Evidence Based Practice and Applied Nursing Research

Nursing practice continues to make encouraging progress in the delivery of essential services to patients. Investment in research is among the factors driving this progress. Researchers continue to explore various strategies that nursing practitioners can adopt as they seek to improve the quality of care that they offer to patients. While the growth that the profession has witnessed is encouraging and should be celebrated, serious problems remain. The unacceptable long waiting times at the emergency department are among the major problems that require urgent solutions. Research has revealed that if not addressed properly, this problem will continue to hurt patient outcomes.

Healthcare Problem 

The long waiting times that patients face at the emergency department is the problem that needs to be addressed. It has been observed that despite the severity of their conditions, patients are forced to wait for long hours. Stakeholders in healthcare recognize that the long wait times pose a serious threat to the wellbeing and health of patients. This is why they have implemented a range of initiatives that include challenging nurses to embrace teamwork. Research findings show that these initiatives have had some positive effect on such measures as patient satisfaction and wellbeing (Shen & Lee, 2017). However, the fact that patients continue to wait for long hours before receiving much-needed treatment can only mean that these initiatives are inadequate. More needs to be done.

Significance of the Problem 

The ill effects that long wait times have on patient health and wellbeing are what make this problem significant. One of the impacts that being made to wait for long hours has on patients concerns quality of care. Patients who wait too long find their experience to be unsatisfactory and are more likely to rate their experience as poor (Shah et al., 2015). The failure to meet the needs and expectations of these patients erodes trust and confidence in the medical community. If they are truly committed to safeguarding the reputation of the profession, medical practitioners need to take action with nurses being in the lead.

The significance of the problem of the long wait times goes beyond diluting the patient experience. In addition to denying patients the opportunity to experience quality care, the long wait times also leads to crowding and exhausts a facility’s resources and capabilities (Sayah et al., 2014). Essentially, when patients wait for hours before being attended to, an overcrowding problem which underscores the limited capacity of a facility arises. The long wait times are often symptomatic of larger underlying issues that a facility faces. For example, it could be that the facility is understaffed or that its protocols are not designed efficiently to allow for patients to receive treatment quickly.

The primary goal of any healthcare practitioner is to safeguard the health of patients. Long waiting times make it difficult for the practitioners to accomplish this goal. It has been noted that there are patients whose situations worsen as they await treatment and in more serious cases, death occurs (Barata et al., 2015). Patients who require services at the emergency department often present with life-threatening conditions and illnesses. To improve their situation, practitioners need to provide adequate, high-quality and urgent care. The long hours that the patients have to wait makes it nearly impossible for them to receive the proper care that they need.

Relevance to 2020 Goals 

In order to understand the urgency with which the problem discussed above should be addressed, it is important to link it to the Healthy People 2020 goals. These goals capture the vision of the American government regarding the delivery of healthcare services to citizens. Improving safety with the objective of safeguarding human health is one of the goals (Hesse et al., 2014). As revealed through the discussion above, the long wait times expose patients to great harm. By reducing the amount of time that patients have to wait before receiving treatment, the medical community will be bolstering government efforts to achieve the Healthy People 2020 goals. Making it possible for American to lead long and healthy lives is another goal that reducing waiting times will help to accomplish. The long waiting times are responsible for complications and deaths at emergency departments across the nation. When practitioners institute measures to minimize waiting times, they will create a climate that enhances the quality of life, thereby inching the country closer to attaining the Healthy People 2020 goals.

Current Practice 

As noted earlier, there are various strategies and initiatives that practitioners implement as they seek to reduce the wait times at the emergency department. Triage is one of the strategies that are currently in use (Shen & Lee, 2017). Essentially, this practice involves prioritizing patients based on the severity of their condition. Patients who are in desperate need of care receive treatment first. Basically, triage involves rationing medical services. While it ensures that those who are in the direst need of care receive it first, this practice does not address the root causes of the long waiting times. There is need for the medical community to explore better solutions.

Impact on Cultural Background 

If the problem of long waiting times is to be fully understood, it is important to consider the impact that it has on the cultural backgrounds of patients and organizations. Today, an increasing number of healthcare providers are adopting the principle of lean service delivery. This principle underlies the interventions that can be used to solve the challenge of long waiting times. Redundancies and inefficiencies are chiefly to blame for the long waiting times. By leveraging the emerging culture of lean service delivery, these issues can be addressed, thereby reducing waiting times. Providers can eliminate unnecessary bottlenecks that hamper the timely delivery of care.

