Emergency Department Patient Flow: The Influence of Hospital Census Variables on Emergency Department Length of Stay

Objectives:  The objective was to evaluate the association between hospital census variables and emergency department (ED) length of stay (LOS). This may give insights into future strategies to relieve ED crowding.
Methods:  This multicenter cohort study captured ED LOS and disposition for all ED patients in five hospitals during five 1-week study periods. A stepwise multiple regression analysis was used to examine associations between ED LOS and various hospital census parameters.
Results:  Data were analyzed on 27,325 patients on 161 study days. A significant positive relationship was demonstrated between median ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the percentage of ED patients admitted each day. There was no relationship in this cohort between ED LOS and ED volume, total hospital occupancy rate, or the number of scheduled cardiac or surgical procedures.
Conclusions:  In multiple hospital settings, ED LOS is correlated with the number of admissions and census of the higher acuity nursing units, more so than the number of ED patients each day, particularly in larger hospitals with busier EDs. Streamlining ED admissions and improving availability of inpatient critical care beds may reduce ED LOS.     

Retention Priorities for the Intergenerational Nurse Workforce

TOPIC.  Retention of senior, Gen-X, and Millennial nurses is influenced by manager interactions and efforts to create a satisfying work experience.
PURPOSE.  The purpose of this project was a generational assessment of job satisfaction, work environment, and desired characteristics of managers in an effort to improve nurse retention.
SAMPLE AND METHODS.  Data from staff nurses at 22 southern hospitals collected by online survey included measures of job satisfaction and perceptions of safety, the Nurse Manager Desired Traits survey, and the Nursing Work Index-Revised.
FINDINGS.  The satisfaction with work environment scores for the whole group ( n =  1,773) were high. Subscale scores showed highest satisfaction with nurse/physician relationships; lowest was nurse control of practice. A specific satisfaction question showed the younger nurses were less satisfied than those over age 40. Nurse safety concerns were expressed by 40% of the sample. One third of Millennial nurses plan to leave their job within the next 2 years. Over two thirds plan to be gone within the next 5 years. Especially alarming is the fact that 61% of the nurse group stated they plan to leave their current jobs within 10 years.
RECOMMENDATIONS.  (a) Create model managers; (b) empower staff nurse councils; (c) stabilize staffing; (d) revamp incentives; and (e) focus on safety.     

The effect of variations in nurse staffing on patient length of stay in the acute care setting

This study examines the relationship between nurse staffing and patient length of stay (LOS). Data were collected on nurses employed and patients admitted to one of four study units located in two Midwest hospitals. Three nursing variables (hours per patient day [HPPD], skill mix, and nursing expertise) were collected through survey and administrative forms. The nursing data were then linked with patient-specific characteristics (deviation from expected LOS) to test the relationship at the patient level of analysis. Average HPPD was a positive predictor of deviation from expected LOS, whereas overall expertise was a negative predictor of deviation from expected LOS. Higher staffing levels may result in patients being discharged sooner than expected. Nurse administrators must consider the quantity as well as quality of staff when determining optimal staffing levels. Unit staffing levels must include nurses who have both experiential and theoretical knowledge in order to achieve optimal patient outcomes.     

Situational and dispositional predictors of nurse manager burnout: a time-lagged analysis

Background  Burnout among nurses is a serious condition that threatens their own health and that of their patients. In current health care settings, nurses are particularly at risk for burnout given the increased patient acuity and the worsening nursing shortage.
Aim  This study examined the influence of effort-reward imbalance, a situational variable, and core self-evaluation, a dispositional variable, on nurse managers' burnout levels over a 1-year period.
Methods  A predictive longitudinal survey design was used to examine the relationships described in the model. One hundred and thirty-four nurse managers responded to a mail survey at two points in time.
Results  As hypothesized, both personal and situational factors influenced nurse manager burnout over a 1-year time frame. Although burnout levels at Time 1 accounted for significant variance in emotional exhaustion levels 1 year later (β = 0.355), nurses' effort-reward imbalance (β = 0.371) and core self-evaluations (β = −0.166) explained significant additional amounts of variance in burnout 1 year later.
Conclusion  Both personal and situational factors contribute to nurse manager burnout over time.
Implications for nursing management  Managers must consider personal and contextual factors when creating work environments that prevent burnout and foster positive health among nurses at work.     

