1. 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
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
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), Retrieved from
x/abstract;jsessionid=EDF7E9BEC921E5FD319B74F0500A5287.f03t02
Government Accountability Office. (2009). Hospital Emergency Departments. Retrieved from
Doody, C. M., & Doody, O. (2011). Introducing evidence into practice: Using IOWA model. British
Journal of Nursing, 20(11), Retrieved from
_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), Retrieved from
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),
doi:  /j x
Stover-Baker, B., Stahlman, B., & Pollack, M. (2012). Triage nurse prediction of hospital admission.
Journal of Emergency Nursing, 38(3),
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), Retrieved from
publication/ _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), Retrieved from
com.contentproxy.phoenix.edu/science/article/pii/S
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.