- Email: [email protected]
Should You Close Your Waiting Room? Addressing ED Overcrowding Through Education and Staff-Based Participatory Research
RESEARCH
SHOULD YOU CLOSE YOUR WAITING ROOM? ADDRESSING ED OVERCROWDING THROUGH EDUCATION AND STAFF-BASED PARTICIPATORY RESEARCH Authors: Paula Tanabe, PhD, MPH, RN, Michael A. Gisondi, MD, Sara Medendorp, BA, Laurie Engeldinger, RN, Lisa J. Graham, RN, BSN, MPH, and Martin J. Lucenti, MD, PhD, Chicago, Ill, and Albany, NY
Introduction: The purpose of this project was to develop operational criteria to “close the ED waiting room”. Methods: A prospective, staff-based participatory research model was used. Nurses at an urban ED with 70,000 visits attended a four-hour workshop concerning ED overcrowding. The workshops consisted of two parts, (1) educational sessions that reviewed key concepts of ED overcrowding, followed by (2) discussions of a proposal to “close the waiting room” as a means to decrease overcrowding. During the discussions, nurses were asked to develop guidelines to safely and consistently “close the waiting room.” The investigators defined the waiting room as “closed” when (1) ambulatory patients could be taken directly to a room or hallway space for bedside triage,
Paula Tanabe, Illinois ENA, is Research Assistant Professor of Emergency Medicine and the Institute for Healthcare Studies, Northwestern University, Chicago, Ill. Michael A. Gisondi is Assistant Professor of Emergency Medicine, Northwestern University, Chicago, Ill. Sara Medendorp, Northwestern University, Chicago, Ill.
registration, and initiation of care, or (2) patients were triaged in the waiting room and then taken directly to a care space for registration at the bedside. The primary outcome measure of the project was the development of guidelines to open (use) or close (not use) the ED waiting room. Results: Seventy three of 100 nurses participated in the workshops. ED waiting room closure criteria were developed as 4 “Questions to Guide the Use of the Waiting Room.” These dichotomous (yes/no) questions reflected issues of available staff, available care space (traditional ED bed spaces and designated hall spaces), patient acuity, and additional surge capacity. Discussion: Staff-based participatory research was an effective method to design an operational change. Nurses developed four explicit criteria describing when the waiting room should be closed.
T
doi: 10.1016/j.jen.2007.08.009
he epidemic of overcrowding has made it a challenging time to practice in the emergency department. 1 Emergency departments are faced with rising volumes, high patient acuity, hospital crowding, a serious nursing shortage, increasing regulations, and changes in medicine and technology that are occurring at a rampant pace.2 The total number of visits to emergency departments increased from 90.3 million in 1993 to 113.9 million in 2003.3 Emergency departments have struggled to keep pace, as shown by 2001 data that reported 7.7% of 36.6 million adults who sought care in a hospital ED described trouble receiving emergency care, with over half citing long wait times as a cause.4 In addition to emergency department staff, nursing and physician administrators, educators, and clinical nurse specialists are held accountable to meet these challenges, and improve patient satisfaction. To address overcrowding at our institution, physician and nursing leadership identified the need to keep the waiting room “closed” whenever possible, to facilitate the flow of patients during off-peak hours. For the context of this project, the phrase “closing the waiting room” means that patients are either taken immediately to a treatment space
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Laurie Engeldinger, Northwestern Memorial Hospital, Chicago, Ill. Lisa J. Graham is Emergency Services Manager, Northwestern Memorial Hospital, Chicago, Ill. Martin J. Lucenti is Assistant Professor of Emergency Medicine, Northwestern University, Chicago, Ill. This project was supported by the 2005 Emergency Medicine Foundation and Emergency Nurses Association Foundation Team Grant. Dr. Tanabe was partially supported by a grant from the Illinois Department of Healthcare and Family Services to Northwestern Memorial Hospital under the Excellence in Academic Medicine Act. Portions of this project were presented at the Scientific Assembly of the American College of Emergency Physicians on October 15, 2006, in New Orleans, Louisiana. For correspondence, write: Paula Tanabe, Northwestern University, 259 E. Erie, Suite 100, Emergency Medicine, Chicago IL 60611; E-mail: [email protected]. J Emerg Nurs 2008;34:285-9. 0099-1767/$34.00 Copyright © 2008 by the Emergency Nurses Association.