Principle-based concept analysis: recognition in the context of nurse–patient interactions

Title.  Principle-based concept analysis: recognition in the context of nurse–patient interactions.
Aim.  This paper is a report of a principle-based concept analysis of recognition in the context of nurse–patient interactions.
Background.  Recognition is a concept employed in practice and research. Since nursing is patient-centred and care is problem-driven, the specificity and accuracy of recognition may have an impact on how nurses label patient phenomena, interventions initiated and patient outcomes.
Data sources.  The data set included 98 English language articles published from 1997 to 2008 and retrieved through Medline and CINAHL searches.
Methods.  Principle-based concept analysis was used to examine the state of the science according to major perspectives of the philosophy of science. Conceptual components were integrated into a theoretical definition and the process of recognition was conceptually modelled.
Findings.  The scientific literature dealing with recognition in the context of nurse–patient interactions relies on implied meaning. Recognition is a process marked by an awareness of evidence coupled with the formulation of a conceptual label summarizing the identified pattern of patient phenomena. Contextual features of the nurse, patient and organization are relevant during nurse–patient interactions, resulting in pivotal points in nursing care. These pivotal points are the moments of recognition when the nurse consciously applies a summary label to interpreted evidence. Outcomes of recognition include a choice to act or not to act, each option carrying significant outcomes for nurses, patients, and at times, organizations.
Conclusion.  A working definition was produced that will serve as a foundation for future concept-driven research to advance the concept toward greater precision and usefulness in nursing science.     

Patient acuity: a concept analysis

Title.  Patient acuity: a concept analysis.
Aim.  This paper is a report of a concept analysis of patient acuity.
Background.  Patient acuity is a widely-used term in the health sciences literature, but often without specification of its exact meaning. Concept clarification is therefore needed to delineate the meaning of patient acuity.
Data sources.  A review of the Pubmed, CINAHL, MEDLINE and PsychInfo databases for the keyword 'acuity' in the title or abstract of papers in English language journals, as well as searches for the term 'acuity' and 'acute' in the Merriam-Webster and Oxford English Dictionaries were the data sources for this concept analysis. Papers were excluded if 'acuity' was not present in the title or abstract. Publication dates of the literature included in the review ranged from 1974 to 2008.
Findings.  The attributes of acuity are severity, intensity and the pairing of acuity measurements with another concept. These attributes were organized according to Holzemer's Outcomes Model for Health Care Research as patient-, provider- or system-related. The sub-categories of attributes identified were physical, psychological, nursing care needs, workload, complexity, case-mix, patient classification systems, urgency/triage scales and other uses.
Conclusion.  Researchers are encouraged to specify which attribute of acuity they are studying and to develop measurement tools specific to that attribute, in order to move the science towards standardization of the concept of acuity and its measurement.     

Emergency Department Patient Satisfaction: Examining the Role of Acuity

OBJECTIVES: To explore the relationships between patient acuity, perceived and actual throughput times, and emergency department (ED) patient satisfaction. The authors hypothesized that high-acuity patients would be the most satisfied with their throughput times, as well as the overall ED visit. The authors also expected overall ED satisfaction to be more strongly associated with perceived throughput times compared with actual throughput times, regardless of acuity. METHODS: This was a prospective survey of 1,865 ED patients at a large, inner-city hospital during a one-month period. Data were collected on patient demographics, acuity of patient illness, actual waiting time for evaluation by a physician, and actual overall length of stay. Patient satisfaction with various throughput times (i.e., perceived throughput time) and overall ED visit was assessed by using a seven-point scale (1 = poor, 7 = excellent). Analysis of variance, analysis of covariance (ANCOVA), and correlations were conducted to explore the hypotheses. RESULTS: Patients with "emergent" acuity perceived their throughput times more favorably and were more satisfied with their overall ED visit compared with "urgent" and "routine" patients (all p < 0.01). Once the effects of perceived throughput time were controlled for by using an ANCOVA, acuity no longer predicted overall ED satisfaction. Correlations showed that overall ED satisfaction was more closely linked to perceived throughput times than to actual throughput times (average r = 0.62 vs. -0.12). CONCLUSIONS: "Emergent" patients are more satisfied than "urgent" and "routine" patients with their ED visits. "Emergent" patients perceived their throughput times more favorably than other patients, especially their wait for physician evaluation. Changing perceptions of throughput times may yield larger improvements in satisfaction than decreasing actual throughput times, regardless of patient acuity.     

