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Quality Improvement and Public Health - Tetanus Immunization in the Emergency Department

Department of Emergency Medicine and the Quality Improvement Research Group, Reston Hospital Center, Reston, Virginia

Donna Alvis, R.N.

Department of Emergency Medicine and the Quality Improvement Research Group, Reston Hospital Center, Reston, Virginia

Eric Silfen, M.D.

Department of Emergency Medicine and the Quality Improvement Research Group, Reston Hospital Center, Reston, Virginia

The administration of tetanus toxoid vaccine to both adults and children represents an often ne glected, but medically necessary procedure for pa tients who receive traumatic injuries to nature's nat ural surface barrier, the skin. While performing ret rospective chart reviews, the collaborative practice environment fostered in the Emergency Department at Reston Hospital Center, (wherein the physician and nursing staff are schooled in Deming's Quality Improvement-FOCUS-PDCA-methodology, and the concepts of "patient care clinical process ownership," and "professional job enlargement and job enrich ment" diffuse throughout the Emergency Services Systems design), identified a potential problem with tetanus immunization related to existing standing or ders. Initial data collection utilized count-between methodology. Over a 31-day period, 216 patients who required tetanus immunization were identified . Ap propriate tetanus toxoid administration was "missed" 20 times, with a median of 9 appropriate tetanus immunizations before an administration was "missed." Flow chart analysis of the tetanus toxoid administra tion process identified the sources of variation of that process. A pilot PDCA cycle was instituted to redefine the process, control the variability, and measure the results. Upon completion of the third PDCA cycle of 31 days, 367 patients were identified who required tetanus immunization. Appropriate tetanus toxoid ad ministration was "missed" 3 times with a median of 120 appropriate tetanus immunizations before an ad ministration was "missed." Conclusions include: a) The appearance of special cause variation, (disaster situations), must be recognized as having the potential to disrupt healthcare process improvements. b) Sim plicity of process, staff clinical education, concepts of "patient care clinical process ownership," "profes sional job enlargement, and job enrichment," and a high level of patient education and awareness of the need for tetanus immunization resulted in the noted improvement. c) Significant health care improve ments can be achieved using Quality Improvement methodology.

American Journal of Medical Quality, Vol. 9, No. 4, 165-171 (1994)
DOI: 10.1177/0885713X9400900407


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