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for registration and triage at the bedside, or, patients are placed in a treatment space for bedside registration immediately after triage in the waiting room. Alternatively, patients do not sit in the waiting room. The waiting room always remains “open,” in that visitors still wait in the waiting room, and patients also wait in the waiting room when immediate placement is not possible. This concept has been explored previously. Data from the REACT (Rapid Entry and Accelerated Care at Triage) investigators reported improvements in overall waiting time after implementation of many departmental strategies aimed at reducing wait times, one of which was immediate placement of patients in open beds.5 The rationale for “closing the waiting room” stems from queuing theory. This model explains the impact of time-varying demands in the ED waiting room resulting from statistical fluctuations in individual patient arrival times and the variability in the time needed by a provider to treat patients.6 Data from The National Hospital Ambulatory Medical Care Survey describe a relatively low volume of patient arrivals during the night followed by a steep increase around 9 am, peaking around noon and remaining high through the evening.3 The basis for this project is that “closing the waiting room” during low-volume periods of the day will help reduce the backup that occurs during busier times. Although the “close the waiting room” initiative had been identified as desirable, neither a formal policy nor criteria had been developed. Furthermore, education of those who would implement this system had not been conducted. In 2005, the investigators received the Team Grant from the Emergency Nursing and Emergency Medicine Foundations to investigate the question “Should You Close Your Waiting Room?” The project used a novel method, staff-based participatory research, to develop criteria to encourage closure of the waiting room whenever possible. This article examines the effectiveness of the method chosen to create the waiting room closure criteria. The specific aims of the project were to: (1) measure ED nurses’ exposure to overcrowding concepts; (2) develop criteria to “close the waiting room” using staff-based participatory research; and (3) assess staff nurse perceptions to the workshops’ ability to impact operational change. This article does not report outcomes from application of the final closing the waiting room criteria. These outcomes are being evaluated and will be reported separately.
from the success observed with community-based participatory research, which allows members of a community to provide their knowledge and personal experience in identifying a problem to be studied. These community members then use study results to help support relevant program and policy development.7 In a similar manner, ED nurses were educated on the problem of overcrowding and participated in the development of criteria to “close the waiting room,” as an operational solution to ED overcrowding. Our Institutional Review Board approved the study protocol and considered the project exempt from consent. SETTING
The study was conducted at a large, urban, academic medical center with an annual ED census of 70,000 patient visits per year. The emergency department has 21 rooms for general care, 7 rooms for urgent care, 2 resuscitation bays, and 23 ED observation beds. Due to daily periods of overcrowding, 18 hallway spaces are used routinely for patients awaiting test results or an inpatient bed. SELECTION OF PARTICIPANTS
All ED nurses at our institution were eligible to participate in 1 of 9 overcrowding workshops scheduled between 9/1/05 and 12/31/05. At the time of the study, our department employed 6 nurse managers, 14 charge nurses, and 80 staff nurses. Although participation was voluntary, the project was supported as a process improvement project and nurses were strongly encouraged to participate by the nursing leadership. Nurse participants were informed of their role in the development of this research project and were compensated for their participation at an averaged hourly rate. STUDY PROTOCOL
This project used a prospective, staff-based, participatory research model. The rationale for this methodology stems
Emergency nurses attended 1 of 9 workshops (4 hours each) concerning ED overcrowding. The workshops consisted of 2 parts: (1) educational sessions that reviewed key concepts of ED overcrowding, followed by (2) discussions of a proposal to “close the waiting room” as a means to decrease overcrowding. During the discussions, nurses were asked to develop guidelines to safely and consistently “close the waiting room.” The investigators defined the waiting room as “closed” when (1) ambulatory patients could be taken directly to a room or hallway space for bedside triage, registration and initiation of care, or (2) patients were triaged in the waiting room and then taken directly to a care space for registration at the bedside. Emergency medicine faculty were informed of the project and guidelines were discussed at faculty meetings and communicated by the investigators on an individual basis. The initial 2 hours of the workshop consisted of several short educational didactic sessions presented by the
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Methods
STUDY DESIGN
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investigators on the following topics: ‘Overview of the Research Project’; ‘Principles of ED Overcrowding’; ‘Queuing Theory and Departmental Surge Trends’; and ‘The Impact of Triage and Registration on Delays to Care.’ The remainder of the workshop was spent discussing the proposed “close the waiting room” initiative. Four questions were used to facilitate this discussion: Who should make the decision to close the ED waiting room? What guidelines should be used to close the waiting room? What are the associated facilitators of this initiative? What are the associated barriers to this initiative? At the end of each workshop, participants were asked to develop specific operational guidelines to “close the ED waiting room.” The workshops were developed by a team of nurse and physician investigators who have expertise in adult education and clinical operations. Each workshop was held in a conference room with no more than 10 participants. The initial 3 workshops were conducted by the investigators for nurse managers and charge nurses only, using a trainthe-trainer model. Charge nurses and investigators cofacilitated an additional 6 workshops for the remainder of the ED staff nurses. Initial guidelines were created during the 3 charge nurse sessions. These guidelines were presented during the staff nurse workshops and suggestions for modification were sought. A pre-workshop survey assessed prior exposure to overcrowding education and served as a needs assessment tool to augment curriculum design. A post-workshop evaluation was distributed at the end of each session and was used to assess the impact of the participatory research process. OUTCOME MEASURES
The primary outcome measure was the development of guidelines to open (use) or close (not use) the ED waiting room. A pre-workshop survey measured participants’ previous exposure to overcrowding education and their attitudes about potentially “closing the waiting room.” The survey was developed by the investigators based on the literature. Psychometric properties of the survey were not evaluated. Specifically, subjects reported the total number of hours spent previously learning about overcrowding concepts through lectures, workshops, or readings. Participants also reported if and how many hours per day they thought the waiting room should remain closed. A post-workshop evaluation measured the perceived impact of the participatory research process. At the end of each session subjects were asked to rate their agreement (Likert scale, 5 = strongly agree) with the following statements: “The program allowed for direct nursing input on this operational change,” and “This operational change will be more successful because of nursing input.”
