1. Solving the Dilemma of Wait Times in the Emergency Department by: Nicole Chan

2. Introduction/Background ● ED has become overcrowded and unable to meet the demands of its patients ● 2010 Affordable Care Act ● Institute of Medicine (IOM) confirms ED overcrowding is becoming a national epidemic

3. Introduction/Background Cont’d ● Current research in the nursing and medical community on ways to reduce wait times in the ED ● Key Findings ● Clinical Implications

4. Introduction/Background Cont’d ● PICOT: In ED patients, how does the implementation of a fast track or rapid treatment zone, compared to ED’s who have not implemented a fast track or rapid treatment zone, decrease wait times and improve quality of care for patients prior to discharge from the ED?

5. Key Findings ● A fast track is the most common intervention reviewed to effectively reduce wait times and length of stay in the ED ● Fast track: an addition to the main ED where low- acuity patients are evaluated by a mid-level care provider. ● Positively impacts nursing by improving ED flow

6. Clinical Implications ● Plan for change: o designate a room/number of beds to be the fast track area o arrange staff including a mid-level care provider and nurses o use current triage acuity system to designate low- moderate acuity patients to triage

7. Barriers/Facilitators to Change Barriers: ● Current triage system may not support optimization of flow in a fast track Facilitators: ● no additional renovations to ED required ● no additional staffing required ● no additional policy changes needed ● no additional training required ● no compromise in patient care

8. Ethical and Cultural Considerations ● Patient population served and perception of mid-level care providers compared to the MD ● Lack of resources including translators ● Ethical principles of Beneficence and Justice

9. Expected Outcomes and Measurement Expected Outcomes: ● reduced wait times and length of stay ● improved ED flow ● better nursing care Measurement of Outcomes: ● 3 months ● Electronic Medical Record (EMR) o wait times and lengths of stay

10. Conclusion ● Fast track is a promising solution for ED overflow ● Fast tracks improve wait times and lengths of stay ● Improved nursing care is an additional benefit ● Research is needed for potential nationwide implementation ● Cultural considerations must be addressed regarding scope of practice of mid-level care providers and patient education

11. References Aksel, G., Bildik, F., Demircan, A., Keles, A., Kilicaslan, I., Guler, S., &... Dogan, N. (2014). Effects of fast-track in a university emergency department through the national emergency department overcrowding study. Journal Of The Pakistan Medical Association, 64(7), 791-797. Cheng, I., Lee, J., Mittmann, N., Tyberg, J., Ramagnano, S., Kiss, A., &... Zwarenstein, M. (2013). Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times. BMC Emergency Medicine, 13(17). doi:10.1186/1471-227X-13-17 Considine, J., Lucas, E., Martin, R., Stergiou, H. E., Kropman, M., & Chiu, H. (2012). Rapid intervention and treatment zone: Redesigning nursing services to meet increasing emergency department demand. International Journal Of Nursing Practice,18(1), 60-67. doi:10.1111/j.1440-172X.2011.01986

12. References Doyle, S. L., Kingsnorth, J., Guzzetta, C. E., Jahnke, S. A., McKenna, J. C., & Brown, K. (2012). Outcomes of implementing rapid triage in the pediatric emergency department. Journal Of Emergency Nursing: JEN: Official Publication Of The Emergency Department Nurses Association, 38(1), 30-35. doi:10.1016/j.jen.2010.08.013 Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., Williamson, K.M. (2010). Critical appraisal of the evidence: Part I. AJN, 110(7). 47 – 52. Gutierreez, S. (n.d.). Texas Man Dies After Waiting 16 Hours for Treatment in ER. Retrieved April 6, 2015, from http://www.emsworld.com/news/10336183/texas-man-dies-after-waiting-16-hours-for-treatment-in-er Han, J. H., France, D. J., Levin, S. R., Jones, I. D., Storrow, A. B., & Aronsky, D. (2010). The effect of physician triage on emergency department length of stay. The Journal Of Emergency Medicine, 39(2), 227-233. doi:10.1016/j.jemermed.2008.10.006

13. References Marco, C. A., Moskop, J. C., Schears, R. M., Stankus, J. L., Bookman, K. J., Padela, A. I., &... Bryant, E. (2012). The ethics of health care reform: impact on emergency medicine. Academic Emergency Medicine: Official Journal Of The Society For Academic Emergency Medicine, 19(4), 461-468. doi:10.1111/j.1553- 2712.2012.01313.x Paul, J., & Lin, L. (2012). Models for improving patient throughput and waiting at hospital emergency departments. Journal Of Emergency Medicine (0736-4679), 43(6), 1119-1126. doi:10.1016/j.jemermed.2012.01.063 Rankin, J. A., Then, K. L., & Atack, L. (2013). Research: can emergency nurses' triage skills be improved by online learning? Results of an experiment. Journal Of Emergency Nursing, 3920-26. doi:10.1016/j.jen.2011.07.004 Stauber, M. A. (2013). Advanced nursing interventions and length of stay in the emergency department. Journal of Emergency Nursing, 49(3), 221-225, doi:10.1016/j.jen.2012.02.01510.1016/j.jen.2012.02.015

14. References Theunissen, B., Lardenoye, S., Hannemann, P., Gerritsen, K., Brink, P., & Poeze, M. (2014). Fast Track by physician assistants shortens waiting and turnaround times of trauma patients in an emergency department. European Journal Of Trauma & Emergency Surgery, 40(1), 87-91. doi:10.1007/s00068-013-0324-0 White, B. A., Brown, D. M., Sinclair, J., Chang, Y., Carignan, S., McIntyre, J., & Biddinger, P. D. (2012). Supplemented Triage and Rapid Treatment (START) improves performance measures in the emergency department. The Journal Of Emergency Medicine, 42(3), 322-328. doi:10.1016/j.jemermed.2010.04.022