Patient Care in Emergency Departments

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Introduction

Hospitals have emergency departments (ED) for the specific purpose of providing medical care to patients who come to the facility without prior appointment. In most cases, the patients are brought in with conditions that require immediate attention from the medical staff. To this end, EDs are required to provide initial treatment to illnesses and injuries that may be life threatening (Quin 2000, p. 404). Operations in EDs go on for 24 hours, except in cases where patients and staff volumes are low. In the current paper, the author examines the process of care at the ED for patients presenting with chest pains. The study relies on data from a general hospital with a bed capacity of 100.

Care in an ED is provided though an 8 step process. To this end, practitioners are advised to make use of a time flow sheet in the assessment of cases presented to hospitals for primary care. Table 1 is an ideal time flow chart:

Table 1: Time Flow Chart

The patient flow table illustrates all the procedures carried out on a patient. As already mentioned, the author of this paper will examine the care provided to patients who are presented to the ED with chest pains. The first step involves registration. Particulars of the patient, such as their age and gender, are recorded. From here, the client is taken through the triage. According to Carson, Clay, and Stern (2010, p. 17), a triage is the immediate sorting of patients according to the seriousness of their condition. The other steps include placement on a bed as the patient awaits a doctor’s visit.

A series of tests, which include ECG, blood analysis, and x-rays, are carried out. Once the shift ends, an assessment of the patient is made (Carson et al. 2010, p. 18). Consequently, a decision to admit or discharge the client is arrived at based on the outcome of the shift assessment. A time-flow sheet is used to develop an ideal map of the process involved to provide care to patients. Consequently, issues like throughput time, value added time, and non-value added time can be calculated from the time-flow charts.

In this paper, a sample of 9 patients was obtained from the ED of the general hospital. The time metrics for each patient are illustrated in the paper, together with a map of the process of care. The data is used to establish points of delay within the primary care process. According to Carter et al. (2010, p. 22), once the points of delay are identified, it is possible to improve the process. To this end, the report provides an ideal future state value stream map for care at the ED.

Literature review

Overview of Chest Pain Treatment in Emergency Departments

Emergency departments are overwhelmed with incidences of people presenting serious conditions for treatment. A study by Quin (2001, p. 406) illustrates that many patients who come to EDs complain of chest pains. Quin (2001, p. 406) makes reference to the United States where chest pains make up for approximately 6% of attendance at EDs. The pain is associated with a number of conditions. One of them is acute coronary ailment. To this end, the process of care in such cases should ensure that triage identifies the patients with an acute coronary syndrome.

Effective treatment of an acute coronary syndrome depends on early diagnosis. The report by Carter et al. (2010, p. 32) indicates that patient care for individuals with chest pains suffers a setback when it comes to the discharge process. Carter et al. (2010, p. 32) suggest that premature discharge of such patients may result in fatalities. Negligence on the part of the doctor can impact heavily on their career. Consequently, time-flow sheets provide an ideal procedure for patient care at the ED.

The diagnosis of chest pain related illnesses is largely dependent on the mode of testing carried out on a patient. Quin (2000, p. 404) observes that the problem with emergency assessment patients is the limitations of diagnostic tests for acute or chronic related pains. For instance, electrocardiography (ECG) is used in the diagnosis of acute myocardial infarction. The study by Quin (2000, p. 404) found that only 40% to 65% of patients make use of the ECG. The diagnosis is even less useful among patients with unstable angina. Serum markers for myocardial necrosis can diagnose approximately 66% of patients with acute myocardial infarction on their arrival at the ED. The above are some of the diagnostic difficulties faced by physicians, which may result in misdiagnosis. ED physicians have a low capacity for taking in patients presenting with chest pains. The situation is especially critical when diagnosis is inconclusive.

The argument by Quin (2000, p. 403) illustrates the challenges faced by medical practitioners in EDs. Chest pains require complex testing procedures. Unfortunately, not many hospitals have the necessary equipment required for diagnosis of chest related ailments. Quin (2000, p. 404) points out that the success rate of diagnosis is usually around 63% in most EDs in the US. Nevertheless, the traditional approach to diagnosis for chest pains is expensive. In addition, it takes time to ascertain one’s exact ailment.