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TABLE
Sample characteristics Participant characteristic
Current role, n (%) Nurse manager Charge nurse or patient care coordinator Staff nurse Triage nurse, n (%) Highest level of education, n (%) Diploma Associates Bachelors Masters PhD Missing Years experience, mean (SD) Nurse ED nurse Triage nurse Triage nurse at study site
Results
4 17 52 60
(6) (23) (71) (82)
4 12 50 5 1 1
(5.5) (16.4) (68.5) (6.8) (1.4) (1.4)
12 8 8 4
(8) (7) (8) (5)
The majority of participants were staff nurses. A patient care coordinator at the study site is responsible for quality improvement in the emergency department. ED, emergency department; n, number, SD, standard deviation.
DATA ANALYSIS
Descriptive statistics were used to analyze previous exposure to overcrowding education and agreement with statements about the research process. A χ2 statistic with odds ratio (OR) and 95% confidence interval (CI) were calculated to predict whether triage nurses are more likely to believe the waiting room should be closed compared with nurses who do not triage. Results
Seventy-three nurses participated in at least 1 of 9 overcrowding workshops. Of these, 82% functioned as triage nurses. Nurse role, experience, and education levels are presented in the Table. PRE-WORKSHOP SURVEY
Nurses reported spending the following mean (SD) number of hours learning about overcrowding: lectures = .59 (1.5), workshops = .29 (1.2), and readings = .95 (1.75). The total mean (SD) hours of exposure to overcrowding concepts was 1.83 (3.1). Eighty-one percent of participants reported that attempts should be made to potentially “close the waiting room,” an average goal of 7.5 hours per day (SD = 7.4 hours). Triage nurses were significantly more
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SHOULD WE USE THE WAITING ROOM? Northwestern Emergency Medicine 2006 THE GOAL: When staffing, space and acuity allow, patients who present to the ED triage desk should be directed to an open bed on arrival. Ideally, the initial triage assessment and patient registration should be performed at the bedside. The triage assessment may be performed at the triage desk when open care space is limited, but patients should then be escorted to care areas immediately. Registration should always take place at the bedside when the waiting room is closed.
Questions to Guide the Use of the Waiting Room: 1. Does either team have an available staff member (nurse or physician) to initiate care for a new patient? Yes: There are nurses with open care spaces in their assignments, or residents available to assess a new patient. No: Due to high volume and/or acuity, there are no team members who could assess a new patient at this time.
2. Is there adequate available care space in the main room to accept patients directly from triage? Nightshift:
Yes: There are 6 or less patients in the hall, or 26 or less patients in the main ED. (26/39 spaces = 1/3 empty) No: There are greater than 6 patients in the hall or more than 26 patients in the main ED.
Days/Evenings:
Yes: There are 8 or less patients in the hall, or 28 or less patients in the main ED. No: There are greater than 8 patients in the hall or more than 28 patients in the main ED.
3. Is the acuity of the ED reasonable to safely close the waiting room at this time? Yes: At least one team is without critically ill patients, and that team has an available staff member. No: Both teams have patients that require one-to-one nursing and physician staff at the bedside.
4. Is there additional capacity available in Urgent Care or the Observation Unit? Yes: Consider using UC for appropriate “oranges” -or- Consider using the OU for ED-2 or inpatient holding. No: UC & Extended Triage are closed or full -or- Inadequate available space or staffing in the OU.
FIGURE Should we use the waiting room?
likely to believe that the waiting room should be closed when compared with non-triage nurses (OR = 4.64, 95% CI = 1.18, 18.23).
would be more successful because of nursing input (mean = 4.69 [.67]).
