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The time that patients spend in Emergency Department (ED) without receiving the assistance or being transferred to the other department is usually prolonged, and it is a challenge for ED administrators and nurses who need to organize the effective process of the patient data exchange between departments. When the ED does not use the standardized procedure of filling in and sharing nursing reports, the risk of handoff mistakes increases significantly (Peterson, Gurses, & Regan, 2014). Risks are also associated with patient walkouts because of the long wait times (Love, Murphy, Lietz, & Jordan, 2012).
The problem of the significant patient length of stay in ED is also observed in Lincoln Medical & Mental Health Center, and it can be addressed with the help of applying the appropriate handoff protocols to make the process of exchanging the data standardized and efficient, using phone call handoffs, assigning a provider in triage, and implementing a super track procedure. The purpose of this paper is to describe the problem of prolonged patient stays in the ED of Lincoln Medical & Mental Health Center, identify groups of stakeholders, discuss the project conceptualization, concentrate on the nurse’s and leader’s roles and responsibilities, analyze outcomes, and explain the project’s significance.
Foundational Work
Issue and Context
The issue of crowding in EDs is discussed as typical of healthcare facilities providing the emergency services. The capacity of the nurse staff and practitioners is usually lower than it is necessary to address the problem (Hsia, Asch, Weiss, Zingmond, & Gabayan, 2013).
As a result, the time of patients’ stay in ED increases significantly, leading to delays in diagnosing and transferring, the patients’ dissatisfaction, problems associated with the patient safety, and even decreases in the quality of provided services (Meisel, Shea, Peacock, Dickinson, & Paciotti, 2015). Delays are observed due to an inappropriate reference to the phone call hand off procedure, problems in assigning IP beds, and issues associated with transportation (Pearce & McCarry, 2014).
In order to improve the process of working with patients in ED, administrators implement protocols that are directed to make the procedure easier, assign providers in triage (PIT), and launch super track processes. These initiatives are viewed as potentially leading to reducing the length of patients’ stay and addressing a range of associated throughput issues such as the poor quality and delays in the service provision.
For this project, the issue of patients’ staying in ED is researched in the context of Lincoln Medical & Mental Health Center. This center has recently started the project oriented to the ED transformation, and the reduction of patient length of stay is one of its goals. The implementation of initiatives to address the issue is at the final stage, and it is important to evaluate the effectiveness of using patient handoff protocols and PIT and super track processes as the ways to resolve the problem and focus on the most advantageous strategy to be used in the center.
Stakeholders
The main stakeholders associated with the project implementation are nurses, ED administrators and authorities, physicians, patients, and the community. According to Esbenshade (2015), the improvement of the procedure of filling in and sharing the information between nurses and other practitioners affects the work process of nurses and physicians directly. The outcomes, possible errors, and other implications can be assessed and resolved by ED administrators and authorities. They are also responsible for the project organization and development. Patients and the community are directly influenced by changes in the procedures of working with clients in ED. This initiative is expected to lead to reducing stay times and increasing the care delivery.
Most affected populations
Elder persons, people having problems with insurance, children, and non-English speakers are most affected by the prolonged stay times in ED and the ineffective data exchange procedure (Sun, Hsia, Weiss, Zingmond, & Liang, 2013). Elder people and children suffer from the necessity to stay in ED without the provided assistance most significantly. People having problems with insurance also cannot receive the answer regarding the possibility of the help or the actual care during a long period of time. Non-English speakers stay in ED without the help because they cannot provide the nurse with the information about their problems or the disease and family history. Thus, the factors that make these people vulnerable are age, economics, education, and language among other ones.
Other affected groups
The issue also influences such groups as relatives. In many cases, patients in ED stay with their relatives, and they cannot leave their family members till the transference occurs, or care is delivered. In this case, the meaningful factors include culture, age, language, and job position because they can prevent relatives from the effective interaction with nurses (Choi, Tsai, McGillivray, Amedee, & Sarafin, 2014).