The challenges associated with the diagnosis of patients with chest pains create the need to examine ED units meant to cater for such cases. The process is evaluated to ensure that patients are provided with quality medical care (Carson et al. 2010, p, 41). The review of literature focuses on patients presented to the ED with symptoms associated with acute coronary syndrome. In the United States, the first unit for chest evaluation was established in 1981. According to Quin (2000, p. 405), chest pain care in EDs evaluates clinical effectiveness and proper patient care management in hospitals.

The degrees of pain are illustrated in the definition provided by Conway and Higgins (2011). The various terms are defined below:

Acute pain

It is pain that occurs suddenly, but which does not last for long. It is associated with a specific event, injury, or illness. Acute pain can be managed at an individual level when patients acquire over-the-counter medication. It can be a recurrent problem with pain episodes interspersed with pain-free periods.

Chronic pain

It is defined as long lasting discomfort. The pain can last for more than 6 months. In most cases, chronic pain is difficult to treat. It can be managed for many patients, but cure may be unlikely. Chronic pain can affect every aspect of a person‘s life with respect to their ability to work and perform common tasks. Persons with this discomfort find it difficult to maintain friendships and family relationships. ED helps to restore such patients to their normal routine.

Conway and Higgins (2011, p. 11) argue that patient care in the ED is dependent on the ability of the professionals to distinguish between the two types of pain.

Patient Management at Emergency Departments

Literature review on patient management with respect to chest pain evaluates the approach undertaken. The study by Quin (2000, p. 405) identifies 8 peer reviewed articles that discuss patient management in EDs. According to Quin (2000, p. 405), chest pain units should be located within the ED or somewhere close. Medical employees in such facilities focus on establishing risk levels depending on the nature of the chest pain. For instance, Quin (2000, p. 405) points out that non-traumatic chest pains pose a low risk with respect to acute myocardial infarction.

Medical practitioners face a huge task of identifying the exact illness relating to chest pains. The study by Quin (2000) points out that an effective diagnosis relies on an appropriate testing and triage procedures. The triage phase relies on the patient’s history, while the testing stage requires effective equipment. Quin (2000, p. 405) argues that the Goldman algorithm is the appropriate tool to use in triage. The algorithm is a validated tool that separates patients with chest pain into groups with differing degrees of discomfort. The separation is dependent on the history, examination, and ECG findings.

Effective patient management requires adherence to the protocols of ED. Carson et al. (2010, p. 77) recommend the use of time-flow sheets. The step-by-step procedure enhances the testing processes. As illustrated in Table 1, the time flow sheet exhausts all possible testing avenues before a diagnosis can be established. Patient management at an ED with respect to chest pains is dependent on strict adherence to the procedures illustrated in the time flow sheet.

The Process of Care for Chest Pains at EDs

Emergency workers deal with a number of situations. Chest pain is one of the most common chronic conditions presented to them. In this regard, studies have been carried out to evaluate the best techniques of an effective chronic care. For instance, the study by Conway and Higgins (2011, p. 98) found that there are special strategies aimed at providing chronic care at emergency departments. The primary objective of this care is to avert progression of complications associated with the chronic disease suspected.

The procedures recommended for application in an ED environment are meant to maximize the wellbeing and quality of life of the patient. According to Conway and Higgins (2011, p. 88), the care given to patients at an ED is sufficient to warrant a discharge. Consequently, effective patient care at the ED helps to decongest wards by avoiding unnecessary admissions. The arguments raised by scholars seek to evaluate the process of patient care to understand the models that can be applied.

The process of care in an ED environment is understood by elaborating all the requirements. In this regard, a suitable study evaluates the following questions, which are commonly raised:

1. What are some of the models of care for pain management that have been implemented and evaluated for their effectiveness in the ED settings?
2. How are hospital in-patient, ED, and out-patient pain services tailored to address chest pains?
3. Which models of care produce positive outcomes at individual and hospital levels?
4. Which models of care have no evidence of a positive outcome?

Existing studies on the subject demonstrate a strong conceptual commitment to the bio-psychosocial model of pain. Consequently, time flow sheets are developed to provide the necessary treatment strategies, which can be implemented to address increasing cases of chest pain in EDs (Conway & Higgins 2011, p. 4). The bio-psychosocial approach is the most recommended model of care for patients who come to the ED with chest pains. The model focuses on individual outcomes. However, Conway and Higgins (2011, p. 4) suggest that most ED members of staff are unfamiliar with this form of pain management. Such a review supports the need for a step-by-step procedure of care. Figure 1 is an illustration of an ideal model that can be used when carrying out patient care at an ED.