CLOSURE GUIDELINES
Discussion
ED waiting room closure criteria were developed as 4 “Questions to Guide the Use of the Waiting Room.” These dichotomous (yes/no) questions reflected issues of available staff, available care space (traditional ED bed spaces and designated hall spaces), patient acuity, and additional surge capacity. Overall goals for the initiative were refined and linked to the guidelines as presented in the Figure. Participants agreed that the research format allowed for direct nursing input about the “close the waiting room” initiative. The mean (SD) agreement score was 4.79 (.5). Most participants also agreed that this operational initiative
This project attempted to increase the success of a challenging operational and cultural change in our emergency department by using staff-nurse participation in the design of the process change. Closing the waiting room represents one possible solution that may help diminish the burden of ED overcrowding. It is clearly not the only solution. Any interventions aimed at decreasing overcrowding would likely contribute to improvements in patient satisfaction and safety. Despite the overwhelming nature of the overcrowding crisis, nurses in our sample had received very little formal education on this problem. This may or may not be reflective of other emergency departments. Nurse managers and
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POST-WORKSHOP EVALUATIONS
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educators are under tremendous pressure to provide education on new therapies, equipment, technology, and regulatory requirements. It is a challenge to find the time to provide nurses with education on the one issue that they struggle with on a daily basis; overcrowding. We believed the time spent educating nurses about this dilemma and receiving their input in the design of the operational change would increase the ultimate success of the change, in this case, “closing the waiting room” during low volume periods. This project used staff-based participatory research methods to allow direct input from those who would be responsible for “closing the waiting room.” Magnet status acknowledges the important role of staff nurses in the actual process of devising and improving nursing practice. In addition to staff nurse input, a commitment from administrators through adequate nurse training is necessary to maximize the potential for successful practice change.8 We had tremendous support from nursing leadership throughout the entire project. Staff-based participation in the change process is not a new concept, but often it is neglected for several reasons. Historically, a hierarchical method of developing and implementing change is necessary to rapidly react to a problem. This may result in the development of a policy with or without associated education, and without staff input. Although occasionally such policy making is required, we believe the inclusion and empowerment of staff will facilitate successful practice change, when time is available for staff education. The main purpose of the project was to develop actual criteria to close the waiting room. The criteria that were created are very practical and user-friendly, “Is there available staff ”, “Is there availale space” (space includes hall spaces), “Is the acuity reasonable?”, and finally, “Are there any other areas of the ‘department’ with additional capacity?” Although simple and intuitive, the criteria are not only easy for the charge nurses to remember, but can be adapted easily in any emergency department. These 4 criteria represent important, core principles. If the answer to any 1 of these questions is “no,” patients should not be brought back for care. The simplicity of the criteria enhance the likelihood that they will be remembered and used. Finally, we assessed nurse participant satisfaction with the staff-based participatory research methodology used. As anticipated, the nurses responded favorably to this approach and generally agreed the project will be more successful because of nurse participation. Several limitations should be discussed. The project was conducted at one center, a high-volume, urban Level 1 trauma center. The survey was not evaluated for validity and reliability, although it was developed based on concepts
identified in the literature. Results may not be generalizable to other settings, however the process used to develop the criteria is supported by the Magnet mission. We have no reason to believe staff-based participation in practice change cannot be successful in other emergency departments. Most importantly, the outcomes of the criteria, (decreasing overcrowding) were not assessed in this article. Evaluation of the operational impact of the closure criteria is still on-going.
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Conclusion
Staff-based participatory research with emergency department nurses was an effective method to design an operational change that may reduce ED overcrowding. Emergency department staff nurses created 4 explicit criteria describing when the waiting room should be closed. Acknowledgments The authors wish to thank Deb Livingston and James G. Adams for their support of the project, as well as the emergency department staff nurses and physicians who participated in the project and struggle with overcrowding on a daily basis.
REFERENCES 1. Institute of Medicine Committee on the Future of Emergency Care in the US Health System. Report brief: The future of emergency care in the United States health system. Washington, DC: National Academies Press; 2006. 2. Institute of Medicine Committee on the Future of Emergency Care in the US Health System. Hospital-based emergency care: At the breaking point. Washington, DC: National Academies Press; 2006. 3. McCaig L, Burt C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; May 26, 2005. p. 358. 4. Kennedy J, Rhodes K, Walls CA, Asplin BR. Access to emergency care: Restricted by long waiting times and cost and coverage concerns. Ann Emerg Med 2004;43:567-73. 5. Chan TC, Killeen JP, Kelly D, Guss DA. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen. Ann Emerg Med 2005;46:491-7. 6. Green LV, Soares J, Giglio JF, Green RA. Using queuing theory to increase the effectiveness of emergency department provider staffing. Acad Emerg Med 2006;13:61-8. 7. Green LW, Mercer SL. Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Am J Public Health 2001;91:1926-9. 8. Rondeau KV, Wagar TH. Nurse and resident satisfaction in magnet long-term care organizations: Do high involvement approaches matter? J Nurs Manag 2006;14:244-50.
