Nurse Practitioner in Triage to Reduce Emergency Department Crowding Susan Franks, BS, RN BACKGROUND RESULTS (PROJECTED- NOT ACTUAL) IF THE PROJECT IS UNSUCCESSFUL Emergency Room crowding is a continuing problem: - Emergency providers are mandated to treat/ stabilize by EMTALA - Less primary care providers are available - Emergency room visits are increasing annually - Inpatient admissions are increasing, yet there is a shortage of impatient beds Emergency Room crowding contributes to: -Sick patients waiting longer -Ambulance diversion -Medical errors -Patient elopements -Extended lengths of stays -Adverse outcomes -Increased mortality -Patient dissatisfaction REVISING AN UNSUCCESSFUL PROJECT SOLUTION Outcome measures may be unfavorable (time measures increased, more patients leave without being treated, patient dissatisfaction). Or outcomes may be unchanged or only slightly improved, but the staff have not coped well or some other unforeseen effects are experienced. The team should start over, beginning with reviewing the team membership. Feedback from involved staff and patients should be reviewed. The steps in the Iowa Model should be followed, including another literature review. TERMINATING AN UNSUCCESSFUL PROJECT SOLUTION Finally, unfavorable effects of the project may cause the team to decide to terminate the the project. This termination does not mean the project was a failure and this should be communicated to everyone involved. All outcomes are evidence to professional colleagues and this experience may add to the collection of evidence others review when implementing change in other facilities or when searching for data. The team and staff should be proud of their contribution to improving the knowledge base for their profession. Effect of Nurse Practitioner on Length of Stay and Time from Arrival to Assessment NOT ACTUAL DATA PROBLEM How can patient throughput be improved to ease emergency department crowding? COMMUNICATING RESULTS WITHIN THE HOSPITAL Team will meet weekly during implementation to discuss progress Data and progress will be shared at all departmental and relevant intrahospital meetings Written reports will be posted in department and submitted to hospital leadership OUTSIDE THE HOSPITAL Project will be written up and submitted for publication in professional journals Project will be shared will local professional organizations Project will be shared with hospital’s parent corporation OBJECTIVES Effect of Nurse Practitioner on Patient Satisfaction and Number of Patients Who Leave Without Being Seen Improve efficiency of triage by adding a Nurse Practitioner, who can begin work-ups and treatment on patients with ESI Levels 2 & 3 and who can treat and release patients with ESI Levels 1 & 2. GOALS: decrease emergency department length of stays decrease number of patients who leave without being seen decrease time from arrival tor provider assessment increase patient satisfaction scores NOT ACTUAL DATA IMPLEMENTATION REFERENCES Create team of stakeholders and affected personnel Develop policy and procedures for new triage system Train ED staff, physicians, nurse practitioners in new system Evaluate understanding of new system Set up physical area and needs to accommodate more people and tasks American College of Emergency Physicians. (2011). Definition of boarded patient, policy statement. Clinical & Practice Management. Retrieved from http://www.acep.org/Clinical--- Practice-Management/Definition-of-Boarded-Patient/ Barish, R. A., Mcgauly, P. L., & Arnold, T. C. (2012). Emergency Room Crowding: A Marker of Hospital Health. Transactions of the American Clinical and Climatological Association, 123, 304– 311. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3540619/ Bernstein, S. L., Aronsky, D., Dusela, R., Epstein, S., Handel, D., Hwang, U., … Asplin, B. R. (2009). The effect of emergency department crowding on clinically oriented outcomes. Academic Emergency Medicine, 16(1), 1-10. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j. 1553-2712.2008.00295.x/abstract;jsessionid=EDF7E9BEC921E5FD319B74F0500A5287.f03t02 Government Accountability Office. (2009). Hospital Emergency Departments. Retrieved from http://www.gao.gov/new.items/d09347.pdf Doody, C. M., & Doody, O. (2011). Introducing evidence into practice: Using IOWA model. British Journal of Nursing, 20(11), 661-664. Retrieved from http://www.researchgate.net/publication 51466031_Introducing_evidence _ into_nursing_practice_Using_the_IOWA_model Harding, K. E., M.P.H., Taylor, N. F., PhD., & Leggat, S. G., PhD. (2011). Do triage systems in healthcare improve patient flow? A systematic review of the literature. Australian Health Review, 35(3), 371-83. Retrieved from http://search.proquest.com/docview/910806287? accountid=458 Rowe, B. H., Guo, X., Villa-Roel, C., Schull, M., Holroyd, B., Bullard, M., Vandermeer, B., … , Innes, G. (2011). The role of triage liaison physicians on mitigating overcrowding in emergency departments: A systematic review. Academic Emergency Medicine, 18(2), 111-120. doi: 10.1111/j.1553-2712.2010.00984.x Stover-Baker, B., Stahlman, B., & Pollack, M. (2012). Triage nurse prediction of hospital admission. Journal of Emergency Nursing, 38(3), 306-310. Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., … , Goode, C. J. (2002). The Iowa Model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509. Retrieved from http://www.researchgate.net/ publication/11580356_The_Iowa_Model_of_Evidence_Based_Practice_to_Promote_ Quality_Care White, B. A., Brown, D. F., Sinclair, J., Chang, Y., Carignan, S., McIntyre, J., & Biddinger, P. D. (2012). Supplemented triage and rapid treatment (START) improves performance measure in the emergency department. Journal of Emergency Medicine, 42(3), 322-328. Retrieved from http:// www.sciencedirect. com.contentproxy.phoenix.edu/science/article/pii/S0736467910002908 OVERCOMING BARRIERS TO CHANGE IF THE PROJECT IS SUCCESSFUL… Limited resources Extremely busy department with high patient acuities Resistance to change, dependence on “tradition” Most hospitals operate with limited resources and emergency departments are no different. Budgets are tight, staff feel overworked, and supplies are rationed carefully. Add to this a busy department and very sick patients, and the result is an environment that rarely embraces change. Over 50% of the staff have over 10 years of experience. This experience enhances the skill and knowledge of the staff, but it also promotes the attitude of “this is how we’ve always done it,” which often frustrates any change efforts. Lewin’s Change theory will be used to assist the team to overcome these challenges. The staff will be included at every step of the implementation process, which encourages their buy-in and input; it gives them a stake in the success of the project. Feedback will be given regularly and often, and successes will be celebrated regardless of how small they seem. Team leaders will directly support the staff to help with implementation of changes. Needed resources will be provided. Finally, part of training will include reviewing the research evidence and discussing how these changes may help ease the crowding and workload in the department, and allow the staff to deliver better quality care. MAINTAINING A SUCCESSFUL PROJECT SOLUTION If outcome measures are favorable (time measures have decreased, less patients leave without treatment, patient satisfaction improved), the team should maintain the changes implemented and determine the frequency that they should meet to continue monitoring outcomes. The team may decide to make the changes permanent at this point, or it may decide it wants data collected for a longer period. When the changes are made permanent, policies and procedures need to be made permanent as well. The outcome measures may be passed on to the department quality improvement committee for monitoring. This success should be celebrated hospital-wide, perhaps made part of a marketing strategy for improved patient care, and the outcomes should be published and shared professionally. EXTENDING A SUCCESSFUL PROJECT SOLUTION Alternatively, the success of the changes implemented may lead to other ways to improve the triage process. The team should act as if starting the project over; primarily, is there evidence to support the proposed extension? Following the Iowa Model, the same steps should be followed for implementation of more changes.