Exploring strategies to improve emergency department intake

Background

The emergency department (ED) is the point of entry for nearly two-thirds of patients admitted to the average United States (US) hospital. Due to unacceptable waits, 3% of patients will leave the ED without being seen by a physician.

Objectives

To study intake processes and identify new strategies for improving patient intake.

Methods

A year-long learning collaborative was created to study innovations involving the intake of ED patients. The collaborative focused on the collection of successful innovations for ED intake for an “improvement competition.” Using a qualitative scoring system, finalists were selected and their innovations were presented to the members of the collaborative at an Association for Health Research Quality-funded conference.

Results

Thirty-five departments/organizations submitted abstracts for consideration involving intake innovations, and 15 were selected for presentation at the conference. The innovations were presented to ED leaders, researchers, and policymakers. Innovations were organized into three groups: physical plant changes, technological innovations, and process/flow changes.

Conclusion

The results of the work of a learning collaborative focused on ED intake are summarized here as a qualitative review of new intake strategies. Early iterations of these new and unpublished innovations, occurring mostly in non-academic settings, are presented.     

Use of continuous quality improvement to facilitate patient flow through the triage and Fast-Track areas of an emergency department

Application of Continuous Quality Improvement techniques can identify (a) major causes of delay in evaluation and treatment of ambulatory patients in an Emergency Department (ED) and (b) rational solutions to reduce those delays. To confirm this hypothesis, a prospective interventional study was conducted at a tertiary care teaching hospital with 50,000 emergency visits per year. Participants included all patients discharged from the ED in three separate time periods. A formal continuous quality improvement process was used to document the current process of ambulatory care patient flow and prioritize the causes of delay. Solutions were defined and presented to the hospital administration. Two solutions were implemented immediately. The effect of these changes was assessed by comparing the time interval from presentation to discharge from the ED (length of stay) and the time interval from presentation to generation of a chart (chart generation). These differences were compared by analysis of variance on consecutive patients seen in a 48-hour control period and two postintervention 48-hour periods. The interventions that were identified and immediately implemented were the addition of an admission clerk and the reduction of the Fast-Track nurse function to include only patient placement and vital signs. The length of stay for all patients was significantly reduced from a mean of 163 ± 170 min to 115 ± 86 and 122 ± 105 min in two separate postintervention 48-hour samples. The mean length of stay for Fast-Track patients not requiring X-ray, electrocardiogram, or blood tests was 92 ± 46 min. After the intervention, this was reduced to 73 ± 46 and 67 ± 31 min in the same two 48-hour samples. Chart generation times were significantly reduced from a mean of 21 ± 18 min to 8 ± 6 min. We conclude that the formal application of Continuous Quality Improvement techniques in the Emergency Department can result in appropriate changes in the process of patient flow, leading to measurable and significant reductions in length of stay for Fast-Track patients.     

Review article: Emergency department models of care in the context of care quality and cost: A systematic review

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost‐effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost‐effectiveness.     

Emergency nurse practitioner care and emergency department patient flow: case-control study

Objective: The present study aimed to compare ED waiting times (for medical assessment and treatment), treatment times and length of stay (LOS) for patients managed by an emergency nurse practitioner candidate (ENPC) with patients managed via traditional ED care. Methods: A case–control design was used. Patients were selected using the three most common ED discharge diagnoses for ENPC managed patients: hand/wrist wounds, hand/wrist fractures and removal of plaster of Paris. The ENPC group (n = 102) consisted of patients managed by the ENPC who had ED discharge diagnoses as mentioned above. The control group (n = 623) consisted of patients with the same ED discharge diagnoses who were managed via traditional ED care. Results: There were no significant differences in median waiting times, treatment times and ED LOS between ENPC managed patients and patients managed via traditional ED processes. There appeared to be some variability between diagnostic subgroups in terms of treatment times and ED LOS. Conclusion: Patient flow outcomes for ENPC managed patients are comparable with those of patients managed via usual ED processes.     