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SHOULD YOU CLOSE YOUR WAITING ROOM? ADDRESSING ED OVERCROWDING THROUGH EDUCATION AND STAFF-BASED PARTICIPATORY RESEARCH Authors: Paula Tanabe, PhD, MPH, RN, Michael A. Gisondi, MD, Sara Medendorp, BA, Laurie Engeldinger, RN, Lisa J. Graham, RN, BSN, MPH, and Martin J. Lucenti, MD, PhD, Chicago, Ill, and Albany, NY
Introduction: The purpose of this project was to develop operational criteria to “close the ED waiting room”. Methods: A prospective, staff-based participatory research model was used. Nurses at an urban ED with 70,000 visits attended a four-hour workshop concerning ED overcrowding. The workshops consisted of two parts, (1) educational sessions that reviewed key concepts of ED overcrowding, followed by (2) discussions of a proposal to “close the waiting room” as a means to decrease overcrowding. During the discussions, nurses were asked to develop guidelines to safely and consistently “close the waiting room.” The investigators defined the waiting room as “closed” when (1) ambulatory patients could be taken directly to a room or hallway space for bedside triage,
Paula Tanabe, Illinois ENA, is Research Assistant Professor of Emergency Medicine and the Institute for Healthcare Studies, Northwestern University, Chicago, Ill. Michael A. Gisondi is Assistant Professor of Emergency Medicine, Northwestern University, Chicago, Ill. Sara Medendorp, Northwestern University, Chicago, Ill.
registration, and initiation of care, or (2) patients were triaged in the waiting room and then taken directly to a care space for registration at the bedside. The primary outcome measure of the project was the development of guidelines to open (use) or close (not use) the ED waiting room. Results: Seventy three of 100 nurses participated in the workshops. ED waiting room closure criteria were developed as 4 “Questions to Guide the Use of the Waiting Room.” These dichotomous (yes/no) questions reflected issues of available staff, available care space (traditional ED bed spaces and designated hall spaces), patient acuity, and additional surge capacity. Discussion: Staff-based participatory research was an effective method to design an operational change. Nurses developed four explicit criteria describing when the waiting room should be closed.
T
doi: 10.1016/j.jen.2007.08.009
he epidemic of overcrowding has made it a challenging time to practice in the emergency department. 1 Emergency departments are faced with rising volumes, high patient acuity, hospital crowding, a serious nursing shortage, increasing regulations, and changes in medicine and technology that are occurring at a rampant pace.2 The total number of visits to emergency departments increased from 90.3 million in 1993 to 113.9 million in 2003.3 Emergency departments have struggled to keep pace, as shown by 2001 data that reported 7.7% of 36.6 million adults who sought care in a hospital ED described trouble receiving emergency care, with over half citing long wait times as a cause.4 In addition to emergency department staff, nursing and physician administrators, educators, and clinical nurse specialists are held accountable to meet these challenges, and improve patient satisfaction. To address overcrowding at our institution, physician and nursing leadership identified the need to keep the waiting room “closed” whenever possible, to facilitate the flow of patients during off-peak hours. For the context of this project, the phrase “closing the waiting room” means that patients are either taken immediately to a treatment space
August 2008 34:4
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Laurie Engeldinger, Northwestern Memorial Hospital, Chicago, Ill. Lisa J. Graham is Emergency Services Manager, Northwestern Memorial Hospital, Chicago, Ill. Martin J. Lucenti is Assistant Professor of Emergency Medicine, Northwestern University, Chicago, Ill. This project was supported by the 2005 Emergency Medicine Foundation and Emergency Nurses Association Foundation Team Grant. Dr. Tanabe was partially supported by a grant from the Illinois Department of Healthcare and Family Services to Northwestern Memorial Hospital under the Excellence in Academic Medicine Act. Portions of this project were presented at the Scientific Assembly of the American College of Emergency Physicians on October 15, 2006, in New Orleans, Louisiana. For correspondence, write: Paula Tanabe, Northwestern University, 259 E. Erie, Suite 100, Emergency Medicine, Chicago IL 60611; E-mail: [email protected]. J Emerg Nurs 2008;34:285-9. 0099-1767/$34.00 Copyright © 2008 by the Emergency Nurses Association.