PICO Table 

P (Population)	Patients visiting emergency departments
I (Intervention)	Introducing operational efficiencies such as better work flows
C (Comparison)	Other interventions such as increasing staff
O (Outcome)	Reduction in wait times

Pico Question 

The following is the PICO question that will guide the research process: Do better workflows help to reduce wait times for patients at emergency departments, compared to such other interventions as increasing staff-to-patient ratio?

Search Strategy 

A rigorous strategy was adopted for the search of the literature that helps to answer the PICO question provided above. The strategy involved exploring various databases that hold academic literature. While various databases were consulted, Google Scholar served as the primary source. This database was selected because it hosts a huge volume of academic literature and features a tool that allows users to define such issues as the years of publication within which the search should be confined.

Keywords 

As part of the literature search process, a number of keywords were used. These keywords helped to identify research articles that were relevant. Some of these keywords include: long wait times, emergency department, interventions, operational efficiencies, improved workflows, among others. Thanks to these keywords, articles that were both relevant and insightful were found. Offered in the following section is a discussion of some of the articles.

Number and Types of Articles 

The search process allowed for about 20 relevant articles to be selected. However, since the assignment required only 7 articles, a further scrutiny of the articles was conducted. The purpose of the scrutiny was to identify articles that best answered the PICO question. After the scrutiny, the 7 required articles were selected. Two of the articles were of the non-research type while the other five were of the research variety. The latter type involved various research processes that ranged from observational studies to pre and post-intervention analysis. On the other hand, the non-research articles included a report and policy guidelines.

Research and Non-Research Evidence 

All the articles that were reviewed provide important insights that practitioners can adopt in their quest to streamline workflow so as to minimize waiting times. The article authored by Isabel Barata (2015) and her colleagues is among the non-research type whose insights can facilitate the development of effective interventions. In the article, Barata and her team outline best practices that facilities can adopt to ensure that patients visiting emergency departments are treated promptly. After discussing the problems that long wait times can cause, they proceed to describe such approaches as lean methodologies, innovation in staffing and enhanced workflow as among the interventions that hold the greatest promise. The article’s relevance lies in the fact that it establishes efficient workflows as an effective strategy for promoting the delivery of prompt care to patients in emergency departments.

Various scholars have conducted research with the aim of determining the impact that improved workflow has on wait times. Shen and Lee (2018) are among these researchers. They set out to establish if by adopting a number of interventions, an emergency department would witness a drop in patient waiting times. The interventions included promoting teamwork, ensuring that the number of practitioners at the emergency department matches the size of the patient population that the department attends to. According to the findings that Shen and Lee obtained, these interventions are indeed effective. These findings are in line with the observations that other researchers have made regarding the tremendous impact that streamlined workflows have on patient wait times.

Shen and Lee are not the only researchers whose study confirms that lean workflows help to reduce waiting times. They are joined by Bashkin (2015) and his team who also performed research to determine how emergency departments can help to keep wait times at low levels. Their study was of the observational variety. Some of the interventions that they examined include improved communication, organizational reforms and better time management. As can be expected, Bashkin and his team observed that these interventions work. This finding underscores the effectiveness of improved workflows.

In a non-research article that was featured in Oncology Rounds, Ashley Riley (2016) joined the scholarly community in sharing her thoughts on how better workflows can reduce wait times. The article begins by stating that long wait times have negative impacts on patient satisfaction. She then proceeds to present improved workflows as an effective intervention. Her article also identifies the barriers of which practitioners should be wary as they design and implement new workflows. Overall, the insights that Riley shares show that improved workflows are effective and should therefore be adopted across emergency departments.