Paramedics and triage: Effect of one training session on triage in the emergency department

This 3-stage intervention study enrolled all adult patients referred to a universitybased emergency department (ED) during randomly assigned 1-week preeducation or posteducation periods. Triage decisions recorded by ED paramedics (n=8) both before and after an educational training session were compared to decisions made by emergency physicians (EPs). Triage decisions of paramedics and EPs in the preeducation phase showed poor consistency (κ =0.317, κ=0.388). Triage decisions in the posteducation phase increased slightly but were still found to be low. On the other hand, consistency between the triage assessments recorded by paramedics and EPs of the general appearance of patients increased from low in the preeducation phase to moderate in the posteducation phase (κ =0.327, κ=0.500, respectively). The training session was associated with a slight increase in the consistency of triage decisions recorded by paramedics and EPs.     

Review article: Identifying occupational violence patient risk factors and risk assessment tools in the emergency department: A scoping review

Occupational violence (OV) is a daily risk for ED staff. It contributes to staff stress, sick leave, turn‐over and burn‐out, and limits the capacity of staff to provide unimpeded quality care to patients and their families. Many factors contribute to incidents of OV; however, early detection of such risk factors could pre‐empt incidences of OV during ED episodes of care. A five‐stage methodological framework for scoping reviews was used to identify, summarise and synthesise OV risk factors from five key databases. A validated tool was used to appraise the quality of included studies. Independent evaluation by the reviewers was used throughout. Patient factors were extracted and described from 24 methodologically and geographically diverse papers. Methodological quality for these studies varied from moderate to high. A total of 34 OV risk factors were identified. Although there was variation in, and differences between, staff‐perceived and objective (documented) OV risk factors, patient risk factors can be categorised into three main groups: clinical presentation, behaviours and past history. Five existing ED OV risk assessment tools were identified, with limited supporting evidence for each. The results support the development of a reliable and validated OV risk assessment tool to be initiated at triage.     

Current status of emergency department triage in mainland China: A narrative review of the literature

In this review, the current status of emergency department triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic. Literature was identified through electronic databases, and was included for review if published between 2002 and 2012, included significant discussion of daily emergency department triage in mainland China, was peer reviewed, and published in English or Chinese. Thematic analysis was used to identify themes which emerged from the reviewed literature. This resulted in 21 articles included for review. Four themes emerged from the review: triage process, triage training, qualification of triage nurses, and quality of triage. The review demonstrates that there is currently not a unified approach to emergency department triage in mainland China. Additionally, there are limitations in triage training for nurses and confusion around the role of triage nurses. This review highlights that emergency department triage in mainland China is still in its infancy and that more research is needed to further develop the role of triage.     

Review article: A systematic review of emergency department incident classification frameworks

As in any part of the hospital system, safety incidents can occur in the ED. These incidents arguably have a distinct character, as the ED involves unscheduled flows of urgent patients who require disparate services. To aid understanding of safety issues and support risk management of the ED, a comparison of published ED specific incident classification frameworks was performed. A review of emergency medicine, health management and general medical publications, using Ovid SP to interrogate Medline (1976–2016) was undertaken to identify any type of taxonomy or classification‐like framework for ED related incidents. These frameworks were then analysed and compared. The review identified 17 publications containing an incident classification framework. Comparison of factors and themes making up the classification constituent elements revealed some commonality, but no overall consistency, nor evolution towards an ideal framework. Inconsistency arises from differences in the evidential basis and design methodology of classifications, with design itself being an inherently subjective process. It was not possible to identify an ‘ideal’ incident classification framework for ED risk management, and there is significant variation in the selection of categories used by frameworks. The variation in classification could risk an unbalanced emphasis in findings through application of a particular framework. Design of an ED specific, ideal incident classification framework should be informed by a much wider range of theories of how organisations and systems work, in addition to clinical and human factors.     

A systematic review: The role and impact of the physician assistant in the emergency department

This systematic review describes the role and impact of physician assistants (PAs) in the ED. It includes reports of surveys, retrospective and prospective studies as well as guidelines and reviews. Seven hundred and twelve studies were identified of which only 66 were included, and many of these studies were limited by methodological quality. Generally the use of PAs in the ED is modest with 13–18% of US EDs having PAs although academic medical centres report PA use in 65–68% of EDs. The evidence indicates that PAs are reliable in assessing certain medical complaints and performing procedures, and are well accepted by ED staff and patients alike. There is limited evidence as to whether PAs improve ED flow or are cost‐effective. Future studies on work processes, cost‐effectiveness, unfamiliar patients' willingness to be treated by non‐physician providers, and ED physicians' acceptability of PAs are needed to inform and guide the integration of PAs into EDs.     

