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Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)
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Emergency Department cowding: A Role for the Clinical Nurse Leader (CNL)

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Decribes a leadership role for the Clinical Nurse Leader in Decreasing Emergency Department Crowding

Decribes a leadership role for the Clinical Nurse Leader in Decreasing Emergency Department Crowding

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  • IntroductionAn organizational assessment of a southeastern hospital, revealed that waiting time was a chief problem. Increased waiting times result from internal and external forces, and have a direct effect on quality of care and stakeholder satisfaction. The stakeholders were identified as patients and their families, the , ED staff, hospital staff, members of the community, and the Emergency Medical System.
  • Multidiscipline ED flow improvement strategies can be relatively inexpensive depending on the facility’s needs. A study by McHugh, Van Dyke, & Moss, 2012) studied six hospitals involved in process improvement strategies related to ED crowding, and found processes that were less than $200, or as high as $500,000. Two strategies that had no extra costs were , protocols for consults, and the development of Fast-track guidelines. Fast-tracks are usually separate geographical areas in the ED, that help streamline non-urgent cases out of the ED.
  • Problem overview:ED crowding is a public health concern and a threat to patient safety (Trzeciak, S. & Rivers, E., 2003). According to the American Hospital Association, there are 40% fewer inpatient beds in the US due to recent regulations (Richardson, L., Asplin, B., & Lowe, R., 2002). ED crowding is a symptom of our broken health care system and not just an ED problem. Patients are living longer and are older coming into the ED for care. Patients are sicker when they come into the ED seeking care. There are more uninsured patients than , and ED’s can not turn patients away due to federal laws.
  • Many Emergency Departments have closed their doors , due to an inability to profit, increased government regulations and rising healthcare costs. There are 40% less ED beds in the US now to treat patients (Richardson, et al., 2002).
  • ED’s experienced a 20% increase in visits in a 5-year period, according to Richardson et al., (2003). The ED at hospital “X” has experienced an 18% increase in patient volume over this past year as well, according to the present ED Director. These factors are all contributory to ED crowding, increased waiting times and increased ambulance diversions. Many EDs can divert ambulances to the next closest hospital, when their EDs are overburdened with volume or acuity. This ambulance diversion is communicated to the EMS system.Ambulance diversions are considered a safety concern for patients in need of emergent care and to disaster preparedness, according to Joint Commission for Hospital Accreditation (Rivers, 2002). There was an increased burden on our EMS system and during Hurricane Katrina, the 911 World Trade Center Disaster and recently Hurricane Sandy.
  • Asplin, B., Magid, D., Rhodes, K., Solberg, L., Lurie, N. & Camargo, C., describe ED crowding in terms of a conceptual model of input,throughput and output (2003), which that exists within an acute care system. This conceptual model can be broken down into three separate interdependent components, that can be manipulated to improve ED crowding. A patient’s journey through an Emergency Department can be tracked utilizing processes, computer technology and other external factors which affect his or her experience.
  • The input segment of this conceptual model consists of these unscheduled patients : 1) emergency care- ambulances and walk-ins, 2) patients transferred from other facilities or offices for emergency conditions, 3) unscheduled urgent care due to lack of capacity in other ambulatory care areas, 4) the desire for immediate care for convenience- conflicts with work or family. EDs have been healthcare’s “safety net” for person with access barriers (Asplin et al., 2003). It is through the throughput and the output components of this conceptual model, that strategies can be most effective. We do not have much control of who arrives through our ED doors (input).
  • The throughput component of the ED has to do with registration, triage process, time placed in exam room, time evaluated by provider, diagnostic studies, consults, and ED boarding of inpatients.
  • Patients in the ED community are considered to be boarding as inpatients, after two hours has passed and the patient does not have a disposition. An example of this would be, a patient who is admitted to the hospital but is waiting for a clean bed. ED boarding of patients places additional strain on ED staff. ED Providers and nursing are required to provide the same level of care for admitted patients, while juggling the needs of new ED patients.Patients leaving before treatment, which include PLBM, PLAM, LAMA leave EDs vulnerable for sentinel events, patient complaints and litigation.
  • The throughput component identifies ED length of stay (LOS), which is an important factor in ED crowding (Asplin et al., 2003). The Emergency Nurses Association (ENA) recommends evaluating ED throughput processes in regard to the operations, staffing and patient care (ENA, 2012). Increased LOS decreases the quality of care and poses safety risks for ED patients. Process process improvements that target throughput, can decrease ED crowding and reduce waiting times.
  • Output can also be targeted as a strategy to decrease length of stay in the ED.
  • A study by Exadakytylos, A., Evanelopoulos, D., Wullscheger, M., Burki, L., & Zimmerman (2008), showed that real-time data was instrumental in evaluating problem areas for EDs ,in order to develop strategies to decrease LOS. Computer tracking systems such as the one at hospital X ‘s ED can be used to track all of the components of the patient’s stay in the ED. The current information management system has real-time tracking ability, but it is not currently used in its maximum potential.
  • Strategic PlanA plan to develop a multidiscipline ED Flow Team will be initiated to identify problems in the input and output components of the ED . The ED Flow team will need top-down support , as well as staff acceptance in order to be effective . Performance measures for EDs such as, LOS and patient satisfaction for evaluating quality and reimbursements.
  • Transcript

