Quality improvement initiatives in nursing are aligned with the National Quality Strategy goals of better care, healthy people and communities, and affordable care; therefore, the participation of nurses in forward-thinking projects is a key to refining the process of delivering health care in the US (Weston & Roberts, 2013). Health care organizations around the country initiate quality improvement endeavors that increase patient outcomes by increasing the level of patient engagement, utilizing modern information technologies (IT), and reducing medical errors (Weston & Roberts, 2013).
The success of such projects is well-documented in a wide-range of health care institutions, which means that nurses should take active steps to improve the effectiveness of services they provide.
The aim of this paper is to outline a quality improvement initiative for an emergency department (ED) of West Kendall Baptist Hospital. The paper will discuss the benefits of the initiative, its cost, and outcomes evaluation.
Numerous studies have demonstrated the adverse effects of ED overcrowding across a wide-range of quality metrics. For example, the findings of a study by Sun et al. (2013) reveal that “patients who were admitted on days with high ED crowding experienced 5 percent greater odds of inpatient death” (p. 605). Furthermore, the study suggests that ED overcrowding increases the length of stay and costs per admission (Sun et al., 2013). It follows that by improving the efficiency of the national EDs, it is possible to ameliorate the negative outcomes of high crowding levels.
The purpose of this initiative is to address the problem of ED overcrowding at West Kendall Baptist Hospital by changing the traditional approach to triage. The ED department of the hospital consists of 34 private examination rooms, two trauma rooms, and two isolation and decontamination areas (“Emergency services,” n.d.). The hospital is one of nine health care institutions in Miami-Dade County that has been certified as a Primary Stroke Center by the state’s agency for healthcare administration (“Emergency services,” n.d.). The ED of West Kendall Baptist Hospital had almost 64, 000 visits last year (“West Kendall,” 2017).
The ED health care services in the hospital are provided by certified emergency physicians, nurse practitioners (NPs), registered nurses, nursing assistants, and physician assistants (PAs) (“Emergency services,” n.d.). A high level of staff cohesion in the department will become an important asset for the implementation of the initiative.
The target population for the quality improvement initiative is patients of the ED who fall under three to five Emergency Severity Index (ESI) levels. The initiative will exclude pediatric patients of the department because six examination rooms for pediatric emergencies are located in a dedicated area of the hospital (“Emergency services,” n.d.). The first and second ESI level patients will be barred from the pilot phase of the initiative because they do not pass through the triage area.
These patients proceed immediately to “a resuscitation area where dedicated providers evaluate them and initiate treatment and diagnosis within minutes” (Nestler et al., 2012, p. 1236). Patients experiencing behavioral health issues will also be excluded from the initiative. At West Kendall Baptist Hospital, such patients do not enter the department’s main triage area. Instead, they are triaged at a behavioral health care area. All patients who are not covered by the exclusion criteria will be subject to the quality improvement initiative regardless of their mode of arrival to the department.
There is ample evidence suggesting that the introduction of a senior emergency physician in the triage process substantially reduces the length of stay, thereby improving patient outcomes and increasing levels of staff satisfaction (Ebrahimi et al., 2016). Unfortunately, limited resources of the department preclude the presence of a senior physician in its triage area. The initiative is based on the findings of a study conducted by Love, Murphy, Lietz, and Jordan (2012), in which a nurse practitioner or physician assistant conducted an initial assessment in a triage area of an ED.
To address the issue of crowding at West Kendall Baptist Hospital’s ED, a nurse practitioner will be relocated to the department in the capacity of a triage liaison provider (TLP). The relocation will also change the current mode of the triage process at the hospital. The new triage arrangement will necessitate the presence of the following health care professionals: a TLP, a registered nurse, a patient care technician, an electrocardiogram technician, and a financial registrar (Love et al., 2012).
During the triage process, the team of health care specialists will evaluate arriving patients. Upon assigning a triage nurse to ambulatory patients, a TLP will conduct a medical screening examination (MSE). If a need arises, additional tests will be initiated by the team. After the assessment, patients with low ESI levels will be released to a waiting room.
The primary benefit of the initiative is to reduce the severity of ED overcrowding issue in the hospital. In terms of tangible results, the program will help to reduce the number of patients who leave without being seen (LWBS) and decrease the length of stay at the institution.
The cost that will be incurred by West Kendall Baptist Hospital during the implementation of the initiative will be within acceptable budgetary limits. It has to do with the fact that the financial implications of the project presuppose the allocation of an NP and an electrocardiogram technician to the department. The health care practitioners will be needed during high-volume hours and will be reimbursed accordingly. The institution will be able to quickly recover its investment cost by reducing the number of patients who leave prior to MSE (Love et al., 2012).
For the purpose of evaluating the intervention’s outcomes, two performance benchmarks will be used. The first standard is door-to-physician time, which will be set at less than thirty minutes (Love et al., 2012). The second benchmark is the share of LWBS patients, which will be set at less than two percent (Tropea et al., 2012).
The quality improvement initiative has been reviewed by the student’s supervisor who stated that it is aligned with the hospital’s mission to create a compassionate care environment. The supervisor has argued that the introduction of changes to the conventional triage process could be approved if formally proposed. The initiative’s strengths indicated by the health care professional included the reduction of LWBS rates and its low cost. However, the supervisor has stated that the need to provide additional training to a NP appointed as a TLP is the initiative’s weakness.
The paper has detailed the quality improvement initiative for West Kendal Baptist Hospital’s ED. It has been argued that the introduction a NP and an electrocardiogram technician to the triage area in the capacity of TLPs can substantially improve patient outcomes. The paper has also justified the cost of the project and showed that it falls within an acceptable financial range.
Ebrahimi, M., Mirhaghi, A., Mazlom, R., Heydari, A., Nassehi, A., & Jafari, M. (2016). The role descriptions of triage nurse in emergency department: A Delphi study. Scientifica, 21(1), 1-7.
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Love, R., Murphy, J., Lietz, T., & Jordan, K. (2012). The effectiveness of a provider in triage in the emergency department: A quality improvement initiative to improve patient flow. Advance Emergency Nursing Journal, 34(1), 65-74.
Nestler, D., Fratzke, A., Church, C., Scanlan-Hanson, L., Sadosty, A., Halasy, M.,… Hess, E. (2012). Effect of a physician assistant as triage liaison provider on patient throughput in an academic emergency department. Academic Emergency Medicine, 19(11), 1235-1241.
Sun, B., Hsia, R., Weiss, R., Zingmond, D., Liang, L., Han, W.,…Asch, S. (2013). Effect of emergency department crowding on outcomes of admitted patient, Annals of Emergency Medicine, 61(6), 605-611.
Tropea, J., Sundararajan, V., Gorelik, A., Kennedy, M., Cameron, P., & Brand, C. (2012). Patients who leave without being seen in emergency departments: An analysis of predictive factors and outcomes. Academic Emergency Medicine, 19(4), 439-447.
West Kendall Baptist Hospital. (2017). Web.
Weston, M., & Roberts, D. (2013). The influence of quality improvement efforts on patient outcomes and nursing work: A perspective from chief nursing officers at three large health systems. The Online Journal of Issues in Nursing, 18(3), 1-19.