- Email: [email protected]
Nursing perspectives on the emergency department
Emerg Med Clin N Am 22 (2004) 117–129
Nursing perspectives on the emergency department Sherri-Lynne Almeida, Dr PH, MSN, MEd, RN, CENa,b,c,* a
Team Health Southwest, 6750 West Loop South, Suite 460, Bellaire, TX 77401, USA b Division of Acute and Continuing Care, University of Texas–Houston, Graduate School of Nursing, 1100 Holcombe Blvd., Houston, TX 77030, USA c Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016, USA
Emergency nursing Emergency nursing is the care of individuals of all ages with perceived or actual physical or emotional alterations of health that are undiagnosed or that require further interventions. The care is episodic, primary, and usually acute. The profession of emergency nursing has evolved over the last 30 years, nurses have become more responsible and accountable for their practice. Emergency nursing practice is defined through specific role functions as delineated in the Emergency Nurses Association’s (ENA) Standards of Emergency Nursing Practice, Scope of Practice Statement, and Emergency Nursing Core Curriculum. Nursing roles include patient care, research, education, consultation, advocacy, and management. Emergency department (ED) management is one of the most challenging fields in health care today. Over the last 30 years, we have experienced dramatic changes in the provision of emergency care within the United States. We have seen the implementation of managed care, the closure of many hospitals and inpatient beds, the downsizing of nursing and other ancillary staff, nursing shortages, strike actions, decreased reimbursement to hospitals and providers, diversion, and physician work stoppages; yet through all of these changes, one thing remained: patients in need of care. Emergency departments nationwide are experiencing an exponential growth in patient visits while simultaneously feeling the impact of a sluggish economy.
* Team Health Southwest, 6750 West Loop South, Suite 460, Bellaire, TX 77401. E-mail address: [email protected] 0733-8627/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0733-8627(03)00099-3
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The ED is the only provider many people ever know. It serves not only as a receiving center for critically ill and injured people, but also as a 24-hour shelter for the walking well, worried, and wounded. Increasing visits and admissions have led to the development of diversion policies and a common state of ED crowding. To balance all the issues facing EDs today, the ED nurse manager must use strong organizational skills and effective interpersonal communication skills and must implement sound financial principles. Emergency department nurse manager The title of ED Nurse Manager has undergone many changes in the last several years and varies across the country. No matter the title, however, the roles and responsibilities are similar. The roles and responsibilities of the ED nurse manager are more complex than they were a decade ago. Because of the dramatic changes that have occurred in health care, the ED has seen an increase in visibility, responsibility, and delivery. Increases at a time when resources are being decreased can present the ED nurse manager with daily challenges and opportunities. As the ED evolves into the major diagnostic and resuscitation site of the health care system, the ED manager has been forced to evolve to keep pace and make this possible. The body of information required to be an ED nurse manager has grown considerably in mass and complexity. In the best of all worlds, the ED nurse manager possesses a strong background in the practice of emergency nursing, management, and leadership. They uphold the standards of professional performance as outlined by the Emergency Nurses Association [1]. Box 1 lists the ENA’s Standards of Professional Performance. These standards provide an excellent framework for practice; however, it is incumbent on each institution to develop more refined qualifications and a position description to include responsibilities. The author briefly discusses the most common responsibilities placed on today’s ED nurse manager. Box 1. ENA standards of professional performance Quality Performance appraisal Education Collegiality Ethics Collaboration Research Resource use
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Administrative management Being an administrative leader requires flexibility, openness, innovation, proficiency, and patience. Managers in the twenty-first century are involved in and often direct financial and strategic planning, business development, and outcomes management. There is a complex list of issues that fall under each of these categories. These issues affect the daily operations of an ED. Those which have the greatest impact on patient care are addressed in this article. The ED nurse manager plays a vital role in the development and enhancement of programs that are designed to address the issues set forth. Outcomes management There are two areas the ED nurse manager must focus on when measuring outcomes. They are clinical and organizational. As the administrative leader, the ED nurse manager is charged with the tasks of measuring, monitoring, and evaluating each outcome assessed. The data obtained during this process should be compared with standards, protocols, and guidelines. The final analysis should correlate process to outcomes. Changes in the health care delivery system have greatly affected patient care in the ED. Increasing numbers of ED patient visits, delays at discharge, longer ED stays, overcrowding, and diversion to other ED facilities may lead to decreased quality of care and patient dissatisfaction [2,3]. The national shortage of nurses also is creating a perception that EDs may have difficulty providing quality care [3]. The ED nurse manager must ensure that quality indicators identify expected outcomes of care and are specific to the plan of care. In many facilities, clinical pathways or practice policies have been implemented. The purpose of these pathways/policies is to move the patient’s care along a delineated timeline that allows for specific standards of care and a method by which data can be obtained to determine compliance. The use of such guidelines affects clinical outcomes and organizational outcomes. Organizational outcomes are measured by improvements in the health care and well being of the population served relative to costs incurred [4]. Cost containment is an ever-prevailing theme that affects the clinical and the business side of managing an ED. The ED nurse manager and the medical director should collaborate and develop operational systems that lend efficiencies and consistencies to departmental operations. There are many factors in an ED that significantly affect overall financial status. These factors include salary cost and staffing, health care delivery systems (eg, triage, fast tracks), use of diagnostic testing, and the use of supplies/equipment. A well managed ED should consider incorporating cost containment practices into the everyday practice environment, and collaboration between the ED nurse manager and the medical director is essential to this goal.
