The last ten years has shown an increase in the demand for emergency and urgent medical care in the United States and abroad. This rapidly rising demand has created the challenge to process the increasing numbers of patients presenting at emergency departments (EDs) at any given time. The result is heavy over crowding and resulting over operating capacity at EDs nationwide. This overcrowding positively correlates with poor patient outcomes, patient dissatisfaction, increased hospital stays, ambulance diversions and inadequate or compromised patient care (Bradley, 2005; Cowan and Trzeciak, 2004).
ED OVERCROWDING Since the early 1990s, patient presenting to EDs have been increasing by approximately 2 million individuals per year. At the same time, many EDs were forced to close due to budget cuts and lack of staffing. Again, in 2001 and 2002, incredible leaps in ED visits were again noted to be in the 2-3 million range. This problem is now recognized as one of the top ten major issues being confronted by the Institute of Medicine (Hwang & Concato, 2004). Effects Of Ed Overcrowding
Overcrowding and extended lengths of stay place excessive stress on already understaffed ED departments which can lead to medical errors which can affect both patients and caregivers. Confidentiality can be compromised, and high levels of stress can lead to burnout and turnover rates among staff and dissatisfaction and even refusal of care by patients who choose to walk out of the ED entirely because of wait times (Overcrowding, 2004). Studies by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) indicate that patient mortality can also be attributed to these ED delays as a result of overcrowding.
The JCAHO points to general staffing shortages and availability of qualified staff as major contributors to these deaths (Bradley, 2005). The ratio of ED nurses to patients does not allow for focused attention on each patient, and the ration of physicians and physician’s assistants (PAs) is even smaller (Cowan and Trzeciak, 2004). As costs continue to rise and budgets continue to stagnate, the need to more efficiently utilize existing emergency room personnel as a means to expedite patient flow through the ED becomes more urgent. POINT OF CARE TESTING
The focus of this paper in reference to the above problem is to examine ways that ED efficiency can be improved through point of care testing (POCT) improvements and the implementation of triage protocols which allow nurses to order these POC diagnostic tests. Technology has evolved to the point that its utilization in ED situations can greatly diminish the patient stay duration and increase the efficiency of the ED as a whole. Studies have shown that increasing the utilization of POCT in EDs can decrease the amount of time patients remain in the ED because test results are made available more quickly.
POC tests that were formerly completed in central hospital laboratories can now be implemented in the ED. Some of these tests include blood glucose, blood gasses, cardiac markers, troponin, CK-MB, myogtobin, BNP, urinalysis, fecal occult and gastric occult blood, cholesterol, neonatal bilirubin, blood coagulation and clotting, HIV, influenca, RSV, Group A and B strep, H. pylori serology and CLO testing, and STDs (Haugh 2006). Rapid diagnosis via POCT can decrease the time a patient spends in the ED.
In a sophisticated simulation model representing 55,000 actual patient visits spanning a period of 90 days between December and March of 2007, lab result turnaround times decreased as the number of patients processed through the ER increased resulting in “compelling improvement in ED efficiency with decreasing lab turnaround time” with all testing performed at a level of 85% accuracy or better, which was equivalent to prior laboratory accuracy ratings (Storrow et al, 2008).
In a study of 369 patients at Massachusetts General Hospital in Boston, a pilot POCT program decreased the wait time for test by 87% and a general decrease in the length of ED stay per patient by an average of 41 minutes. These results were gained with no decrease in the amount of physician satisfaction in the accuracy of the lab results (Park, 2003). In general use of POCT has shown a 100% increase in emergency test result turnaround time (Haugh, 2006). As technology becomes available, more and more testing can be implemented at the point of care.
Methodist Hospital in San Antonio, Texas, recently implemented POCT for its patients presenting to the ED with chest pain, which constitute roughly 10% for its ED patients. The large hospital lab struggled with the need to produce cardiac marker testing results for 5000 patients daily within 60 minutes even though physicians recommended a 30 minute turnaround time. The addition of cardiac marker testing POC technology enabled ED personnel to provide these test results and to identify potential heart attack victims in approximately 15 minutes in the ED (Burns, 2007).