The power of partnership to shape the future of nursing: the evolution of the clinical nurse leader

Aim(s)  This article describes the evolution of the clinical nurse leader role and demonstrates the vital nature of partnerships between academia and practice in the design and implementation of this new role.
Background  The health care system as it exists in the United States may put patients at risk in terms of safety and quality of care. Nursing leadership from across the US recognized a need for nursing practice and academia to work in partnership to develop workable and effective solutions. The vision was of a nurse generalist who would be prepared to address the complexities that make the current systems dysfunctional.
Evaluation  Review, share experiences and discuss the benefits of engaging stakeholders with broad and diverse viewpoints.
Key issues  Engaging a group of stakeholders with diverse backgrounds, varied world views and experiences for the purpose of developing common mutually beneficial goals, creates synergy and greater commitment to the goals, which results in success.
Conclusion(s)  The power of partnership in the development and implementation of the CNL is evident. Old ways of trying to 'go it alone' are no longer viable in a complex health care environment.
Implications for nursing management  With continued collaboration, practice and academia can continue to confront challenges and develop effective solutions.     

Effect of case managers with a general medical patient population

The objectives of this study were to evaluate the effect of inpatient case management (CM) on a general medical service and to determine if a prediction rule, identifying patients likely to need discharge planning services, could define a subset of patients for whom CM would be most effective. We hypothesized that CM would have greatest impact on patients predicted to be at highest risk of needing discharge planning to arrange for post-discharge medical services. We carried out a prospective controlled study. Six general medicine teams from a 600-bed urban teaching hospital were randomly assigned to CM (n = 4) or standard care (SC) (n = 2). Number of patients = 302 (207 CM; 95 SC). Case managers participated in daily physician team rounds and coordinated discharge planning for CM patients; SC patients received discharge planning from staff nurses or discharge planners when requested by physicians. The outcomes measured were deviation from the hospital length of stay (LOS) expected for a patient's diagnosis, patient satisfaction and non-acute medical service utilization during the month after discharge. Overall, patients from CM and SC teams did not differ in their deviation from expected LOS, post-discharge medical service utilization and patient satisfaction. However, after stratifying patients by their predicted need for post-discharge medical services, only patients in the 'high risk' category had a significantly shorter LOS under CM (2.9 days shorter than SC patients; P = 0.02). We concluded that, in this study, the effect of case managers on a general medical service was limited to shortening LOS only among a stratum of high risk patients.     

Predictors of patient satisfaction with inpatient hospital nursing care

The purpose of this predictive nonexperimental study was to investigate the influence of registered nurse (RN) job satisfaction, context of care, structure of care, patient-perceived nurse caring, and patient characteristics on patient satisfaction with inpatient hospital nursing care in an academic medical center in north-central West Virginia. Convenience samples of patients (N = 362) and RNs (N = 90) were recruited from two medical units, two surgical units, and three intensive care step-down units. Causal modeling identified patient-perceived nurse caring as the major predictor of patient satisfaction, with nurse/physician (RN/MD) collaboration as the only other direct predictor. Age had an indirect influence on patient satisfaction. Strategies to achieve and maintain patient satisfaction should address the enhancement of patient-perceived nurse caring and RN/MD collaboration.     

Non-psychiatric hospitalization of people with mental illness: systematic review

Title.  Non-psychiatric hospitalization of people with mental illness: systematicreview.
Aim.  This paper is a report of a literature review of the evidence regarding outcomes experienced by severely mentally ill individuals hospitalized in general medical-surgical settings for non-psychiatric conditions.
Background.  Severely mentally ill individuals experience chronic medical illnesses at a rate greater than the general population. When hospitalized in non-psychiatric settings, they tend to be experienced as 'difficult' by nurses and to have longer lengths of stay.
Data sources.  The CINAHL and PUBMED databases were searched from 1 to 9 March 2008 to identify studies published between 1998 and 2008 investigating outcomes among people with mental illness hospitalized for non-psychiatric illness in general hospitals.
Methods.  Included studies were those published in English in peer reviewed journals and investigating patient outcomes. The studies were reviewed for relevance and inclusion criteria; the methodological quality of studies was not evaluated.
Results.  Twelve studies met inclusion criteria. All studies examining length of stay, costs of care or resource utilization showed increased measures for patients with psychiatric comorbidity. Interventions described included psychiatric liaison psychiatry and nursing, which failed to demonstrate improvement in outcomes.
Conclusion.  Nurses play a pivotal role in improving the inpatient care of this vulnerable population, but they struggle in their attempts to do so. Research to determine the best approaches to promote nurses' knowledge, positive attitudes and self-confidence in caring for patients with psychiatric comorbidity is needed. Investigation of the patient perspective on the inpatient experience might also provide insight for designing effective care processes.     