Project Conceptualization
Theoretical framework
The theory that provides the background and framework for the problem discussion and the initiative implementation is Ida Jean Orlando’s theory of a nursing process. The main concepts of this theory that guide the intervention implementation and project are the patient’s need for help, the immediacy of the provided help, and the appropriateness of the nurse’s action (Arora, 2015).
According to Orlando’s theory, the patients come to healthcare facilities with a certain problem, and time and quality of interactions between a patient and a nurse directly affect their experience. Another important aspect is the appropriateness of the nurse’s action because she should make an effective decision while addressing each case (Arora, 2015). In this project, it is possible to observe the lack of immediacy and the importance to improve the nurse’s action in terms of reacting to patients’ needs and exchanging the information.
It is also important to concentrate on definitions of key terms and concepts related to the research. The key concepts used in the project are the ‘length of patient stay’, ‘handoff protocol’, ‘no-delay report’, ‘provider in triage (PIT)’, and ‘super track procedure’. In the context of ED, the ‘length of patient stay’ can be defined as the time during which patients cannot leave the ED and be transferred to the other department or hospital (Meisel et al., 2015).
The terms ‘handoff protocol’ and ‘no-delay report’ are used in the project to identify the standardized protocol that is used by nurses to exchange the information regarding the patient’s state and handoff recommendations (Wentworth, Diggins, Bartel, Johnson, & Hale, 2012). The ‘provider in triage’ is a nurse or physician who completes the initial assessment of patients who are identified as requiring the immediate care (Love et al., 2012). The ‘super track’ is a procedure of completing the quick assessment of a patient before finishing all registration procedures (Pearce & McCarry, 2014).
Outcomes
The first outcome of the project is the presentation of an analysis of available interventions to address the problem of a long patient stay in the ED of Lincoln Medical & Mental Health Center. The report provides the information on advantages and disadvantages of traditional and innovative approaches to administering and exchanging the patient data and ways of conducting patient assessments. The other outcome is the provision of a detailed PowerPoint Presentation including the assessment of using handoff protocols, PIT, and super track in the center to address the problem of delays.
The final outcome is the formulated recommendations to improve the procedures based on observations, interviews, documentation and patient data analysis and assessment. The effectiveness of using procedures is assessed in the context of Lincoln Medical & Mental Health Center, and the numerical and qualitative data on changes in the length of patients’ stay are provided. Baker and Esbenshade (2015) note that the focus on both quantitative and qualitative data is important to collect the objective and detailed information.
Solution
The current project provides an effective solution to the problem in terms of supporting the necessity of using handoff protocols, phone call handoffs, PIT, and super track procedures in the ED of Lincoln Medical & Mental Health Center with references to the evidence and analysis of quantitative and qualitative data. In addition to protocols, nurses often use traditional face-to-face communication channels or phones, admission and feedback reports, written or typed reports on the patient’s assessment, and computer technologies to upload reports in the system (Starmer et al., 2014).
However, the risk of errors using such reports and the time required to fill and exchange them are significant, and the application of technology-based handoff protocols is the most efficient measure to reduce stay times in ED, address delays, and increase the quality of the provided care. PIT allows avoiding patients’ walkouts, and a super track procedure guarantees immediate assessments of the appropriate quality.
Project Implementation
Nurses’ Role and Responsibility
Role and responsibility
In spite of the fact that problems of exchanging the patient data between nurses and conducting on-time assessments are often discussed as issues to resolve by administrators, they are within the nurses’ area of focus and control. The nurse’s task is to provide the assessment and care to all patients in the ED without delays and share the information with other nurses (Cornell, Gervis, Yates, & Vardaman, 2013).
