Saskatoon Health Region is great at admitting people to hospital.  Where we struggle, according to Jason Shand, Emergency Room Nurse Clinician at Royal University Hospital (RUH), is the communication that follows once the patient is admitted.

Shand compares the situation to driving a car.

“You’re in the car, you’re going very quickly, you’ve gotten to that point, we’ve got them admitted and then we stop,” he says. “There’s not a lot of information sharing about what the patient’s plan of care is.”

That’s why Shand is excited about the work Team Five has been doing during the Better Every Day 14 Day Challenge.

The team involved in this work, consisting of a nurse, a physician, a physiotherapist and a pharmacist, has developed what they are calling an Initial Integrated Plan of Care Form to bring care providers from the emergency room and the Clinical Teaching Unit team together at the same time.

Two people look at a form

Gaylene Molnar (left) and patient advisor Mickey Booth discuss the form in the ER.

The goal is that each patient admitted to a Clinical Teaching Unit team in the emergency room at RUH has an initial plan of care developed right in the emergency room that will follow the patient up to the Clinical Teaching Unit.

“Previously, there was no single plan of care,” explains Gaylene Molnar Director, Nursing Practice and Education and Care Delivery and Review Design. “The physician had a plan of care, the nurse had a plan of care, physiotherapy and pharmacy had their own plans of care. With this, they all still do their own assessments, but they are brought together so that everyone, including the patient and their family, is aware of the care needs and goals to provide the best outcome for the patient.” This work starting in the emergency department is the first baby step to beginning a single patient plan of care.

The new Care Form (below) also delves a little deeper into a patient’s situation and history. By getting a better understanding of issues such as a person’s living situation, mobility, and cognition, care providers can create a better, more comprehensive plan.RR-2015-02-11-plan-of-care-form-2

“Traditionally, we haven’t always gathered a great functional patient history,” says Molnar. “Mobility and cognitive status are the two biggest factors that make people unable to go home after admission, so if we can get a baseline right away in the emergency room, it will better impact a patient’s outcomes in the long term.”

Patient advisor Mickey Booth says the work the team is doing is a game changer.

“From the patient’s point of view, the biggest frustration for a patient, especially in the emergency department is a lack of information,” she says. “Now with this, it’s going to be so comforting for patients and families because they know that this has been set in place for either themselves or their family members and they aren’t stuck in no-man’s land. The care is starting at ground zero.”

Shand agrees. ”I’m really just so excited about how this going to benefit the patient,” he says. “We’re going to have more information for the patient to let them know what is going on and it’s going to make our work easier because we’re going to have more bang for the buck for the patient because that’s who we’re focused on here.”

The form is currently on its fourth revision and is continually being improved upon based on feedback by those who are using it.

For more stories and information about the Better Every Day 14 Day Challenge, visit