Patient registration

Patient care begins with the registration of clients upon entry into the ED. In this phase, particulars of the patient are recorded. According to Quin (2000, p. 405), the registration involves gathering information about the age, gender, occupation, and insurance details of the patient. The major objective of this phase is to place the patient in the hospital’s system for treatment and subsequent billing.

Triage

As already mentioned, triage is the process through which patients are sorted based on the degree of seriousness their conditions present. Carson et al. (2010) argue that “the terms ‘triage’ and ‘see and treat’’ are used confusingly” (p. 16). Patient care at ED views the two definitions in a unique manner. They are believed to be mutually exclusive. Triage can be carried out by any medical practitioner. However, the ‘see and treat’ process is a procedure carried out by a doctor. Triage evaluates the need for urgency in the provision of treatment to the patient.

There are different types of triages normally applied in an ED setting. According to Quin (2000, p. 404), the following are the main types of triages in the medical field:

1. Simple triage
2. Reverse triage
3. Undertriage
4. Continuous integrated triage
5. Advanced triage.

When it comes to the ED setting, some of these triages appear to work best. According to Conway and Higgins (2011, p. 13), an advanced triage is essential in EDs. It ensures that the necessary resources are availed for the patients who need them the most. To this end, the triage phase informs the actual treatment procedure to be administered to a patient.

Stabilization of pain

The pain endured by a patient with chest complications brings about unease to their bodies. In this regard, it is advisable to contain the pain presented by the clients. The stabilization of discomfort helps the patient to endure the remaining procedures without major complaints (Carson et al. 2010, p. 18). Consequently, pain killers are administered to the patient depending on their degree of pain.

Doctor consultation

Patients are required to give an account of their general feeling to the doctor. The symptoms experienced are pointed out. In this regard, the clients are advised to be as honest as possible. According to Conway and Higgins (2011, p. 17), consultation with a doctor is the starting point in ascertaining the actual diagnosis. The doctor will propose an ideal testing and treatment plan.

Comprehensive testing and results

Diagnosis of chest related conditions requires blood and x-ray testing. In this regard, requests are made to the laboratory and radiology departments to book the patient for testing. Consequently, the client undergoes a number of examinations in the respective areas. The results are then presented to practitioners for analysis and eventual diagnosis.

Shift assessment

Emergency departments have three main shifts. The morning, afternoon, and evening shifts are manned by different medical staff. According to Conway and Higgins (2011, p. 18), each shift has a medical staffer on call. The staffer makes an assessment of the results and the condition of the patient. Consequently, a decision for admission or discharge is made.

Patient Care at an Emergency Department

Overview

The previous discussions provide an insight into the process of care at an emergency department. However, a more practical approach is essential in establishing the entire process of care for patients with chest pains. In this regard, a study of 9 patients was carried to provide data for these purposes. The study aims to illustrate how time flow sheets for patients can be developed.

The ED caters for patients who require urgent medical assistance. According to Quin (2000, p. 404), patients are required to spend a maximum of three hours in the ED. Consequently, the procedures involved in the provision of care are required to take the least time possible.

The study comes up with a time metric for each patient. According to Quin (2000, p. 404), the process of patient care at the ED requires an evaluation of time metrics. A comprehensive evaluation of these concepts allows the medics to come up with an ideal mapping of the processes of care. The study illustrates instances of delay and how best to avoid them. By the end of the process, the author seeks to come up with an ideal state value stream map. The recommendations will greatly improve the process of care at various emergency departments around the world.

