An Overview of the Problem and the Setting Where it Occurs
In as far as nursing practice is concerned; there are many challenges that are encountered in the emergency department (ED) that call for a quality improvement initiative. However, this paper will focus on overcrowding in the ED which has been attributed to high inpatient mortality, high cost of care for admitted individuals as well as a longer time of stay by the patients (Di Somma et al., 2015). As a result, many patients arrive at the ED but due to overcrowding, they are forced to leave with receiving medical services as expected. The inability of the ED to deliver or provide urgent and high-quality medical care services is represented by crowding in emergency rooms and poor patient flow within the department. Patient flow and the subsequent overcrowding within the ED is influenced by various factors such as longer waiting time, increased investigation turnaround times, and dispositions decision delay (Di Somma et al., 2015). The relationship between emergency department mortality rates and overcrowding within the department or emergency rooms indicate the need to consider overcrowding within the ED as a major public health concern. In order to ensure high quality and reduce ED mortality rate, the quality improvement initiative proposed is to reduce the length of time the patient spend in the emergency department.
Explanation Why Quality Improvement is Needed and the Expected Outcomes
The need for the proposed quality improvement is highlighted by the fact that EDs around the globe are faced by a number of challenges/problems which are posed by the increasing number of patients and the departmental inability to meet healthcare quality and demand (Di Somma et al., 2015). This is associated with limited resources within the department as well as the health sector in general. As a result, overcrowding in the emergency department has remained a worldwide and internationally-felt phenomenon. Patient crowding in the emergency department is facilitated by far greater demands in which the department is subjected compared with the entire health facility/hospital’s ability to ensure delivery of timely and quality care in the department (Di Somma et al., 2015). Various factors classified as either extrinsic or intrinsic have been associated with poor emergency department services. Some of the intrinsic factors which affect patient flow are staffing levels (especially nursing) and departmental layout while increased patient demand and low inpatient bed availability represent the extrinsic factors (Di Somma et al., 2015). This shows the impact of the entire system on the ED’s patient flow. Past research studies indicate that a negative relationship between inpatient bed occupancy and the patient admission probability.
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With the proposed quality improvement initiative, it is expected that there will be a significant reduction in ED crowding as the time that patient spends in the department is reduced (Di Somma et al., 2015). This is realized by improving patient flow within the department. The end results will be improved patient satisfaction and reduced patient mortality rates in the emergency department as well as the entire healthcare facility (Di Somma et al., 2015). Some of the expected changes in the ED are increased patient admission in the department, a significant shift in ED workload which helps in minimizing the overcrowding issue.
How Previous Research Demonstrates Support for the Quality Improvement Initiative and its Projected Outcomes
Previous research studies have demonstrated support for these proposed quality improvement initiative in a number of ways. First, these studies have demonstrated evidence which shows the link between crowded emergency departments and low-quality care patient care (Sonis et al., 2017). The studies also observed that crowding in ED leads to delayed delivery of care to the patient which contributes to increased mortality rates (Sonis et al., 2017). Research has found that patient opting to leave before they have received full care in the ED is another sign of emergency department overcrowding (Sonis et al., 2017). According to these studies, this scenario was observed in at least two percent of all the emergency department visits in the US. Adoption and implementation of various overcrowding reduction strategies such as rapid assessment, utilization of doctor/nurses triage, and rapid streaming in the department have led to a marked improvement in patient flow (Sonis et al., 2017). Additionally, bed-side testing or point of care testing have been observed to minimize the incidence of delayed disposition decisions within the emergency department, thus increased timely discharges among patients.
According to Sonis et al. (2017), in addition to contributing to the challenge of ED crowding, long ED waits also contribute to increased patient mortality as well s morbidity. The studies indicate this as the reason why the United Kingdom became the first nation to adopt compulsory nationwide clinical indications as patients trying to get emergency services experienced long and unbearable waits. The introduction of the 4-hour rule in the emergency department which ensures that patients receive healthcare services and be discharged or admitted within four hours have been found to enjoy immense success for a long time. Consequently, there was a major improvement on the ED’s length of stay to 96 percent up from 77 percent by 2004 even with up to 37 percent increase in the number of emergency department presentations (Sonis et al., 2017). This has motivated the development and implementation of more clinical indicators in an attempt to solve the problem of ED overcrowding.
