administrators, managers and educators from diverse parts of the province to address day-to-day issues (e.g., opioid crisis and overcrowding in emergency departments). Other important structures of the network include the Data and Performance Measurement Working Group, Education Working Group and Research Advisory Board. The data group develops standardized reporting of data across Alberta to support emergency department leads with planning and program development. The Education Working Group brings together Clinical Nurse Educators provincially and supports standardized training for nurses working in emergency departments. The Research Advisory Board, comprising academics and clinician scientists, provides advice on enhancing the emergency care research environment in Alberta.

Patient and family advisors serve on network committees and working groups, and broader patient and family engagement is achieved through focus groups and surveys. The Patient Experience project works closely with patients to develop patient-facing materials including a patient journey map and way-finding signage. The ECSN has 4 strategic directions aligned with the organizational goals of AHS (see figure). These goals reflect the need for a balanced approach to addressing health outcomes, costs, patient experiences and working environments for clinicians to ensure health system improvement. The network’s strategic directions recognize that research, partnerships, responding to patient needs and ensuring that staff in emergency departments have what they need to do their jobs are important to achieving AHS’ goals within emergency care.

The network has made it a priority to develop knowledge translation materials and harmonize provincial policies to standardize care across the province.3 Seventeen provincial policy documents have been developed, with 20 more in progress (15 new and 5 revisions), as well as 60 clinical order sets. Education efforts for clinicians are also key to harmonizing care. The Emergency Nursing Provincial Education Program offers new nursing staff a standardized orientation to the emergency department.4 The program provides robust training to small emergency departments with no dedicated educational infrastructure, improves consistency across sites and reduces duplication of training efforts. Between June 2012 and August 2019, 3421 newly hired staff completed the program, and 2349 existing staff registered to receive the training as part of ongoing professional development.

Strategic directions of the Emergency Strategic Clinical Network (ESCN).

Image courtesy of Alberta Health Services

The ESCN also supports evidence-informed change in practice by providing new channels for clinical practitioners to access and share information. For example, the network organized a Quality Improvement and Innovation Forum in 2019 in which 32 teams from emergency departments across Alberta presented quality-improvement projects. The ESCN also commissioned the Emergency Care Premium Literature Service, an open resource that provides its 485 current registered users with summaries of noteworthy academic articles relevant to emergency medicine practice.5

Since launching, the ESCN has worked to develop the evidence base for emergency care, and build capacity for local research in emergency medicine, by funding researchers. To date, the network has funded 36 undergraduate summer students and 13 systematic review projects through peer-reviewed grants. Funding by ESCN has also supported 23 journal publications, which helped to lay the groundwork for larger initiatives (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190591/-/DC1). For example, a funded review on children’s mental health6 enabled a trial of a new model of coordinated mental health and addictions care for children presenting to emergency departments.7

Work is also underway to improve care for other underserved populations who frequently access emergency services, including research focusing on quality of care in emergency departments for patients who are First Nations. This work is co-led with First Nations partners, including the Alberta First Nations Information Governance Centre, Tribal Councils and Nations.8

Other projects include efforts to coordinate care for residents in long-term care facilities using a centralized transfer pathway and community paramedics,9 and a province-wide initiative to better serve patients living with opioid use disorder. Support for the opioid response work has been strong across Alberta. As of August 2019, it operates in 39 emergency departments with plans to expand across the province over the next 8 months. The project involves starting evidence-based treatment with buprenorphine/naloxone for eligible patients and providing next-business-day walk-in referrals to addiction clinics in the community. Evaluation of the project uses administrative data to track the number of patients started on the medication, attendance rates at follow-up appointments and prescription filling after initial treatment in the emergency department. Alberta Health Services has reported preliminary results,10 and the ESCN is ensuring transparent reporting of evaluation methods alongside results through formal publication.

The ESCN’s projects depend on the network’s members being passionate about emergency care, and also on its strong and respected research network. Some challenges have posed barriers to success. Alberta Health Services is a large organization with many areas of activity and authority. The ESCN must compete for clinicians’ and administrators’ time and resources. It does not have operational authority within Alberta’s emergency departments. Therefore, it is essential that the network provides convincing data and evidence for its projects to gain the support of emergency department clinicians and administrators. Ensuring relevance of the ESCN to local contexts is challenging given Alberta’s geography, the mix of rural and urban emergency departments, change fatigue at the front lines, lack of authority for the network to change clinician practice and no research focus at most sites.

With 7 years’ experience as part of Alberta’s health system, the ESCN is well-positioned to address existing and emerging challenges. Over the next 3 years, the network anticipates substantial involvement in the implementation of Alberta’s new provincial clinical information system. Through its projects, the ESCN will continue to work toward greater coordination between emergency care and community-based health services.