If this procedure does not work effectively, it influences the speed and quality of the provided care. In this context, nurses are responsible for discussing the issues with the leader and make efforts to improve the situation because of such professional, social, and ethical considerations as the necessity to provide the high-quality care in time and avoid crowding in ED. If the required patient data is not administered and shared effectively and handoff errors are observed, this situation involves ethical and legal aspects of providing services of the poor quality (Eberhardt, 2014). Patients can leave EDs without any adequate assistance. The nurse’s responsibility in this case is to guarantee that the accurate assessments were conducted, the data were shared, and the patient length of stay was decreased to the possible minimum.
Support
It is important to note that the project supports the nurse professional standards of practice directly because it aims at identifying the tool that can guarantee the increases in the efficiency of the activities performed by nurses in ED. The aspect of excellence in relation to the nursing practice means that medical errors are avoided, and the provided treatment and care are appropriate and based on the exchanged data.
However, the problem is in the fact that the handoff procedure is usually associated with administration and medical errors. Thus, the focus on the effectiveness of technology-based handoff protocols addresses the question of the quality of nurses’ activities in ED directly (Peterson et al., 2014). Moreover, the effective realization of the PIT and super track principles is possible only while involving other healthcare providers. In addition, the connection of the project with principles of the patient-centered care is also obvious because the attention to patients guarantees the provision of the high-quality care and accurate data in protocols to ensure the on-time delivery of services.
Project Leadership
Role and responsibility
As a leader, a researcher conducting the evaluation of initiatives in ED is responsible for cooperating with nurse leaders and ED administrators whose duties are to develop and implement changes in Lincoln Medical & Mental Health Center. It is important to organize the collection of the data, consult administrators regarding the goals and objectives of their changes, and communicate with the nurse staff in order to assess the actual alternations in their work progress that are associated with the implementation of the handoffs, PIT, and super track procedures(Wentworth et al., 2012).
While performing as a leader and an evaluator, it is necessary to pay attention to standards of communication followed in the ED and certain criteria that are used to determine whether the time for care delivery is appropriate and whether the procedures were completed effectively. All details in the work of nurses are important to be taken into account. In addition, the cooperation with the project mentor and ED administrators is important to understand what recommendations can be most advantageous for this organization.
Strategies
In order to collect and assess the necessary information and data on the regular number of patients in the ED of Lincoln Medical & Mental Health Center and the initiatives proposed to be implemented in order to address the delays problem and the process of implementing SBAR (Situation, Background, Assessment, Recommendation) reports, PIT, and super track procedures, it is important to use certain strategies.
They are also important to evaluate the first outcomes, strengths, and weaknesses of the procedures to reduce the length of the patient’s waiting time. They include the use of appropriate data collection tools; the regular communication with the mentor, ED administrators, the nurse staff, and patients; the leadership strategy (Sharif & Scandura, 2014). If the importance of using the effective data collection tools is obvious, it is significant to accentuate the roles of communication and leadership strategies to implement the project as it is necessary to state the personal credibility as a researcher, a leader, and an evaluator who can objectively assess the change initiatives to address the problem and propose the best option supported by the logical and helpful recommendations.
Systems
The systems that are important to promote the effective organizational change include the professional networks within the organizations and the computerized systems guaranteeing the effective exchange of the information. While implementing the initiatives in ED, it is important to communicate their significance and usefulness to the nurse staff, provide the necessary training, and encourage the active sharing of opinions regarding the change (Baker & Esbenshade, 2015).
While using the nurse networks for the communication and analyzing the technological systems used for the initiative realization, it is possible to conduct the efficient evaluation of the change outcomes in order to state what actual positive achievements can be observed regarding the patient stay in ED after using handoff protocols and proposed procedures to reduce delays.
Outcomes and Significance
Achievement of Outcomes
The actual outcomes of the project are the report, presentation, and recommendations to follow while using handoff protocols, the PIT process, and super track procedures in the ED of Lincoln Medical & Mental Health Center. However, for the purpose of the project, the following assessment criteria were identified in order to evaluate the outcomes associated with the implementation of initiatives in the working process of ED in the center: documented decreases in the length of patient stay; documented increases in the speed of interacting with patients in ED and the speed of procedures; decreases in the patient dissatisfaction; improvements in the communication and exchange of data between nurses; increases in the patient assessment rates; decreases in the number of errors; decreases in patient walkouts.
