Emergency Care Plans Can Save Lives
For individuals who are taking life-saving medications and who require urgent assessment and treatment when ill, emergency care plans can be a key mechanism for sharing medical and medication information with the receiving care team. An incident report shared with ISMP Canada highlights the value of emergency care plans to improve communication among care providers, as well as patients’ health outcomes.
INTRODUCTION
For individuals who are taking life-saving medications and who require urgent assessment and treatment when ill, emergency care plans can be a key mechanism for sharing medical and medication information with the receiving care team. An incident report shared with ISMP Canada highlights the value of emergency care plans to improve communication among care providers, as well as patients’ health outcomes.
INCIDENT DESCRIPTION
A person living with Addison disease was taken to the emergency department (ED) by ambulance because of a brief loss of consciousness and respiratory distress secondary to COVID-19 infection. Upon arrival, they were immediately isolated, as per the institution’s pandemic protocols, and their personal supply of hydrocortisone tablets (intended for regular administration) was stored by staff. The patient provided medical documents; however, a timely review did not occur. The patient could not speak without triggering a painful cough and was therefore unable to explain the need for injectable hydrocortisone (as per the medical document). The patient waited for 20 hours in the ED before being seen by a physician and missed 2 scheduled doses of oral hydrocortisone, as well as the needed emergency dose of injectable hydrocortisone.
Following this experience, the patient did not feel confident that hospital protocols would allow timely care during an adrenal crisis; they felt compelled to manage any future concerns at home. The patient experienced an adrenal crisis 11 more times within the year, and these were treated by calling the specialist and self-injecting hydrocortisone. The community pharmacy team provided clinical guidance when specialists/clinicians were not accessible in the rural region and facilitated access to community-based nursing care.
BACKGROUND
The use of emergency care plans is a key opportunity for improvement in health care. Care plans are useful in both emergency situations and primary care settings to optimize patients’ health and treatment outcomes.1-3
A recent consumer newsletter encouraged patients to request a care plan to ensure continuity of safe and effective care.4
Addison disease is a rare disorder in which the adrenal glands do not produce enough cortisol and, in most cases, aldosterone. Patients with this disease require hormone replacement therapy, such as fludrocortisone or hydrocortisone. In the event of an infection, injury, or missed corticosteroid dose, patients could be at risk for adrenal crisis. Adrenal crisis is a medical emergency that can lead to shock, requiring immediate medical attention, including parenteral administration of hydrocortisone.5
An emergency care plan is a succinct document that sets out the type of support a patient should receive during a health crisis. It can be helpful to guide health care providers who may not be familiar with the patient and their medical condition. Emergency care plans are particularly useful for describing the presentation, implications, and treatment of less common diseases, as well as providing emergency contact information. An emergency care plan is developed by the primary care team, together with the patient and family, and is designed to be carried with the patient at all times. Ideally, the emergency care plan is included in health care information systems.
An emergency care plan can be helpful for patients living with serious medical conditions, including cardiac disease, cancer, mental health disorders, endocrine disease, epilepsy, chronic kidney disease requiring dialysis, chronic obstructive pulmonary disease, metabolic diseases, and bleeding disorders, as well as rare disorders. If sudden illness or injury occurs, such patients may find themselves at an unfamiliar hospital that does not have their health records and treatment plans to guide clinicians. Medical identifiers (e.g., tattoo, necklace, bracelet [Figure 1], wallet card) can be helpful in directing emergency care providers to necessary medical and medication information.
FIGURE 1. An example of a medical identifier bracelet.
DISCUSSION
Triage in the ED
Health care professionals are often challenged to triage incoming patients and prioritize those who need immediate medical attention. They may overlook patients whose conditions do not at first appear to be serious.6 For example, patients in the early stages of adrenal crisis may present with nonspecific signs and symptoms.5 ED staff may be unfamiliar with the risks associated with delayed treatment for suspected adrenal crisis.
Communication during an emergency situation
In an emergency situation, clear and comprehensive communication can be difficult between a patient and the health care team. For example, patients who are experiencing adrenal crisis may be confused or feeling weak and in pain.5 Pandemic-related physical distancing protocols and masking requirements further complicate effective communication and may negatively affect the sharing of information between patients and health care providers.
RECOMMENDATIONS
For primary care providers and specialists
- Develop an emergency care plan for any patient who has a chronic condition that requires specific care and treatment during a health crisis.
- The emergency care plan should include a description of the health condition, potential signs and symptoms, and specific care needed.
- The emergency care plan should be succinct and formatted for ease of reading and access to pertinent information.
- Example templates available from the Canadian Addison Society may be helpful.7
- Include the patient in the development of the emergency care plan to ensure they understand their health needs and can actively participate in their own care.
- Advise the patient to wear a medical identifier (e.g., tattoo, necklace, bracelet, wallet card) and share the emergency care plan with family members and/or caregivers.
- Include the emergency care plan in the patient’s health record at the hospital that they are most likely to visit (e.g., where their specialist works).
For acute care providers
- If an emergency care plan is provided by the patient, ensure it is copied and prominently displayed in the patient’s chart (whether paper or electronic) for use by the care team. Review the emergency care plan as soon as possible to assess the need for prioritized treatment. Promptly seek clarification for unfamiliar health conditions and/or medications described in the plan.
- Following the initial ED visit, for patients requiring immediate care during a health crisis, flag the patient’s chart to signal priority triage each time they present to the ED. This proactive approach can help identify patients in need of immediate attention as soon as they arrive at the ED.
CONCLUSION
There is emerging evidence of the value of care plans for communication in the patient’s circle of care, including family members.1-3 Emergency care plans can signal ED staff to provide vulnerable patients with the timely care they require. Technology supports3 (e.g., electronic templates, patient chart alerts) can facilitate increased use and quality of emergency care plans to promote accurate and timely communication of key medical information.
The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program of Health Canada, the Canadian Institute for Health Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and Healthcare Excellence Canada (HEC). The goal of CMIRPS is to reduce and prevent harmful medication incidents in Canada.
Funding support provided by Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.
The Healthcare Insurance Reciprocal of Canada (HIROC) provides support for the bulletin and is a member owned expert provider of professional and general liability coverage and risk management support.
The Institute for Safe Medication Practices Canada (ISMP Canada) is an independent national not-for-profit organization committed to the advancement of medication safety in all healthcare settings. ISMP Canada’s mandate includes analyzing medication incidents, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives.
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