Time Flow Sheet

Time flow sheets illustrate the process of care in an emergency unit. Table 1 is a depiction of an ideal time flow chart. In this study, these flow sheets were prepared for a total of 9 patients. The study was carried out on all three shifts at the hospital. To this end, 3 patients were randomly selected from each shift. Tables 2 to 10 are representations of time flow sheets for the respective patients:

Morning shift

Table 2: Time flow chart for patient #1

Table 3: Time flow chart for patient #2

Table 4: Time flow chart for patient #3

Afternoon shift

Table 5: Time flow chart for patient #4

Table 6: Time flow chart for patient #5

Table 7: Time flow chart for patient #6

Evening shift

Table 8: Time flow chart for patient #7

Table 9: Time flow chart for patient #8

Table 10: Time flow chart for patient #9

As previously mentioned, the recommended duration of stay at the ED should not exceed 3 hours. The following is an analysis of the time metric for each of the patients in this study:

Morning shift:

• Patient 1: Time metric = 0713hrs to 0921hrs = 2 hrs 8minutes
• Patient 2: Time metric = 0923hrs to 1121hrs = 2 hrs 8 minutes
• Patient 3: Time metric = 1013hrs to 1219hrs = 2 hrs 6 minutes

Afternoon shift:

• Patient 4: Time metric = 1223hrs to 1414hrs = 1 hr 51 minutes
• Patient 5: Time metric = 1313hrs to 1509hrs = 1 hr 56 minutes
• Patient 6: Time metric = 1423hrs to 1600hrs = 1 hr 47 minutes

Evening shift:

• Patient 7: Time metric = 1651hrs to 1818hrs = 1 hr 27 minutes
• Patient 8: Time metric = 1659hrs to 1821hrs = 1 hr 22 minutes
• Patient 9: Time metric = 1713hrs to 2028hrs = 3hrs 15 minutes

The average time metric = total time metrics ÷ number of patients = 18 hrs ÷ 9 = 2 hrs

Current State Value Stream Map

Steps of the process

Figure 2 above is a representation of the current state value stream map (CSVSM). A study carried out by Conway and Higgins (2010) points out that the quality of a value stream can be improved by using a structured approach. The CSVSM is given a structure based on seven main tiers. Most CSVSMs are developed on the basis of the contemporary mapping procedure illustrated in figure 1. To this end, an ideal CSVSM is required to have the following steps:

1. Registration
2. Triage
3. Doctor’s Assessment
4. Diagnosis
5. Admission or Discharge

An analysis of the CSVSM illustrated in figure 2 reveals that there were some additional steps, which were included to make the process conclusive. The following is a sequential analysis of the CSVSM above:

1. Registration– The patient’s particulars are recorded. Details touching on insurance and biometrics are noted down.
2. Triage: At this stage, the client’s historical background is mapped out. The ED has three main categories into which the patients are clustered. The patients are sorted out based on the degree of their chest pains and the urgency for medical care
3. Categories of patients – The triage sorts out the patients into three categories. First, there are those with the most severe pain, followed by those who require multiple testing. The map provides care for patients with chest pains who do not require testing. In this regard, the ED takes into account the element of pain as discussed in the context of patient care.
4. Care Units – The patients with ‘the most’ severe pain are placed in the critical care unit. The clients who require multiple testing can be placed in either the critical or the intermediate care unit depending on their age. The elderly are placed in the former, while the young ones are placed in the latter. The patients who do not require testing are placed in the alternate care.
5. Doctor’s assessment: Doctors assess the patients in the respective care units and make recommendations with regards to the need for a diagnostic testing. Patients who do not require diagnostic testing are discharged. However, those who require testing are transferred to the diagnostic testing station. In this station, blood samples, scans, and X-rays are used to establish a concrete diagnosis. Consequently, an ideal treatment regimen is prescribed.
6. Exit from the Emergency Department – the patients are allowed to leave the ED upon after prescription. In this regard, the admission or discharge of a patient is dependent on their mode of treatment.

Average throughput time

The average throughput time helps in establishing the efficacy of patient care in an ED. According to Leslie (2009, p. 104), throughput time is one of the factors associated with ED environments. It is associated with the length of stay at a given hospital. According to Leslie (2009, p. 106), a number of studies have been carried out with a specific focus on the correlation between throughput time and ED factors. The arguments raised in these investigations indicate that the ED length of stay (LOS) increases substantially with a corresponding rise in admissions and ambulance arrivals.

Some studies found that daily mean LOS can increase as a result of elective surgical admission. Leslie (2009, p. 106) opines that some studies fail to provide a significant correlation between throughput time and hours of nursing coverage. In this regard, a computer simulation study of ED operations is needed to point out the relationship between throughput and laboratory service times. Leslie (2009, p. 106) points out that the relationship is inverse with respect to the number of medical staff at an ED facility.