The data analysis demonstrated the positive changes documented according to the identified criteria. Due to the implementation of handoff SBAR protocols, the average time of the patient stay in ED decreased by almost 50% when the number of patients remained to be stable. The admission and handoff processes associated with the use of technology-based protocols improved, and the efficiency increased by more than 30%. The PIT decreased the wait time by 35%.
The super track decreased the wait time by ten times. The improvements associated with the patient satisfaction were stated by more than 80% of respondents who emphasized the decrease in the wait time and improvement of the nurse-patient interaction and care. This project came to the end with the prepared report and recommendations to support the further development of initiatives in order to reduce the waiting time in ED of the center and address the needs of the larger population without errors. It is possible to state that the proposed initiatives are effective to overcome all the inefficiencies that are associated with the provision of the immediate care for patients in ED.
The unanticipated outcomes associated with the project include the increase of the nurses’ interest in using SBAR protocols, PIT, and super track procedures in order to conclude about their effectiveness independently. The reason is that the administration of the center encourages sharing opinions to improve the initiative and guarantee the effective organizational change. According to Sun et al. (2013), this aspect is important to demonstrate the positive attitude of the staff to the organizational changes.
Influencing Factors
Nursing judgment
The nursing judgment as the ability to evaluate the situation as a nurse is directly associated with achieving the outcomes of the project. While understanding the necessity of improving the procedure of performing admission, conducting assessments, and exchanging the data effectively, nurses are interested in using the proposed tools efficiently.
In addition, the interviews indicate that nurses perceive no-delay reports and proposed procedures as effective techniques to provide the patient-centered care when all the data are recorded accurately and shared with other nurses without mistakes while reducing the possibility of further medical errors and when all necessary assessments are made in time. From the perspective of a researcher, the nursing judgment is important to evaluate the actual outcomes of using the implemented procedures while recognizing objectives of their implementation in ED (Meisel et al., 2015). The nursing judgment allows making reliable and evidence-based conclusions.
Knowledge and skills
The completion of the project and the achievement of set goals became possible as a result of the knowledge gained in the sphere of nursing theory and practice, the focus on principles of the patient-centered care, and the analysis of strategies to improve the nursing process. The skills in areas of critical thinking, decision-making, problem-solving, professional communication, teamwork, and cooperation developed during the graduate program are also helpful to organize the research process, build relationships with the staff, and achieve the project goals. Critical thinking and communication skills were most important to conduct the evaluation of the initiative (Starmer et al., 2014).
Such professional values as respect, accountability, and confidentiality contribute to the effective communication with both nurses and patients on the outcomes of the procedures implementation.
Significance
Organization and stakeholders
The completed project has a direct impact on the administration of the work in ED and exchange of the data between the departments of Lincoln Medical & Mental Health Center. This project also has the practical implications for stakeholders as the principles of patient assessment and recording the patient’s data changed. As a result, decreases in delays in data sharing between the departments were addressed, and the quality of the professional interaction increased. Moreover, the project allowed nurses to concentrate on the tools that they could use in order to work with patients and share handoff reports more quickly.
Currently, Lincoln Medical & Mental Health Center is shifting from the pilot stage in implementing such changes as the use of SBAR handoff protocols, the PIT process, and the super track procedure to the final stage of changing the whole process of communicating the admission, conducting assessments, and completing the handoff data in the center. Many organizations do not realize the appropriateness of changing the process of working in ED and avoid referring to the PIT process and the super track procedure. However, the results of this project demonstrate that these initiatives provide stakeholders with significant outcomes.