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for registration and triage at the bedside, or, patients are placed in a treatment space for bedside registration immediately after triage in the waiting room. Alternatively, patients do not sit in the waiting room. The waiting room always remains “open,” in that visitors still wait in the waiting room, and patients also wait in the waiting room when immediate placement is not possible. This concept has been explored previously. Data from the REACT (Rapid Entry and Accelerated Care at Triage) investigators reported improvements in overall waiting time after implementation of many departmental strategies aimed at reducing wait times, one of which was immediate placement of patients in open beds.5 The rationale for “closing the waiting room” stems from queuing theory. This model explains the impact of time-varying demands in the ED waiting room resulting from statistical fluctuations in individual patient arrival times and the variability in the time needed by a provider to treat patients.6 Data from The National Hospital Ambulatory Medical Care Survey describe a relatively low volume of patient arrivals during the night followed by a steep increase around 9 am, peaking around noon and remaining high through the evening.3 The basis for this project is that “closing the waiting room” during low-volume periods of the day will help reduce the backup that occurs during busier times. Although the “close the waiting room” initiative had been identified as desirable, neither a formal policy nor criteria had been developed. Furthermore, education of those who would implement this system had not been conducted. In 2005, the investigators received the Team Grant from the Emergency Nursing and Emergency Medicine Foundations to investigate the question “Should You Close Your Waiting Room?” The project used a novel method, staff-based participatory research, to develop criteria to encourage closure of the waiting room whenever possible. This article examines the effectiveness of the method chosen to create the waiting room closure criteria. The specific aims of the project were to: (1) measure ED nurses’ exposure to overcrowding concepts; (2) develop criteria to “close the waiting room” using staff-based participatory research; and (3) assess staff nurse perceptions to the workshops’ ability to impact operational change. This article does not report outcomes from application of the final closing the waiting room criteria. These outcomes are being evaluated and will be reported separately.
from the success observed with community-based participatory research, which allows members of a community to provide their knowledge and personal experience in identifying a problem to be studied. These community members then use study results to help support relevant program and policy development.7 In a similar manner, ED nurses were educated on the problem of overcrowding and participated in the development of criteria to “close the waiting room,” as an operational solution to ED overcrowding. Our Institutional Review Board approved the study protocol and considered the project exempt from consent. SETTING
The study was conducted at a large, urban, academic medical center with an annual ED census of 70,000 patient visits per year. The emergency department has 21 rooms for general care, 7 rooms for urgent care, 2 resuscitation bays, and 23 ED observation beds. Due to daily periods of overcrowding, 18 hallway spaces are used routinely for patients awaiting test results or an inpatient bed. SELECTION OF PARTICIPANTS
All ED nurses at our institution were eligible to participate in 1 of 9 overcrowding workshops scheduled between 9/1/05 and 12/31/05. At the time of the study, our department employed 6 nurse managers, 14 charge nurses, and 80 staff nurses. Although participation was voluntary, the project was supported as a process improvement project and nurses were strongly encouraged to participate by the nursing leadership. Nurse participants were informed of their role in the development of this research project and were compensated for their participation at an averaged hourly rate. STUDY PROTOCOL
This project used a prospective, staff-based, participatory research model. The rationale for this methodology stems
Emergency nurses attended 1 of 9 workshops (4 hours each) concerning ED overcrowding. The workshops consisted of 2 parts: (1) educational sessions that reviewed key concepts of ED overcrowding, followed by (2) discussions of a proposal to “close the waiting room” as a means to decrease overcrowding. During the discussions, nurses were asked to develop guidelines to safely and consistently “close the waiting room.” The investigators defined the waiting room as “closed” when (1) ambulatory patients could be taken directly to a room or hallway space for bedside triage, registration and initiation of care, or (2) patients were triaged in the waiting room and then taken directly to a care space for registration at the bedside. Emergency medicine faculty were informed of the project and guidelines were discussed at faculty meetings and communicated by the investigators on an individual basis. The initial 2 hours of the workshop consisted of several short educational didactic sessions presented by the
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Methods
STUDY DESIGN
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RESEARCH/Tanabe et al
investigators on the following topics: ‘Overview of the Research Project’; ‘Principles of ED Overcrowding’; ‘Queuing Theory and Departmental Surge Trends’; and ‘The Impact of Triage and Registration on Delays to Care.’ The remainder of the workshop was spent discussing the proposed “close the waiting room” initiative. Four questions were used to facilitate this discussion: Who should make the decision to close the ED waiting room? What guidelines should be used to close the waiting room? What are the associated facilitators of this initiative? What are the associated barriers to this initiative? At the end of each workshop, participants were asked to develop specific operational guidelines to “close the ED waiting room.” The workshops were developed by a team of nurse and physician investigators who have expertise in adult education and clinical operations. Each workshop was held in a conference room with no more than 10 participants. The initial 3 workshops were conducted by the investigators for nurse managers and charge nurses only, using a trainthe-trainer model. Charge nurses and investigators cofacilitated an additional 6 workshops for the remainder of the ED staff nurses. Initial guidelines were created during the 3 charge nurse sessions. These guidelines were presented during the staff nurse workshops and suggestions for modification were sought. A pre-workshop survey assessed prior exposure to overcrowding education and served as a needs assessment tool to augment curriculum design. A post-workshop evaluation was distributed at the end of each session and was used to assess the impact of the participatory research process. OUTCOME MEASURES
The primary outcome measure was the development of guidelines to open (use) or close (not use) the ED waiting room. A pre-workshop survey measured participants’ previous exposure to overcrowding education and their attitudes about potentially “closing the waiting room.” The survey was developed by the investigators based on the literature. Psychometric properties of the survey were not evaluated. Specifically, subjects reported the total number of hours spent previously learning about overcrowding concepts through lectures, workshops, or readings. Participants also reported if and how many hours per day they thought the waiting room should remain closed. A post-workshop evaluation measured the perceived impact of the participatory research process. At the end of each session subjects were asked to rate their agreement (Likert scale, 5 = strongly agree) with the following statements: “The program allowed for direct nursing input on this operational change,” and “This operational change will be more successful because of nursing input.”