From the observations made by Leslie (2009), it is evident that throughput time has a direct impact on ED patient care. The effect is realized as a result of the time taken to go through the various steps in a given CSVSM. To this end, an effective evaluation of throughput time must take into account the workforce and duration taken in the diagnosis phase. Leslie (2009, p.108) supports this perspective based on a comprehensive review of the literature. The literature review illustrates that techniques used to improve ED efficiency help in decreasing LOS.

The relationship between ED efficiency and LOS is brought about by environmental, demographic, and institutional variations. According to Leslie (2009, p. 108), there are significant differences between teaching and non-teaching, small community and large university, trauma and non-trauma centers, as well as large-volume and small-volume hospitals. The variations make it hard to come with a comprehensive indication of specific techniques. Leslie (2009, p. 108) argues that in some studies, the conclusions are not intuitive or widely accepted. For instance, one of the studies found that residents had a slower patient throughput compared to medical students. Unfortunately, there are no studies that provide a comprehensive comparison of ED establishments for all medical students involved.

The throughput process is dependent on the number of practitioners in an ED and their levels of skills. For instance, if there are experienced members of staff, the time taken in the various steps is reduced. Consequently, the throughput time is smaller. However, in cases where the staff members are few and inexperienced the time is extended through delays.

According to figure 2, the throughput time, non-value added time, and value added time for the CSVSM is calculated as follows:

Table 11: Time metrics for CSVSM

Points of Delay

The process of care in an emergency department is required to take the least time possible. Tables 2 to 10 illustrate a huge time spent in the diagnosis phase. It is noted that this stage is more time consuming compared to the rest. One of the reasons could be that the facility has slow machines. On the other hand, the personnel involved might have challenges in performing their tasks (Quin 2000, p. 406) Consequently delays are bound to arise. In this regard, Conway and Higgins (2011) observe that the staffing profile of an ED is dependent on the nature of the service provided.

I cases where tertiary chronic pain services are provided, the personnel include medical staff, clinical psychologists, physiotherapists, and nursing staff. Quin (2000, p. 406) argues that staffers in such establishments are required to have specialist knowledge and experience in pain management. Occupational therapists, pharmacists and psychiatrists can also constitute a pain unit ED. Notwithstanding the staff profile, close working relationships with other services that enable the effective management of pain related cases in an ED. There is also a need to ensure that an ED has enough administrative employees, who can support effective clinical service.

The argument made by Conway and Higgins (2011, p. 6) creates the impression that delays would be reduced in cases where EDs are adequately staffed. Synergy among all the members of staff helps to realize a swift improvement of the patient care process. Consequently delays would be greatly reduced. An elaborate analysis of the points of delay can be observed through the CSVSM in figure 2. The map has several redundant steps. For instance, the registration and triage can be merged to form one step. The roles of these two steps are complementary and can be carried out by the same medical practitioners (Leslie 2009, p. 105)

Future State Value Stream Map

The development of a future state value stream map (FSVSM) involves making proposals for change in the CSVSM. In this regard a number of recommendations, with respect to patient care, are necessary. The recommendations will help come up with a suitable FSVM which can be used a model for providing quality care to patients with chest pains at any ED.

Recommendations for a model of patient care at the emergency department

As already mentioned, chest pain is increasingly becoming a chronic disease. Medical practitioners are required to adhere to the laid down procedure with respect to the provision of care to patients with chronic conditions. The report by Conway and Higgins (2011, p. 52) cites the following as some of the strategies required in the provision of care to

1. preventing the onset of chronic disease for individuals and population groups
2. A reduction in the progression and complications of chronic diseases
3. Maximizing the well being and quality of a patient’s life
4. reducing avoidable admissions and health care procedures through the implementation of best practice in prevention, detection and management
5. Enhancing the capacity of the health workforce to meet population demand for chronic disease prevention and care into the future (Conway and Higgins 2011, p. 52).

Proposed FSVSM

The FSVSM is developed from the recommendations made above and the illustration in figure one. Figure 3 illustrates the changes to the map in figure 2. Several steps have been merged to come up with a short and efficient process of care.