Nursing and healthcare implications
The significance of the project for the community is in the possibility to receive the high-quality care without delays and possible mistakes influencing treatments (Cornell et al., 2013; Peterson et al., 2014). The reduced length of the patient stay in ED associated with the use of protocols and super track procedures leads to using the time for admitting, assessing, and transferring patients more efficiently. This approach contributes to the improvement of the healthcare delivery in the community, the increased health status, and the effective use of human and material resources by Lincoln Medical & Mental Health Center.
Personal significance
The project allows developing not only professional skills, but it also contributes to expanding the area of interest in the nursing research and practice. The project is important to demonstrate how the theory-based strategies and innovative tools can be applied to the practice of nurses and how it is possible to add to the project realization performing as a leader, an investigator, and an evaluator. The knowledge and skills received during the project implementation can contribute to the researcher’s further education, selection of the research area, and practice.
Conclusion
The problem addressed with the help of the project is the prolonged times of staying in ED. If patients do not receive the necessary care in time, and the absence of control over the situation is observed, the lack of effective measures can lead to crowding in ED and the patient dissatisfaction, as well as the low quality of care. Patient handoff protocols or no-delay reports are discussed as one of the effective interventions to be used in EDs in order to address the identified throughput problems. ED administrators, nurses, and patients are most interested in the positive outcomes of using SBAR reports and protocols.
The other approaches include the assignment of providers in triage for EDs and the implementation of the super track procedure for the quick and high-quality assessment of patients. These approaches are supported by Orlando’s theory of a nursing process. The actual outcomes of the project are the selection of the most effective initiatives, decreases in the time of patient staying in ED, and increases in the speed and quality of admission, handoff procedures, and assessments with the following provision of the diagnosis and treatment. The significance of these outcomes is the possibility to address the patients’ needs and contribute to the community’s health status.
References
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Baker, S. J., & Esbenshade, A. (2015). Partnering effectively with inpatient leaders for improved emergency department throughput. Advanced Emergency Nursing Journal, 37(1), 65-71.
Choi, B., Tsai, D., McGillivray, C. G., Amedee, C., & Sarafin, J. A. (2014). Hospital-directed feedback to emergency medical services improves pre-hospital performance. Stroke, 45(7), 2137-2140.
Cornell, P., Gervis, M. T., Yates, L., & Vardaman, J. M. (2013). Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol. Journal of Nursing Administration, 43(7), 422-428.
Eberhardt, S. (2014). Improve handoff communication with SBAR. Nursing, 44(11), 17-20.
Esbenshade, A. (2015). Making the middle count: Three tools to improve throughput for a better patient experience. Advanced Emergency Nursing Journal, 37(1), 58-64.
Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., & Gabayan, G. (2013). Is emergency department crowding associated with increased “bounceback” admissions? Medical Care, 51(11), 1008-1014.
Love, R. A., Murphy, J. A., Lietz, T. E., & Jordan, K. S. (2012). The effectiveness of a provider in triage in the emergency department: A quality improvement initiative to improve patient flow. Advanced Emergency Nursing Journal, 34(1), 65-74.
Meisel, Z. F., Shea, J. A., Peacock, N. J., Dickinson, E. T., & Paciotti, B. (2015). Optimizing the patient handoff between emergency medical services and the emergency department. Annals of Emergency Medicine, 65(3), 310-317.
Pearce, I. S., & McCarry, N. (2014). Let’s chat: Bedside reporting in the ED. Nursing, 44(8), 15-17.
Peterson, S. M., Gurses, A. P., & Regan, L. (2014). Resident to resident handoffs in the emergency department: An observational study. The Journal of Emergency Medicine, 47(5), 573-579.
Sharif, M. M., & Scandura, T. A. (2014). Do perceptions of ethical conduct matter during organizational change? Ethical leadership and employee involvement. Journal of Business Ethics, 124(2), 185-196.
Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D.,… & Lipsitz, S. R. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812.
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