    • 1. Joanne Senn The University of AlabamaClinical Nurse Leader Candidate
    • 2.  An organizational assessment of a southeastern hospital’s Emergency Department (ED), revealed waiting time as a chief problem. The hospital will be called hospital “X”. Increased waiting times have a direct effect on quality of care and stakeholder satisfaction. Stakeholders  Patients and families  ED and hospital staff  Community- includes the Emergency Medical System
    • 3. A Multidisciplinary Emergency Department (ED) Flow Team will be developed, and strategies will be implemented to reduce ED crowding. Why?
    • 4.  According to the American Hospital Association, there are 40% fewer inpatient beds in the US due recent regulations (Richardson, Asplin & Lowe, 2002). ED crowding is complex.  Patients are older and sicker  Less Primary Care Providers  More uninsured persons ED crowding is a public health concern and a threat to patient safety (Trzeciak & Rivers, 2003).
    • 5. • EDs have been healthcare’s “safety net” for vulnerable populations for decades. • poor people • uninsured • Medicaid recipients and Medicare recipients • 40% fewer ED beds in the US, due to rising costs of healthcare (Richardson, et al., 2002).
    • 6. • Ambulance diversion is a safety• EDs in the US had a 20% concern . increase in visits in 5-year span (Richardson et al., 2003). • patients needing emergency care • disaster• The ED at hospital “X” preparedness, according to experienced an 18% increase Joint Commission for Hospital in volume this year (William Accreditation (Trzeciak, 2002) Farohna, ED Director). • Examples: 911 World Trade Center Disaster , Hurricane• All contribute to wait times Katrina, Hurricane Sandy and ambulance diversions.
    • 7.  A conceptual model partitions ED crowding into 3 interdependent components, within the acute acute care system (Asplin, Magid, Rhodes, Solberg, Lurie & Camargo, 2003) 1) Input 2) Throughput 3) Output A patient’s ED journey  has many variables  can be tracked
    • 8. Input* Emergency care- ambulances, walk-ins• Transfers with emergency conditions• Unscheduled urgent care-due to lack of capacity in other ambulatory care areas• Desire for immediate care- convenience, conflicts with work and family• Safety net care- Medicaid, uninsured has increased. ED crowding higher in poor communities (Asplin et al., 2003). Access barriers-  Finances  Transportation  Decreased availability of usual care, i.e.. Primary Care
    • 9. Throughput • Patient arrives in ED • Registered by clerk • Triage by trained RN • Patient placed in ED room • Evaluation by provider and diagnostic tests, treatment, consults • ED boarding of inpatients
    • 10. Output=disposition • Admission • Discharge • Transferred to higher level of care, i.e.., trauma unit, or skilled nursing facility • Patient leaves before seen (PLBM) • Patient leaves after medical screening (PLAM) • Patient leaves against medical advice (LAMA) • Boarder= Patient boarded in ED as an inpatient after 2 hours of admission decision 
    • 11. • Targeting entire ED length of stay (LOS) is important in ED crowding (Asplin et al., 2003).• The Emergency Nurses Association (ENA), recommends evaluating throughput in regard to operations, staffing and care (ENA, 2012).• Increased LOS decreases quality of care and poses safety risks for patients.• Process improvements can target throughput to decrease ED crowding= decreased waiting times.
    • 12.  Asplin (2003) identifies throughput and length of stay (LOS) as a main contributor to ED crowding, hence increased waiting times. The Emergency Nurses Association (ENA, 2006), stated increased LOS decreases quality of care and poses safety risks. ENA recommends evaluating throughput processes: operations, staffing and care. Out put also targeted for process improvement.  Time of disposition  Transfer, admission, discharge  Transportation delays- ambulance
    • 13. Computerized real-time data can be used to develop solutions to ED crowding (Exadakytylos, Evanelopoulos, Wullschleger, Burki & Zimmerman, 2008) The Computer tracking system at hospital X can track real time data  Time of arrival  Time of triage by RN  Time of room placement  Time seen by provider  Time labs and radiology studies complete  Time consults completed  Time of disposition- admit/discharged  Total LOS in ED