August 2008 34:4
TABLE
Sample characteristics Participant characteristic
Current role, n (%) Nurse manager Charge nurse or patient care coordinator Staff nurse Triage nurse, n (%) Highest level of education, n (%) Diploma Associates Bachelors Masters PhD Missing Years experience, mean (SD) Nurse ED nurse Triage nurse Triage nurse at study site
Results
4 17 52 60
(6) (23) (71) (82)
4 12 50 5 1 1
(5.5) (16.4) (68.5) (6.8) (1.4) (1.4)
12 8 8 4
(8) (7) (8) (5)
The majority of participants were staff nurses. A patient care coordinator at the study site is responsible for quality improvement in the emergency department. ED, emergency department; n, number, SD, standard deviation.
DATA ANALYSIS
Descriptive statistics were used to analyze previous exposure to overcrowding education and agreement with statements about the research process. A χ2 statistic with odds ratio (OR) and 95% confidence interval (CI) were calculated to predict whether triage nurses are more likely to believe the waiting room should be closed compared with nurses who do not triage. Results
Seventy-three nurses participated in at least 1 of 9 overcrowding workshops. Of these, 82% functioned as triage nurses. Nurse role, experience, and education levels are presented in the Table. PRE-WORKSHOP SURVEY
Nurses reported spending the following mean (SD) number of hours learning about overcrowding: lectures = .59 (1.5), workshops = .29 (1.2), and readings = .95 (1.75). The total mean (SD) hours of exposure to overcrowding concepts was 1.83 (3.1). Eighty-one percent of participants reported that attempts should be made to potentially “close the waiting room,” an average goal of 7.5 hours per day (SD = 7.4 hours). Triage nurses were significantly more
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SHOULD WE USE THE WAITING ROOM? Northwestern Emergency Medicine 2006 THE GOAL: When staffing, space and acuity allow, patients who present to the ED triage desk should be directed to an open bed on arrival. Ideally, the initial triage assessment and patient registration should be performed at the bedside. The triage assessment may be performed at the triage desk when open care space is limited, but patients should then be escorted to care areas immediately. Registration should always take place at the bedside when the waiting room is closed.
Questions to Guide the Use of the Waiting Room: 1. Does either team have an available staff member (nurse or physician) to initiate care for a new patient? Yes: There are nurses with open care spaces in their assignments, or residents available to assess a new patient. No: Due to high volume and/or acuity, there are no team members who could assess a new patient at this time.
2. Is there adequate available care space in the main room to accept patients directly from triage? Nightshift:
Yes: There are 6 or less patients in the hall, or 26 or less patients in the main ED. (26/39 spaces = 1/3 empty) No: There are greater than 6 patients in the hall or more than 26 patients in the main ED.
Days/Evenings:
Yes: There are 8 or less patients in the hall, or 28 or less patients in the main ED. No: There are greater than 8 patients in the hall or more than 28 patients in the main ED.
3. Is the acuity of the ED reasonable to safely close the waiting room at this time? Yes: At least one team is without critically ill patients, and that team has an available staff member. No: Both teams have patients that require one-to-one nursing and physician staff at the bedside.
4. Is there additional capacity available in Urgent Care or the Observation Unit? Yes: Consider using UC for appropriate “oranges” -or- Consider using the OU for ED-2 or inpatient holding. No: UC & Extended Triage are closed or full -or- Inadequate available space or staffing in the OU.
FIGURE Should we use the waiting room?
likely to believe that the waiting room should be closed when compared with non-triage nurses (OR = 4.64, 95% CI = 1.18, 18.23).
would be more successful because of nursing input (mean = 4.69 [.67]).