As illustrated in figure three, there is a huge point of departure from the CSVSM in figure two. Quin (2000, p. 405) points out that delays in the ED contribute to poor quality of patient care. In this regard, several steps have been merged to reduce an extended period of stay within the ED. The triage is merged with the registration to reduce work duplication by the nurses at the facility. The care unit provides the temporary bed in which the patients will be examined. Based on the general nature of the conditions under examination, all the patients are recommended for a diagnosis once the doctor has made the necessary assessment. Consequently, treatment is provided.

According to Carson et al. (2010, p. 44), patients are referred to the emergency department and are forced to undergo a second triage. The clinician carries out this triage to identify the urgency in which a patient requires medical attention. However, in patient care in an ED requires the patients to be observed in a sequential manner. In this regard, waiting times in such a facility is not required to 20 minutes.

An ideal emergency department has both administrative and medical staff at the reception. In this regard, the patient route is dependent on the type of receptionist to whom a patient interacts with first. In the event that a patient is taken to an emergency department receptionist then they are forced to go though the emergency department ‘triage’. However, if it was the primary care receptionist then they went to primary care ‘see and treat’’. The two receptionists can provide for an ideal mapping since they will have the opportunity to provide a suitable plan of action for the patients (Carson et al. 2011, P. 45).

The proposed FSVSM takes into account the inefficiencies alluded to by Carson et al. (2011, p. 44) above. The proposed map provides for six main steps which would reduce the time taken to 1 hour as opposed to the time illustrated in the current study. The average time metric was found to be 2 hours. The calculations in section 1 illustrate that there were serious delays due to procedural matters.

General hospitals are characterized with emergency departments meant to deal with incidences that require urgent medical attention. The current paper has illustrated the particulars entailed in providing patient care to persons who exhibit chest pains. The study has established that proper care requires emphasis on the time taken for the whole procedure to be concluded. Studies by Carson et al (2010) and Quin (2000) are used to illustrate the importance of mapping of the patient care procedures. In this regard, Conway and Higgins (2011, p. 44) argue that there is an emerging body of evidence which points out the factors that may predispose people to particular responses to pain. Such studies allude to the fact that there is a need for a comprehensive screening process in an ED. The benefit of such screening helps to optimize early intervention. Consequently, care is provided to avert the occurrence of more chronic discomfort in the patient. Literature relating to the effect of these preliminary interventions in hospital admissions is scarce. Research is required with respect to issues like the length of stay and presentations illustrating how they affect patient care in emergency departments.

Mapping enables health practitioners provide comprehensive care to patients. The CSWSM provided for in the current study illustrates that there delays can emerge due to the existence of redundant steps. Emergency departments are required to come up with innovative ways through which throughput time can be reduced while at the same time providing the necessary care to patients.

Table 12 gives a summary of the time metrics relating to the FSVSM. Compared to the CSVSM, the throughput time is less. The same applies to the non-value time.

Table 12: Time metrics for FSVSM

Conclusion

As previously illustrated, a sample of 9 patients is obtained with respect to the ED at the general hospital. The time metrics for each patient are illustrated coupled by a mapping of the process of care. The time flow sheets for the 9 patients were essential in the establishment of points of delay within the entire primary care process. Carson et al. (2010, p. 22) point out that once the points of delay are identified, it is possible to provide ideas on how best to improve the process. The future state value stream map provided for in figure for care at the ED.

The applicability of literature and research touching on ED is limited. According to Leslie (2009, p. 105), studies vary from one institution to the other. Nevertheless, some studies point out a number of overarching alterations with respect to mapping. The alterations are essential in hastening the patients through the ED. In this regard, future studies touching on patient care in ED should highlight improvements in triage, urgent care centers, point-of-care testing, and bedside registration. The development of new models of mapping will enhance the provision of quality healthcare in EDs.

References

Carson, D, Clay, H & Stern, R, Report from the primary care foundation march 2010, Web.

Conway, J & Higgins I 2011, Literature review: models of care for pain management: final report, Web.

Leslie, S 2009, ‘Analysis of the literature on emergency department throughput’, Western Journal of Emergency Medicine, vol. 10 no. 2, pp. 104-109.

Quin, G 2000, ‘Chest pain units’, Western Journal of Emergency Medicine, vol. 173 no. 2, pp. 403-407.

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