The need for POCT increases exponentially in times of natural or national disasters as evidenced in the times of Hurricane Katrina, the terrorist attacks on the Twin Towers or pandemic influence outbreaks such as the swine flu. The need to manage extreme numbers of patients simultaneously makes POCT that much more necessary (Hale, Brock, & Kost et al, 2009). One can anticipate that POCT will develop into more and more branches of medicine and medical diagnoses in the near future. TRIAGE PROTOCOL
While this POCT technology has existed for several years and is increasing in its sophistication, the utilization on a day-to-day basis is also necessary to implement. The best way to more efficiently utilize this technology is to formulate a triage protocol empowering nurses to order such tests rather than wait for the availability of the attending physician. Nurses are primarily responsible for making initial contact with patients to determine specific and pertinent patient data, assess this data to form judgments and to assign patients to a certain level of care (Winn, 2001).
Initially, nurse decision making has been called into question regarding the accuracy of such triage decisions made by members of the nursing staff. Recent studies (Gransson et al. , 2008; Aitken, 2003; Andersson, Omberg & Svedlund, 2006) indicate that Registered Nurses (RNs) use a variety of decision making strategies which follow the sophisticated process of data gathering, hypothesis generation and propositioning. These decision making skills are important in choosing to order diagnostic tests or to refer patients for other procedures, including recommending admittance.
Winn, 2001, notes that experience levels of nurses can determine the way that a triage RN makes a judgment decision based on probability. The more experienced nurses relied on past experiences while the less experienced RNs relied on patient data and more intensive questioning techniques to reach a decision. In this study, the hospital developed a protocol which allowed RNs to increase their level of decision making responsibility which resulted in lower lengths of stay and higher levels of satisfaction among ED patients.
These decisions made by RNs are diagnostically accurate and have been used in a limited capacity such as ordering X-rays for nearly 15 years (Campbell 1995; Davies, 1994). In a study performed in 1999, researchers set out to determine if RNs decisions would mirror those of physicians in similar situations. The independent reviewers evaluated patient scenarios that had be conducted by both RNs and physicians without knowing which group had made which decisions.
They found statistically significant consensus with the diagnostic decisions made by the RNs and those made by the physicians in ED situations (Goodacre, Gillett, Harris & Houlihan, 1999). A landmark study addresses accuracy in terms of predicting which diagnostic tests physicians would order based on patients presenting in an ED, RNs were 76. 3% accurate in ordering X-Rays, 90% accurate in determining whether a patient would be discharged and 98% accurate in determining if a physician would order an electrocardiogram.
This high level of accuracy was important in allowing triage nurses to initiate diagnostic testing (Rausch & Rund, 1981). Beveredge et al (1999) also found a 95% confidence interval between triage nurses and physicians involved with the Canadian Association of Emergency Physicians. This agreement was present despite the differences in age, race and other demographic factors among the 10 RNs and 10 physicians in the study. CHAPTER THREE METHODOLOGY INTRODUCTION Nurses are the first point of contact for patients entering the ED. Thus, they are the first element of improving efficiency in the ED.
The combination of POCT and Triage Protocols which allow nurses to order diagnostic tests will mutually benefit the problems of overcrowding and lengthy stays in EDs. Research has shown that Triage RNs can predict testing ordered by physicians with accuracy. It follows that Triage RNs should be allowed to order diagnostic tests in the ER, now that POCT technology devices are readily available form many conditions. In order to accomplish this feat, however, physicians and patients must be confident in the accuracy of the nurses’ diagnoses. TEST ORDERING GUIDELINES
As research has shown, Triage Nurses display excellent levels of accuracy when ordering x-rays and blood work. In order to maintain the same level of accuracy, these RNs must have the same level of training and develop the same confidence level when ordering other diagnostic tests. POCT will greatly aid in the confidence level of the accuracy of such tests and will also spread to the confidence level of the ordering of such tests. Even so, many studies indicate the efficacy of test ordering guidelines or scales, developed by physicians, which nurses may utilize to make these diagnostic determinations.
