1. Rush University
College of Nursing
Examination of Care in Patients with
Intellectual Disabilities in the Emergency
Department:
Creation and Conduction of a Mock Tracer
Keren Talor and Renee Sandusky

2. Introduction
The management of care of individuals with intellectual disability (ID) can prove a difficult task
in healthcare settings, with the emergency department (ED) posing an additional challenge
given the critical, time-sensitive nature of care provided.
● Patients with ID are more likely to frequent EDs than patients without ID (Lunsky, 2010)
● Patients with ID have difficulty communicating needs (Iacono et al, 2014)
● Nurses have expressed non-confidence in their ability to provide adequate treatment
(Iacono et al, 2014; Sowney & Barr, 2006)
Tailoring nursing care to manage patients with ID is essential to delivering optimal care and
providing appropriate interventions. A tracer, an evaluation tool used to detect gaps in
systemic patient care, will be applied to the ED at RUMC.

3. Mock Tracer
WHAT IS A TRACER?
● Surveying tool
● Method used to evaluate gaps in systemic patient care
● Utilized in healthcare organizations to identify compliance and patient
safety issues prior to official evaluations by regulatory commissions and
agencies
● Highlights deficits in level and consistency of care
● Identifies areas of future focus

4. ● Patients with ID have greater health care needs
● High-end users of EDs in lieu of primary care
● Needs often go unmet
● Increased complexity in provision of primary health care
● Challenges lead to increased difficulty assessing patient’s baseline of
functioning vs syptomoatic behaviors
● Patients with ID require increased health care provider time
(Iacono, Bigby, Unsworth, Douglas, & Fitzpatrick, 2014; Sowney, Brown, & Barr, 2006)
Review of Literature

5. cont
Communicative Impairments
● Effective communication - Most challenging aspect in care of patient with ID
● Communicative Impairments - Up to 90% of patients affected
● Difficulty interpreting internal cues
● Difficulty articulating cues and needs
● Impacts
● Assessment
● Informing patients of status
● Seeking consent (Blair, 2012; Nakken & Vlaskamp, 2007; MENCAP, 2007)
Review of Literature

6. Microsystem Analysis
● 55,000+ annually
● Full range of needs
● 60 private rooms
● 3 Pods:
● A: Triage
● B: Critical care
● C: Peds/Obs
● Psych rooms
Leadership:
● Unit Director: Patricia
Altman
Communication:
● Morning huddle
● Direct verbal exchange
● Customized Epic
format
● Cell phones/pagers
● Emergency Severity
Index (ESI)
Interdisciplinary
Teamwork:
● Physicians, nurses, and
support staff
System:

7. Problem Identification
In the United States, intellectual disability is prevalent in only a small percentage of the
total population.
However, several recent articles have highlighted that this small population
● Reports higher rates of comorbidities
● Engages in a remarkably increased rate of emergency room visits with noted
greater difficulties in
■ Communication
■ Comprehension
■ Navigation of the health care system
Lack of studies analyzing the quality of care in patients with ID within the ED setting
(Ervin, Hennen, Merrick, & Morad, 2014; Iacono, Bigby, Unsworth, Douglas, & Fitzpatrick, 2014; Lunsky et al., 2011; Merrifield, 2011; Sowney, & Barr, 2007; Williamson, Flowers, & Cooke, 2012)

8. Logic Model
Administration
Providers
Epic
Committees
Design tracer
Conduction of
mock tracer
Obtainment of
data
Evaluation of
tracer results
Determination of
gaps in patient
care
Address gaps in
care
Achieved via
inservices,
training, etc.
Improved care of
patients with ID
in the ED based
upon
improvements in
gaps of care
identified

9. Develop and conduct a mock tracer specific to:
● Patients with ID
● Patients in RUMC ED
● Care provided
● Gaps in care
● Barriers
● Continuity of care
● Guardianship
● Transfers
● Discharge
Evidence-Based Intervention

10. 45 questions
● Yes/No and
qualitative
Topics:
● Triage
● Decisions of Care
● Nursing Care
● Transitions of Care
● Discharge
Design based on:
● Joint Commission
● Previously
conducted tracers
● Current research
● Content expert
Evidence-Based Intervention

11. Mock Tracer

12. Mock Tracer

13. Mock Tracer

14. Mock Tracer

15. Data Collection
Conducted on March 12, 2015 at RUMC in the ED
Team consisting of
● GEM students
● Dr. Ailey
● ED unit director
● Social worker
● 2 staff RNs

16. Data Collection
Conducted on March 12, 2015 at RUMC in the ED
Chart audit Interviews

17. Key Findings
Strengths
● Experienced staff
● Excellent care provided to special needs patients
● Excellent crisis management skills
● Impressive understanding on guardianship
● Strong stakeholder support
1st
Place

18. Key Findings
Areas for Improvement
● Ambiguity of diagnosis and terminology
● Lack of confidence in providing care
● Time constraints
● Lack of thorough and consistent documentation
● Lack of post discharge community resources

19. Cost
The development and conduction of the mock tracer was
accomplished at minimal financial cost. Generation of the tracer by
nursing students completing a capstone project, with overseeing
guidance from faculty, mitigated any potential financial costs
associated with the production of salaried work.
Non-financial costs associated with the conduction of the tracer
included the allocation of time on the part of staff in the ED at
RUMC.