    • 14.  Develop a Multidisciplinary ED Flow Team  Members- Clinical Nurse Leader (CNL), MD, RN, LPN (Fast- track), clerk, data specialist, bed coordinator, administrator, lab and radiology personnel, & housekeeping supervisor  Purpose- identify problems with throughput and output  Success depends on-  top-down support  staff acceptance  hospital wide plan  Effect- facilitates positive change decreased wait times  Identify Performance measures set by the ED community, i.e. LOS, decreased patients leaving without seen.  Performance Measures are being developed as CMS will reward hospitals that perform better (Welch, Augustine, Camargo & Reese, 2006).
    • 15. • 0-3 months • Approve budget needs- CNL ($70,000+ meeting hours • Multi-disciplinary ED Flow $10,000=$80,000) team meets weekly x 3 months • Develop strategies to target • 3-6 months throughput and output of ED • Implement strategies and policies processes as follows: • Train staff and communicate • Process changes for throughput- changes through staff meetings labs and radiologic studies and memos turnaround time= 30 minutes • Consults completed within 1 hour • Recruit a CNL to spearhead the (unless emergent, i.e., MI ) ED Flow Strategy • Nurse calls lab and radiology after • Develop policies for process 30 mins for results changes • Physician calls consulting Md • Set rollout date with after 30mins pass, then calls Chief of specialty after 45 minutes. communication to all departments
    • 16. 3-6 months (continued)  6-9 months Output processes  Bed Coordinator communicates with ED charge RN, daily at 2p to discuss transfer  Evaluate effectiveness of process needs with maximum census changes via EDIS  Expectation for ready bed- 15 mins, and  ED staff input via in staff discharge bed- 45 min. meetings  Call ED nurse manager with bed delay  Call Nursing supervisor after 4p-7am with  LOS stay goal = < 2 hours bed delay  Track ambulance diversions  Charge RN calls housekeeping  Evaluate with patient satisfaction supervisor for discharge bed delay tool –Goal 85% satisfied with  Notify bed control as soon as admission overall care decision made  Clinical Nurse Leader reviews results in ED Patient Flow Summary meeting  Enter time admission on tracking system (real-time)  Revise plan as needed  -Transportation-clerk completes paperwork for transfers  -Call ambulance company after 15 min delay  -Call ambulance supervisor after 30 min delay
    • 17. • Strategic Planning for Emergency Department crowding is complex, and EDs should not be alone in the solution.• A Clinical Nurse Leader can play a key role in planning and implementing patient flow strategies.• Decreased ED LOS and increasing efficiency decrease in ED crowding  reduced waiting times and increased quality of patient care.• ED improvement = saved lives , decreased litigation, less ambulance diversions and increased financial rewards for hospitals.
    • 18. Asplin, B., Magid, D., Rhodes, K., Solberg, L., Lurie, N., & Camargo, C. (2003). A conceptual model of Emergency Department crowding. Annals of Emergency Medicine, 42, (2), pp. 173-180.Emergency Nurses Association. (2006). Holding patients in the Emergency Department (White paper).http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Holding_Pati ents__in_the_Emergency_Department__ENAQ_White_Papers. pdfExadakytylos, A., Evangelopoulos, D., Wullschleger, M., Burki, L. & Zimmerman, H. (2008). Strategic emergency management department design: An approach to capacity planning in healthcare provision in overcrowded emergency rooms. Journal of Trauma Management and Outcomes, Retrieved from doi: 10.1186/1752-2897-2-11Richardson, L., Asplin, B. & Lowe, R. (2002). Emergency Department crowding as a health policy issue: Past development, future directions, Annals of Emergency Medicine, 40, (4), pp. 388-391.Trzeciak, S. & Rivers, E. (2003). Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emergency Medicine Journal, 20, pp. 402-405Welsch, S., Augustine, ., Camargo, C, & Reese, C . (2006). Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13: 1074-1080. doi 101197/j.aem2006.05.026

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