Improving geriatric transitional care through inter-professional care teams

Objectives  The aim of this study was to examine the impact of the use of an inter-professional care team on patient length of stay and payer charges in a geriatric transitional care unit.
Methods  An analysis of de-identified administrative records for transitional care patients for the 12-month period (2003–2004) cared for by the inter-professional team ( n  = 163) and cared for by traditional single provider care model ( n  = 176) was carried out. We conducted logistic regression on length of stay and charges controlling for patient demographics and acuity levels.
Results  The inter-professional care team patients had significantly shorter lengths of stay, fewer patient days and lower total charges. Patient diagnosis and acuity were similar across groups.
Conclusion  This study provides empirical evidence of the impact of an inter-professional care model in providing cost-effective transitional care in a nursing home setting. Evidence of shorter lengths of stay, shorter patient days and lower charges suggests benefit in the development and financing of inter-professional care teams for transitional care services.     

Effects of a nurse practitioner on a multidisciplinary consultation team

Title.  Effects of a nurse practitioner on a multidisciplinary consultation team.
Aim.  This paper is a report of a study to evaluate the impact on office hours capacity, patient satisfaction, quality of life and costs of including a nurse practitioner in a multidisciplinary consultation team for patients with hand problems caused by rheumatoid arthritis.
Background.  Over 90% of patients with rheumatoid arthritis suffer symptoms in their hand joints and may be seriously disabled in performing daily, work or leisure activities. A recent promising development in the treatment of patients with a chronic disease is the co-ordinating and accompanying role of a nurse, such as a nurse practitioner, in a multidisciplinary treatment team.
Methods.  A two successive group time-series design was adopted. The intervention group ( n  = 78) visited a clinic with a nurse practitioner assigned to the team during 2003–2004. The control group ( n  = 69) was seen before inclusion of the nurse practitioner. Office hours capacity, patient satisfaction, quality of life and costs were assessed using questionnaires directly after consulting the team, and 3 and 6 months later.
Results.  Between-group comparisons of patient satisfaction and quality of life revealed no statistically significant differences. Changes within groups over time were not demonstrable. Mean office hour capacity increased by 17% ( t  = −1·906, d.f. = 32·879, P  = 0·065). The costs for professional home care or informal care were equal in the two groups.
Conclusion.  Evaluation of clinical practice using pre- and post-test design was impeded by changes in clinical practice, which made concrete conclusions difficult to draw. In future studies the satisfaction of participating clinicians should be evaluated, in addition to that of patients.     

Paediatric nurse practitioner managed cardiology clinics: patient satisfaction and appointment access

evangelista j.-a.k., connor j.a., pintz c., saia t., o'connell c., fulton d.r. & hickey p. (2012)?Paediatric nurse practitioner managed cardiology clinics: patient satisfaction and appointment access. Journal of Advanced Nursing68(10), 2165-2174. ABSTRACT: Aim. This article summarizes a comparative study of patient/family satisfaction and appointment wait times in physician managed vs. paediatric nurse practitioner managed cardiology clinics. Background. Appointment wait times exceeded 40?days in the outpatient cardiology department at a children's hospital. To address the gap in available appointments, paediatric nurse practitioner managed cardiology clinics were implemented. Methods. A sample of 128 patients who presented concurrently in physician or paediatric nurse practitioner managed cardiology clinics from December 2009 through February 2010 was recruited for participation. The hospital's ambulatory patient satisfaction survey was utilized to measure level of patient satisfaction with care. Survey responses were evaluated using Fisher's exact test. Appointment wait times were compared pre and post implementation of paediatric nurse practitioner managed clinics. Results. Sixty-five physician families and 63 paediatric nurse practitioner families completed the satisfaction survey. There was no statistically significant difference in patient satisfaction between clinic types. Appointment wait time decreased from 46 to 43?days, which was not statistically significant. Paediatric nurse practitioner clinics included a statistically higher percentage total of urgent appointments compared to that in physician clinics. Conclusions. Paediatric nurse practitioner managed cardiology clinics are a strategic solution for improving patient access and facilitating high quality patient care while earning high levels of patient satisfaction. This healthcare delivery model illustrates the potential for expanded utilization of advanced practice nurses.     