Review article: Common emergency department presenting complaints of prisoners: A systematic review

Prisoners are a particularly vulnerable minority group whose healthcare needs and management differ substantially from the general population. The overall burden of disease of prisoners is well documented; however, little is known regarding the aetiology and frequency of prisoners’ acute medical complaints requiring an ED visit. Objectives of the review were to identify, review and appraise existing literature regarding prisoners’ presentations to EDs. We performed systematic electronic searches in MEDLINE, EMBASE, PsycINFO, PubMed, Cochrane, and Web of Science using MeSH terms and keywords. Two reviewers abstracted data and conducted quality appraisal using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Nine articles met the predefined inclusion criteria. Apart from two European studies in the past 5 years, there is a scarcity of literature primarily addressing the common presenting complaints to EDs by prisoners. Existing studies demonstrated that prisoners have a disproportionately high burden of traumatic, infectious and psychiatric disease requiring emergency treatment. With the increasing number of emergency presentations made by prisoners each year, it is vital that further research is undertaken to identify trends of these acute medical complaints in order to ensure optimal therapeutic outcomes for prisoners.     

Review article: A scoping review of physiotherapists in the adult emergency department

To provide an overview of the literature that considers physiotherapists working in the ED in relation to their roles, training levels, patient profile, safety, effectiveness, efficiency, cost-effectiveness and the provision of low-value care. We performed a scoping review of the literature. Four databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched from their inception to December 2016 and we updated searches on PubMed in September 2017. Two reviewers independently screened studies for eligibility. We performed a narrative synthesis of quantitative data. We included 27 studies: five randomised controlled trials (n = 1434), 12 prospective observational studies (n = 153 767), six retrospective studies (n = 9968), two survey studies (n = 61), one case report (n = 3) and one qualitative study (n = 11). Physiotherapists primarily managed patients with low urgency musculoskeletal conditions. Physiotherapists appeared to have similar clinical effectiveness and costs compared to other health providers (four randomised controlled trials). Physiotherapists were associated with increased efficiency (eight observational studies) and reduced low-value care (one observational study). Three observational studies reported very low adverse event rates. However, none of the studies followed participants to measure adverse events that became apparent after the ED visit, nor did they consider unsafe discharge decisions or suboptimal follow-up care. The available evidence suggests that physiotherapists may be as effective as other health providers in managing low urgency musculoskeletal conditions in the ED. There is uncertainty about appropriate training and a lack of robust studies investigating the efficiency, safety and cost-effectiveness of this model of care.     

Review article: Scoping review of the characteristics and outcomes of adults presenting to the emergency department during heatwaves

As a result of climate change heatwaves are expected to increase in frequency and intensity and will have detrimental impacts on human health globally. EDs are often the critical point of care for acute heat illnesses and other conditions associated with heat exposure. Existing literature has focused on heatwave-related hospitalisation and mortality. This scoping review aimed to identify, evaluate and summarise current literature regarding patient characteristics and outcomes of ED admissions from heatwaves. A scoping review of the literature was conducted using six databases: Medline, EMBASE, EMCARE, CINAHL, PsycINFO, and Scopus, using MeSH terms and keywords related to ‘heatwave’ and ‘Emergency Department’. Articles were included if they were: published in English from January 2000 to August 2021, related to ED, and examined high temperature periods consistent with heatwave criteria. Articles were appraised using the Mixed Methods Appraisal Tool (MMAT). Thirty-one studies were included, mostly from the United States, Australia, and France. The study designs include retrospective case analysis, case–control, and time-series analysis. Eight studies examined known heatwaves, 21 used different criteria to identify heatwave occurrence, and two focused on heat-related illness. The selected articles display a moderate-high quality on MMAT. ED admissions for both heat-related illnesses and other conditions increased during heatwaves, with up to 18.5 times risk increase. The risk was elevated for all population groups, and substantially in the elderly, male patients with certain comorbidities, medications, or lower socioeconomic status. Outcomes including hospitalisation and mortality rates after ED admissions showed positive associations with heatwaves. The heatwaves resulting from climate change will place increasing demands on EDs providing care for increasingly susceptible populations. Significant public heatwave planning across multiple sectors is required to reduce the risk of overwhelming EDs with these patients.     

Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient

Clinical communication and recognising and responding to a deteriorating patient are key current patient safety issues in healthcare. The aim of this literature review is to identify themes associated with aspects of the hospital clinical handover between paramedics and ED staff that can be improved, with a specific focus on the transfer of care of a deteriorating patient. Extensive searches of scholarly literature were conducted using the main medical and nursing electronic databases, including Cumulative Index to Nursing and Allied Health Literature, Medline and PubMed, during 2011 and again in July 2012. Seventeen peer‐reviewed English‐language original quantitative and qualitative studies from 2001 to 2012 were selected and critically appraised using an evaluation tool based on published instruments. Relevant themes identified were: professional relationships, respect and barriers to communication; multiple or repeated handovers; identification of staff in the ED; significance of vital signs; need for a structured handover tool; documentation and other communication methods and education and training to improve handovers. The issues raised in the literature included the need to: produce more complete and concise handovers, create respectful and effective communication, and identify staff in the ED. A structured handover tool such as ISBAR (a mnemonic covering Introduction, Situation, Background, Assessment and Recommendations) would appear to provide a solution to many of these issues. The recording of vital signs and transfer of these data might be improved with better observation systems incorporating early warning strategies. More effective teamwork could be achieved with further clinical communications training.     

Nurse-led interventions for cancer patients in emergency departments: Systematic review

BackgroundThe Australian government introduced national emergency access targets in 2011 to improve emergency department efficiency. Innovative nursing models of care could achieve these targets with cancer patients, who often present to emergency departments with treatment-related toxicities and poorly-managed symptoms.AimTo investigate whether national emergency access-like targets are achievable with interventions led by Advanced Practice Cancer Nurses when cancer patients attend Emergency Departments.MethodAuthors searched electronic databases CINHAL, MEDLINE and Cochrane to July 2016. Outcomes included length of stay, adverse events, patient satisfaction, and cost effectiveness. Two reviewers independently conducted data extraction and risk of bias assessment using standard Cochrane methodology.ResultsOf the 579 titles retrieved, six randomised control trials met identified eligibility criteria. Nurse-led interventions significantly reduced emergency departments’ length of stay in two studies and improved patient satisfaction in two studies without affecting mortality, readmission and re-examination. Cost data could not be translated to the Australian context because of different salary scales and funding models.DiscussionThis review did not identify investigations of any nurse-led interventions to improve national emergency access-like targets in presenting cancer patients. While it is unclear if Advanced Practice Cancer Nurses can treat cancer patients more efficiently as standard care, there is some indication that Advanced Practice Cancer Nurses might be able to deliver improved length of stay for cancer patients in emergency departments.ConclusionRigorous research is needed to implement and evaluate this role at the interface of the emergency departments and the cancer setting.     

Review article: Effectiveness of ultra‐brief interventions in the emergency department to reduce alcohol consumption: A systematic review

To assess the effectiveness of ultra‐brief interventions (ultra‐BI) or technology‐involved preventive measures in the ED to reduce alcohol harm and risky drinking. Medline, Embase, PsycINFO, CINAHL and EBM reviews were searched for articles published between 1996 and 2015. Randomised controlled trials and quasi‐randomised trials, which compared an ultra‐BI with screening, standard care or minimal intervention for adults and adolescents at risk for alcohol‐related harm presenting to an ED, were included. Outcomes of interest were frequency of alcohol consumption, quantity of alcohol consumed, binge drinking and ED representation. Thirteen studies (nine single centre and four multicentre) were included. Six studies showed a significant reduction in the quantity consumed with intermediate effect size at 3 months (d = ?0.40) and small effect size at 12 months (d = ?0.15). Two studies showed a significant reduction in binge drinking with small effect size at 3 months (d = ?0.12) and 12 months (d = ?0.09). No studies showed an effect on frequency of alcohol consumption or ED representation. Heterogeneity in study design, definition of risky, harmful or hazardous alcohol use, intervention types, outcomes, outcome timeframes and outcome measures prevented the performance of quantitative meta‐analysis. Despite its limited effectiveness in reducing alcohol use in the short‐term, with the large number of people attending EDs with risky drinking, the use of an effective ultra‐BI would have the potential to have a measurable population effect.