Traditionally, these waits were viewed as a way of finding a balance between demand and supply (Sonis et al., 2017). This, however, changed in the early 1990s as a result of systemic disorganization and the ever-increasing demand for high-quality care that caused long initial assessment waits, inpatient bed waits, and overcrowding in the EDs that brought a loud public outcry (Sonis et al., 2017). More research focused on ways of solving the challenge of ED crowding and various recommendations aimed at increasing patient flow and reduce ED crowding. The studies went ahead to suggest various interventions that can be used to ensure improvement in patient flow from those awaiting admissions to the utilization of observational medicine.
Necessary Steps to Implement the Quality Improvement Initiative
According to the CDC (2017), in order to ensure proper implementation of the proposed quality improvement initiative, the following necessary steps must be taken:
Revising the emergency department staffing patterns (CDC, 2017)
This is done by utilizing the analytic application which allows change review of patient arrivals with time. The outcome of the review is used to adjust the nursing staffing to ensure that it better aligns with patient volumes and the departmental needs.
Improvement in the registration process
This step involves the introduction and institution of a faster registration process (CDC, 2017). Given the importance of the registration process as a key component of patient care, it is imperative that the staff in charge of patient registration ensure that the patient is correctly identified when they arrive at the department. This may be achieved by only asking questions that are necessary for the registration of the patient and initiation of patient care while avoiding many unnecessary questions. The remaining questions needed for the completion of the registration process are asked bedside by the emergency department staff as the patient receives care.
Triage workflow improvement
The improvement of the triage workflow is attained by the use of evidence-based triage assessment and evaluation using the ED triage algorithm such as the Emergency Severity Index (ESI) triage acuity scale (CDC, 2017). This algorithm enables the determination of patient acuity and prioritization patient care at triage. The questions by the triage nurse are minimized to ensure that the triage placement, process, and patient care delivery are rapidly and appropriately done. This reduces the number of questions asked in a bid to ensure the severity of the disease is determined and adjusted accordingly. From here, the patient heads for the emergency room or will be asked to wait for treatment/care. This will ensure that resources are properly utilized while the patients receive high-quality care.
Faster/earlier patient access to qualified care provider
This step involves development and implementation of new roles such as triage advanced registered nurse or assistant physician providing care at the ED alongside the triage nurse. This will reduce ED length of stay (CDC, 2017). When the volume of patients to the ED is high, the triage advanced practitioner and the triage nurse work in parallel. Additionally, the triage advanced practitioner may participate in ordering diagnostic assessments which ensures the elimination of wait times while delivering high quality and timely patient care.
Evaluation of the Quality Improvement Initiative
This quality improvement initiative may be evaluated through outcome measurement, structural measurements, and process measurement (Sonis et al., 2017). For outcome measurement, the effect of the introduced change or healthcare services on the overcrowding and patient follow is assessed and measured. Structural measurement entails assessing healthcare’s systems, processes, and capacity (Sonis et al., 2017). This includes staffing (in terms of number, qualification, and staff-to-patient ratios), and technology used. Finally, process measurement involves checking at what measures are in place within the department in order to improve or maintain the quality of patient care (Sonis et al., 2017). This may be through obtaining the percentage of individuals who were served over a given time period as well as the amount of waiting time.
References
Centers for Disease Control and Prevention. (2017). National health care surveys. Retrieved from https://www.cdc.gov/nchs/data/factsheets/factsheet_nhcs.htm
Di Somma, S., Paladino, L., Vaughan, L., Lalle, I., Magrini, L., & Magnanti, M. (2015). Overcrowding in emergency department: an international issue. Internal and emergency medicine, 10(2), 171-175.
Sonis, J. D., Aaronson, E. L., Lee, R. Y., Philpotts, L. L., & White, B. A. (2017). Emergency Department Patient Experience: A Systematic Review of the Literature. Journal of patient experience, 5(2), 101–106. doi:10.1177/2374373517731359