Evidence Matrix 

Authors	Journal Name/ WGU Library	Year of Publication	Research Design	Sample Size	Outcome Variables Measured	Level (I–III)	Quality (A, B, C)	Results/Author’s Suggested Conclusions
Shen, Y., & Lee, L. H.	BMJ Open Quality	2017	Retrospective study	32,420	Wait time	II	B	Better workflow significantly reduced wait times
Shah, S., Patel, A., Rumoro, A., Hohmann, S., & Fullam, F.	Patient Experience Journal	2015	Pre-post study	1,209	Wait times, patient satisfaction	II	B	Communicating with patients and improving workflows leads to enhanced satisfaction and reduced wait times
Sayah, A., Rogers, L., Devarajan, K., Kingsley-Rocker, L., & Lobon, L. F.	Emergency Medicine International	2014	Pre-post intervention analysis	Not indicated	Wait duration	II	B	After the adoption of improved work and patient flow protocol, the hospital witnessed a significant drop in wait times
Bashkin, O., Caspi, S., Haligoa, R., Mizrahi, S., & Stalnikowicz	Israel Journal of Health Policy Research	2015	Observational study	105	Patient wait times, factors to blame for long wait times	III	B	Poorly-designed workflows among the factors responsible for long wait times
Chan, H. Y., Lee, L. L. Y., Lo, W. Y. L., Yu, W. C., Wu, Y. F., Ho, S. T., Yeung, R. S. D., & Chan, J. T. S.	World Journal of Emergency Medicine	2014	Quantitative pre and post-intervention	N/A	Waiting time	II	B	Lean methodologies helped to minimize waiting times

Recommended Practice Change 

The purpose of the literature review was to determine the perspectives of the research community regarding the strategies for minimizing wait times at the emergency department. One of the common themes that the review has revealed is that better workflows hold the key to hastening the delivery of care. All the researchers whose works were reviewed agree that when emergency departments eliminate the barriers that limit healthcare delivery and adopt streamlined workflows, patients are spared the long wait times that characterize most emergency departments. In light of the consensus within the research community, it is proposed that emergency departments should adopt better workflows. The implementation of this recommendation will involve such tasks as clearly defining the roles of each practitioner and eliminating procedures that are either unnecessary or have insignificant impacts on the delivery of care.

The discussion above has indicated that an overhaul of workflow processes holds the key to reducing waiting times at emergency departments. For the proposal to be more helpful, it is necessary to identify some of the specific measures that emergency departments can adopt as part of their efforts to improve workflow. In their article, Shen and Lee identify some of these measures. They include enhanced teamwork, creating a system that details the output of individual practitioners, and ensuring that manpower corresponds to the number of patients requiring treatment. Sayah and his colleagues confirm that redefining schedules and encouraging collaboration help to reduce waiting times. Adopting technology to ease the work of practitioners is another strategy that helps to streamline the workflow. In essence, all workflow improvement processes should be aimed at eliminating redundancies and lowering the amounts of work that individual practitioners perform.

Implementation Process 

The implementation of the improved workflows promises to transform the delivery of services in emergency departments. In the following section, various components of the implementation process are examined.

Key Stakeholders 

If the proposed solution is to be implemented successfully, various stakeholders must become involved. The main stakeholders are patients, nurse practitioners and physicians. Physicians and nurses will be tasked with the mandate of redesigning the workflow. The workflow should be designed such that it eliminates redundancies and promotes efficiency. For example, the nurses and physicians could work together to merge related functions. As an example, the new workflow could see patients undergo registration while simultaneously being diagnosed. The combination of the two functions will reduce the waiting time. Another role that the enhanced workflow will play is that it will enable the nurses and physicians to understand and execute their mandate effectively and without any conflicts. Patients also have critical roles to play if the implementation process is to occur without hitches. Their main responsibility will be to cooperate and work closely with the practitioners. As the new workflow is introduced, chaos and confusion could be witnessed. To ensure that the confusion does not hamper the full adoption of the new workflow, the patients need to work collaboratively with practitioners.

Barriers 

The parties responsible for the implementation of the proposal need to anticipate a number of barriers which could derail the implementation process. Limited support from the practitioners is one of these barriers. The new workflow will force the practitioners to make some adjustments. For instance, the physicians and nurses may need to take on new functions. The changes that the workflow introduces may inspire resentment and resistance. If action is not taken, those opposed to the change could sabotage the implementation process. Another barrier that should be anticipated concerns the financial resources needed to implement the proposal. As they adopt the proposal, emergency departments will need to make costly adjustments. For example, they may be forced to recruit more staff whose effort will be needed for the successful adoption of the new workflow. Without adequate funding, it will be nearly impossible to effect the change.