Many hospitals and healthcare organizations have conducted independent studies to determine an RNs ability to apply a pre-determined set of guidelines to a specific diagnosis (Taboulet et al. , 2009; Kec et al. , 2008). With the development of these guidelines and the utilization of POCT, triage nurses will help efficiently and effectively reduce length of patient stays without sacrificing quality of care of accruing unnecessary costs. Of course, continuing education and constant review of nursing knowledge is a vital part of the success of any triage protocol (Winn, 2001).
POPULATION and DESIGN This study was conducted in a large military hospital’s ED with an average daily census of 150 patients. This study seeks to compare the average length of ED stay of more than 5 hours with wait times which have ranged between 4 and 12 hours with length of ED stays after implementation of POCT and a triage protocol which allows RNs, two nurses in particular to order diagnostic tests and to administer IV fluids, nausea, antipyretics, and/or pain meds.
Data analysis of patients previously treated at the ED were compared to those who entered the ED seeking treatment within a given time period. A comparative study of both time periods at the same hospital allows for the most objective data possible. SAMPLES and DATA COLLECTION PROCEDURES The sample was selected from males and females (non-pregnant) between the ages of 18 and 65 years old who arrived for treatment at the ED between the time periods indicated.
Individuals under the age of 18 are minors and therefore subject to parental influence and pediatric guidelines in the hospital which may differ from general guidelines. Individuals older than 65 may have geriatric needs which would be significantly different than those of the general adult population. In addition, patients who arrived by ambulance or whose condition was considered immediately life-threatening were also excluded from the study.
The sample was constructed based on matching them with similar individuals presenting with similar conditions in a time period from three months prior to the study. The wait times of these individuals was catalogued at the time of the presentation and charted as to demographics, wait time, time seen by a physician, tests ordered and diagnosis, and discharge time. Over the next three months, individuals who presented with similar conditions would be treated by triage nurses equipped with POCT equipment and the power to order diagnostic tests.
Their information was charted as well and compared with the control sample. One individual was designated to collect and maintain all records to ensure consistency, STATISTICAL ANALYSIS Descriptive analysis of demographic variables was examined through frequency distribution. Analysis of the data affecting the research questions was addressed by a t test for statistical significance, specifically between the length of stay for patients assessed and tested by a triage nurse with POCT and those treated earlier through conventional means.
Statistical analysis was completed using the Statistical Packages for Social Sciences software. All testing and data collected was conducted in accordance with university rules and regulations and federal regulations concerning medical records privacy. Consent was granted by all participating individuals. DISCUSSION OF POSSIBLE BARRIERS While every effort was made to maintain the validity of this study, some possible barriers do exist.
First, finding perfectly correlating subjects to provide comparisons was impossible, so minor changes in demographic and presenting conditions may have affected the outcome of the study. In addition, the months of study may have had an impact on the conditions being presented in that certain illness and ailments are more prevalent at certain times of the year. Finally, the ever decreasing budget, especially of a federally operated hospital, is causing increasing cutbacks in staff and supplies, also affecting current length of stays that would not have been the case for stays in the past several months.
Compensating for these barriers can be overcome by avoiding drawing data from winter months so as not to encounter higher than normal samples of flu and respiratory ailments most notably present in the winter. The best option would be to use data from similar season time periods.
Aitken L. M. (2003) Critical care nurses’ use of decision-making strategies. Journal of Clinical Nursing 12, 476–483. Andersson A-K. , Omberg M. & Svedlund M. (2006) Triage in the emergency department – a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care 11(3), 136–145.
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