20. Recommendations
● List of community resources
● Enhance knowledge and education about this population
■ Annual Competency
■ Effective Communication
■ Documentation
● Additional time
● Clarify definition
● Caregiver Familiarity
● Seek additional assistance
■ Utilization of social worker, child-life therapist, interpreter

21. Conclusion
Findings at RUMC - ED aligned with current literature
Implementation of suggested interventions can result in:
 Improved level of provided care
 Increased patient safety
 Enhanced provider confidence
 Increased patient satisfaction

22. Rush University
College of Nursing
Content Expert
Dr. Sarah Ailey

23. Questions?

24. References
Blair, J. (2012). Caring for people who have intellectual disabilities. Emergency Nurse, 20 (6), 15-19.
Bradbury-Jones, C., Rattray, J., Jones, M., & MacGillivray, S. (2013). Promoting the health, safety and welfare of adults with learning disabilities in acute
care settings: a structured literature review. Journal of Clinical Nursing, 22, 1497–1509.
Ervin, D. A., Hennen, B., Merrick, J., & Morad, M. (2014). Healthcare for persons with intellectual and developmental disability in the community.
Frontiers in Public Health, 2 (83), 1-8.
Gaskell, S., & Nightingale, S. (2010). Supporting people with learning disabilities in acute care. Nursing Standard, 24(18), 42-48.
Hirschman, K.B., Paik, H.H., Pines, J.B., McCusker, C., Naylor, M.D., Hollander, J.E. (2011). Cognitive impairment among older adults in the
Emergency Department. Western Journal of Emergency Medicine (12), 56–62.
Iacono, T., Bigby, C., Unsworth, C., Douglas, J., & Fitzpatrick, P. (2014). A systematic review of hospital experiences of people with intellectual
disability. BMC Health Services Research, 14, 1-8.
Lin, J., Yen, C., Loh, C., Hsu, S., Huang, H., Tang, C., et al. (2006). A cross-sectional study of the characteristics and determinants of emergency care
utilization among people with intellectual disabilities in Taiwan. Research in Developmental Disabilities, 27, 657-667.
Lunsky, Y., & Elserafi, J. (2011). Life events and emergency department visits in response to crisis in individuals with intellectual disabilities. Journal Of
Intellectual Disability Research, 55 (7), 714-718.
Lunsky, Y., & Gracey, C. (2009). The reported experience of four women with intellectual disabilities receiving emergency psychiatric services in
Canada. Journal of Intellectual Disabilities, 13 (2), 87‒98.
Lunsky, Y., Gracey, C., & Gelfand, S. (2008). Emergency Psychiatric Services for Individuals With Intellectual Disabilities: Perspectives of Hospital Staff.
American Association on Intellectual and Developmental Disabilities, 46 (6), 446-455.
Lunsky, Y., Lin, E., Balogh, R., Klein-Geltink, J., Bennie, J., & Wilton, A. (2011). Are adults with developmental disabilities more likely to visit EDs? The
American Journal of Emergency Medicine, 29 (4), 463 - 465.
Lunsky, Y., Lin, E., Balogh, R., Klein-Geltink, J., Wilton, A., & Kurdyak, P. (2012). Emergency Department Visits and Use of Outpatient Physician
Services by Adults With Developmental Disability and Psychiatric Disorder. Canadian Journal of Psychiatry, 57 (10), 601-607.

25. References
MENCAP. (2007). Death by indifference. Retrieved from: https://www.mencap.org.uk/death-by-indifference
Merrifield, J. (2011). Meeting the needs of people with a learning disability in the emergency department. International Emergency Nursing, 19 (3),
146-151.
Rush University Medical Center (n.d.a). Emergency department. Retrieved from: https://www.rush.edu/services/emergency-department
Sowney, M., & Barr, O. (2006). Caring for adults with intellectual disabilities: perceived challenges for nurses in accident and emergency units. Journal
of Advanced Nursing, 55 (1), 36-45.
Sowney, M., & Barr, O. (2007). The challenges for nurses communicating with and gaining valid consent from adults with intellectual disabilities within
the accident and emergency care service. Journal Of Clinical Nursing, 16 (9), 1678-1686.
Sowney, M., Brown, M., & Barr, O. (2006). Caring for people with learning disabilities in emergency care. Emergency Nurse, 14 (2), 23-30.
The Arc. (2015). Intellectual disability. Retrieved from: http://www.thearc.org/learn-about/intellectual-disability
The Joint Commission. (2010). The Joint Commission: Advancing effective communication, cultural competence, and patient- and family-centered care:
A roadmap for hospitals. Retrieved from: http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf
The Joint Commission. (2012). The Joint Commission Survey (Part 1): Maximizing Tracer Activities – A Dialogue with Surveyors. Joint Commission
Resources Quality & Safety Network Resource Guide. Retrieved from: http://www.jcrqsn.com/docs/resource_guide/demorgjune2012.pdf
Venkat, A., Pastin, R., Hegde, G., Shea, J., Cook, J., & Culig, C. (2011). An analysis of ED utilization by adults with intellectual disability. American
Journal of Emergency Medicine, 29, 401–411.
Williamson, T., Flowers, J., & Cooke, M. (2012). Quantifying emergency department admission rates for people with a learning disability. Emergency
Medicine
Journal, 29 (9), 771-772.