Strategies for Barriers 

If not addressed, the barriers above could see patients continue to wait for long hours. It is therefore vital for the concerned stakeholders to adopt strategies for eliminating the barriers. Regarding resistance from practitioners, it is recommended that the heads of emergency departments should convey the urgency and the importance of change. They need to persuade the practitioners to understand that if the new workflows are not adopted, patients will continue to develop complications and others will die. This message will resonate with practitioners who are dedicated to protecting patient health. Offering incentives is another strategy that can be adopted to address the resistance. With such incentives as financial rewards in exchange for support for the change, the practitioners are likely to fully endorse the implementation process. To solve the problem of inadequate funding, the emergency departments should broaden their sources of funding. They could appeal to sponsors to provide more funding and identify other partners who could serve as new sources of financing. Another option available to the departments is increasing the fees that patients pay. While unpopular, this strategy will provide the departments with the funding they need to ensure successful implementation.

Indicator to Measure Outcome 

The emergency departments will need to evaluate the effectiveness of the implementation process. One of the indicators that they could use to establish if the new workflows have delivered the intended is the patient wait time duration. The new workflows are meant to reduce the wait times. If it is observed that patients are waiting for less time, there is a basis to conclude that the workflows have worked. For example, suppose that before the workflows were introduced, patients had to wait for four hours. After the adoption of the workflows, the wait time reduced to 2 hours. This reduction is indication that the workflows have worked. On the other hand, if there is no significant decline in the wait times, the emergency departments will have established that better workflows do not reduce wait times.

In conclusion, as more and more patients wait for hours to receive care, the need for urgent interventions become clearer. Observations have been made that in most emergency departments, patients develop complications and some die while waiting to receive treatment. These departments have attempted to implement reforms. Unfortunately, most of these reforms have failed as evidenced by the long waiting times that patients continue to endure. Redesigning workflows is one of the measures that research has established to be effective. Emergency departments need to involve all stakeholders as they adopt this measure if they are to deliver timely and high quality services.

References

Barata, I., Brown, K. M., Fitzmaurice, L., Griffin, E. S., & Snow, S. K. (2015). Best practices for improving flow and care of pediatric patients in the emergency department. Pediatrics, 135 (1), e273-e283.

Bashkin, O., Caspi, S., Haligoa, R., Mizrahi, S., & Stalnikowicz, R. (2015). Organizational factors affecting length of stay in the emergency department: initial observational study. Israel Journal of Health Policy Research, 4 (38). DOI: https://doi.org/10.1186/s13584-015-0035-6

Chan, H. Y., Lee, L. L. Y., Lo, W. Y. L., Yu, W. C., Wu, Y. F., Ho, S. T., Yeung, R. S. D., & Chan, J. T. S. (2014). Lean techniques for the improvement of patients’ flow in emergency department. World Journal of Emergency Medicine, 5 (1), 24-8.

Chartier, L., Josephson, T., Bates, K.. & Kuipers, M. (2015). Improving emergency department flow through Rapid Medical Evaluation unit. BMJ Open Quality, 4 (1). DOI: http://dx.doi.org/10.1136/bmjquality.u206156.w2663

Hesse, B. W., Gaysynsky, A., Vieux, S., Ottenbacher, A., Moser, R. P., Blake, K. D., Chou, W. S., & Beckjord, E. Meeting the healthy people 2020 goals: using the health information national trends survey to monitor progress on health communication objectives. Journal of Health Communication, 19 (12), 1497-1509.

Jarvis, P. R. E. (2016). Improving emergency department patient flow. Clinical and Experimental Emergency Medicine, 3 (2), 63-8.

Riley, A. (2016). Pla, do, check, act: your four-step process to reducing patient wait times. Oncology Rounds. Retrieved October 27, 2018 from https://www.advisory.com/research/oncology-roundtable/oncology-rounds/2016/09/university-of-miami-patient-wait-times

Sayah, A., Rogers, L., Devarajan, K., Kingsley-Rocker, L., & Lobon, L. F. (2014). Minimizing ED waiting times and patient flow and experience of care. Emergency Medical International. DOI: http://dx.doi.org/10.1155/2014/981472

Shah, S. C., Patel, A. K., Rumoro, D. P., Hohmann, S. F., & Fullam, F. (2015). Managing patient expectations at emergency department triage. Patient Experience Journal, 2 (2), 31-44.

Shen, Y., & Lee, L. H. (2017). Improving the wait time to consultation at the emergency department. BMJ Open Quality, 7 (1). DOI: http://dx.doi.org/10.1136/bmjoq-2017-000131