A patient education MAP: an integrated, collaborative approach for rehabilitation.

Because Roosevelt Warm Springs Institute for Rehabilitation has been faced with decreasing patient lengths of stay, increasing patient acuity, and changes in the nurse staffing mix, nurses wanted to ensure that patients and their families were receiving appropriate education and learning the skills required to provide safe and competent self-care in the home. As a result, they developed a patient education action plan. This multidiscipline action plan (MAP) involved changing from a multidisciplinary to an interdisciplinary approach toward patient and family education. This plan provides a framework that is linked to expected outcomes for education during a patient's stay, reduces the redundancy of patient education by professionals from different disciplines, and increases collaboration. Teaching modules that outline and provide all of the information an educator needs to effectively teach a patient or group of patients make up the basis for the MAP system. This article describes the MAP system and the related continuous quality improvement activities, offers documentation forms, and identifies a structural path.     

Gender role attitudes of hospital nurses in Japan: Their relation to burnout, perceptions of physician–nurse collaboration, evaluation of care, and intent to continue working

Aim:  The purpose of the present study is to examine the relationship between gender role attitudes of nurses and burnout, perceptions of physician–nurse collaboration, evaluation of care, and intent to continue working.
Methods:  The subjects of the study were 798 full-time female nurses working in non-managerial positions at three large hospitals. We analyzed five key survey items – gender role attitudes, burnout, perceptions of physician–nurse collaboration, evaluation of care, and intent to continue working – and showed how these items are related using structural equation modeling.
Results:  Whether nurses' gender role attitudes were egalitarian or conservative, we found a direct positive effect on burnout. However, a conservative gender role attitude not only showed a direct positive effect on burnout, but also exhibited a direct negative effect on the intent to continue working and on the collaboration constructs cooperativeness with physicians. Conservative gender role attitudes thus have an indirect positive effect on burnout through the corollaries cooperativeness and intent to continue working. We found that cooperativeness not only has a direct negative effect on burnout, but also an indirect negative effect on burnout through evaluation of care.
Conclusions:  It was found that nurses harboring conservative gender role attitudes are more vulnerable to burnout, and also less likely to improve their quality of care.     

The clinical nurse leader: a catalyst for improving quality and patient safety

Aim  The clinical nurse leader (CNL^®) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice.
Background  Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources.
Method  A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region.
Results  Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model.
Conclusions  With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs.
Implications for nursing management  Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings.     

Impact of Disaster Drills on Patient Flow in a Pediatric Emergency Department

Objectives:  Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-accredited hospitals must conduct disaster drills twice a year, with one incorporating a mass casualty incident to the emergency department (ED). The authors found no studies describing the potential negative impact on the quality of care real patients in the ED receive during these drills. The objective was to determine the impact that mass casualty drills have on the timeliness of care for nondisaster patients in a pediatric ED.
Methods:  Since 2001, nine disaster drills involving mass casualties to the ED were conducted at the authors' institution. The authors studied 5-, 10-, and 24-hour blocks of time surrounding these events and defined quality measures as the timeliness of care in terms of length of stay (LOS) in ED, time-to-triage, and time-to-physician. Drill dates were compared with control dates (the same weekday on the following week). Paired t-tests were used to compare outcomes of interest between drill and control days.
Results:  Nine drill days and nine control days were studied. There was no statistically significant difference between drill dates and control dates in average time-to-triage and time-to-emergency physician and average ED LOS. Admitted patients spent less time in the ED during drill dates.
Conclusions:  Disaster drills at this institution do not appear to significantly affect the timeliness of care to nondisaster drill ED patients. Attention should be paid to the quality of care "real" patients receive to ensure that their care is not jeopardized during an artificial stress to the system during a disaster drill.