CLOSURE GUIDELINES
Discussion
ED waiting room closure criteria were developed as 4 “Questions to Guide the Use of the Waiting Room.” These dichotomous (yes/no) questions reflected issues of available staff, available care space (traditional ED bed spaces and designated hall spaces), patient acuity, and additional surge capacity. Overall goals for the initiative were refined and linked to the guidelines as presented in the Figure. Participants agreed that the research format allowed for direct nursing input about the “close the waiting room” initiative. The mean (SD) agreement score was 4.79 (.5). Most participants also agreed that this operational initiative
This project attempted to increase the success of a challenging operational and cultural change in our emergency department by using staff-nurse participation in the design of the process change. Closing the waiting room represents one possible solution that may help diminish the burden of ED overcrowding. It is clearly not the only solution. Any interventions aimed at decreasing overcrowding would likely contribute to improvements in patient satisfaction and safety. Despite the overwhelming nature of the overcrowding crisis, nurses in our sample had received very little formal education on this problem. This may or may not be reflective of other emergency departments. Nurse managers and
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educators are under tremendous pressure to provide education on new therapies, equipment, technology, and regulatory requirements. It is a challenge to find the time to provide nurses with education on the one issue that they struggle with on a daily basis; overcrowding. We believed the time spent educating nurses about this dilemma and receiving their input in the design of the operational change would increase the ultimate success of the change, in this case, “closing the waiting room” during low volume periods. This project used staff-based participatory research methods to allow direct input from those who would be responsible for “closing the waiting room.” Magnet status acknowledges the important role of staff nurses in the actual process of devising and improving nursing practice. In addition to staff nurse input, a commitment from administrators through adequate nurse training is necessary to maximize the potential for successful practice change.8 We had tremendous support from nursing leadership throughout the entire project. Staff-based participation in the change process is not a new concept, but often it is neglected for several reasons. Historically, a hierarchical method of developing and implementing change is necessary to rapidly react to a problem. This may result in the development of a policy with or without associated education, and without staff input. Although occasionally such policy making is required, we believe the inclusion and empowerment of staff will facilitate successful practice change, when time is available for staff education. The main purpose of the project was to develop actual criteria to close the waiting room. The criteria that were created are very practical and user-friendly, “Is there available staff ”, “Is there availale space” (space includes hall spaces), “Is the acuity reasonable?”, and finally, “Are there any other areas of the ‘department’ with additional capacity?” Although simple and intuitive, the criteria are not only easy for the charge nurses to remember, but can be adapted easily in any emergency department. These 4 criteria represent important, core principles. If the answer to any 1 of these questions is “no,” patients should not be brought back for care. The simplicity of the criteria enhance the likelihood that they will be remembered and used. Finally, we assessed nurse participant satisfaction with the staff-based participatory research methodology used. As anticipated, the nurses responded favorably to this approach and generally agreed the project will be more successful because of nurse participation. Several limitations should be discussed. The project was conducted at one center, a high-volume, urban Level 1 trauma center. The survey was not evaluated for validity and reliability, although it was developed based on concepts
identified in the literature. Results may not be generalizable to other settings, however the process used to develop the criteria is supported by the Magnet mission. We have no reason to believe staff-based participation in practice change cannot be successful in other emergency departments. Most importantly, the outcomes of the criteria, (decreasing overcrowding) were not assessed in this article. Evaluation of the operational impact of the closure criteria is still on-going.
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Conclusion
Staff-based participatory research with emergency department nurses was an effective method to design an operational change that may reduce ED overcrowding. Emergency department staff nurses created 4 explicit criteria describing when the waiting room should be closed. Acknowledgments The authors wish to thank Deb Livingston and James G. Adams for their support of the project, as well as the emergency department staff nurses and physicians who participated in the project and struggle with overcrowding on a daily basis.
REFERENCES 1. Institute of Medicine Committee on the Future of Emergency Care in the US Health System. Report brief: The future of emergency care in the United States health system. Washington, DC: National Academies Press; 2006. 2. Institute of Medicine Committee on the Future of Emergency Care in the US Health System. Hospital-based emergency care: At the breaking point. Washington, DC: National Academies Press; 2006. 3. McCaig L, Burt C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; May 26, 2005. p. 358. 4. Kennedy J, Rhodes K, Walls CA, Asplin BR. Access to emergency care: Restricted by long waiting times and cost and coverage concerns. Ann Emerg Med 2004;43:567-73. 5. Chan TC, Killeen JP, Kelly D, Guss DA. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen. Ann Emerg Med 2005;46:491-7. 6. Green LV, Soares J, Giglio JF, Green RA. Using queuing theory to increase the effectiveness of emergency department provider staffing. Acad Emerg Med 2006;13:61-8. 7. Green LW, Mercer SL. Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Am J Public Health 2001;91:1926-9. 8. Rondeau KV, Wagar TH. Nurse and resident satisfaction in magnet long-term care organizations: Do high involvement approaches matter? J Nurs Manag 2006;14:244-50.
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