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Emergency department nurse staffing Staffing an ED has always been a challenge to ED managers and hospital administrators. Fluctuating patient volumes and acuity prohibit the accurate assignment of staff to the workload; however, managers and administrators have the responsibility of ensuring effective and efficient emergency care delivery systems. Staffing and productivity are critical components of those systems. In the past several years, concern has grown about inadequate nurse staffing, possible adverse outcomes, and the frequency and impact of medical errors. Inadequate nurse staffing may reflect insufficient numbers of nursing personnel in response to an increase in nursing care needs, the replacement of licensed nurses with unlicensed personnel, or the mandate of excessive overtime [5,6]. Many states have passed legislation that mandates nurse staffing in the ED. There is varying opinion, however, as to whether this approach is safe and effective. Staffing with qualified professional registered nurses and ancillary staff is needed to deliver optimal patient care, achieve an operationally efficient department, and maintain a qualified and satisfied nursing staff [7,8]. According to the ENA, for more than a decade health care cost containment, institutional restructuring, nursing staff downsizing, and nursing shortages have resulted in a system that threatens the quality and safety of patient care and the quality of work life for nurses [7–10]. In 1994, the American Nurses Association (ANA) recognized the need for empiric data to drive staffing decisions [10]. Subsequently the ANA identified nine outcomes that were sensitive to nursing intervention as the basis for new research studies [11]. The outcomes included adverse drug events, patient falls and injuries, nosocomial infections, skin breakdown, pain management, educational information, patient satisfaction with care, nursing job satisfaction, and total nursing care hours provided per patient day [11]. In 1996 the Institute of Medicine’s report showed significant work-related injuries and stress for nurses but was unable to demonstrate a relationship between hospital quality of care and staffing patterns in part because of the lack of empiric data on quality of care [7,8]. Nurses continued to report their concerns for patient safety in an environment of inadequate numbers of qualified staff, high workloads, mandatory overtime, and fatigue [12–14]. Occupational injury, job dissatisfaction, burnout, and departure from the nursing profession also were reported. Health care providers’ concerns for quality of care and patient safety and the impact on nurses, however, was largely dismissed without the presence of empiric data [11,13]. Investigators are now able to support what health care providers had been saying, that is, nurse staffing influences patient outcomes. The ANA commissioned a study examining the amount and skill mix of nursing care, patient length of stay, and preventable morbidities, including pneumonia, postoperative infections, pressure ulcers, and urinary tract infections [15].
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Patient data from nine states, 2500 hospitals, and approximately 13 million patients were sampled. The findings showed that morbidity was lower in hospitals with higher registered nurse skill mixes and greater staffing levels [15]. Shorter lengths of stay were associated with greater staffing levels [15]. In a study of 232 acute care hospitals and 124,204 surgical patients, an increase in 1 hour of registered nurse staffing per patient day produced a significant 8.9% decrease in the risk for pneumonia [16]. Adverse events were associated with longer patient stays, and for some events a greater probability of death during hospitalization [16]. Similarly, a study of 168 hospitals, 10,184 nurses, and 232,342 surgical patients showed that in hospitals with higher patient-to-nurse ratios there were higher risk-adjusted 30-day mortalities and 30-day mortalities for patients with complications [12]. In addition, nurses were more likely to experience burnout and job dissatisfaction [12]. To help determine nurse staffing and improve patient safety, workforce measures, such as hours per patient visit and nurse-to-patient ratios, were proposed and have generated considerable debate [17–25]. In EDs, the hours per patient visit method for calculating staffing was based on historic or benchmark data. The previous year’s actual paid hours are divided by the total number of ED visits. The limitation of this method is that it considers patient volume and available nursing hours without consideration of factors such as patient acuity, length of stay, and nursing interventions and activities [10,17]. In addition, decision making based on the prior year’s data may not be accurate for today’s rapidly changing emergency care environments with increased patient acuity, increased lengths of stays, delays in discharge, overcrowding, diversions, and nursing staff shortages. The ANA stated that hours per patient day was a ‘‘one size fits all’’ strategy whose usefulness is questionable [10]. In 2002, California was the first state to propose specific nurse-to-patient ratios [19–25]. Other states are also considering the use of ratios [26]. For EDs, the California Department of Health and Human Services (DHHS) proposed one nurse to four general ED patients, one nurse to two critical care ED patients, and one nurse to one ED trauma patient. No ratios were assigned to triage or radio-dedicated nurses [19–26]. Although supporting the use of ratios to determine nurse staffing, the California Nurses Association was concerned that the ratios should only apply to professional registered nurses [26]. The California DHHS proposal categorizes nurses as licensed practical/vocational nurses and registered nurses [26]. A critical limitation in the use of ratios is that ratios do not take into account the variability found in institutions, available internal and external resources (eg, inpatient beds, equipment, other staff), individual and aggregate patient needs (eg, volume, intensity, demographics, length of stay), and the nursing expertise required by the patient population (eg, knowledge, skills, licensure) [10,18,27]. The use of ratios also was challenged because some investigators [24,27] believed that mandated staffing may be
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interpreted by institutions as the maximum required staffing, when in fact it is the minimal mandated staffing standard. Further, ratios may lead to an acceptance of minimally safe staffing and patient care instead of best practice staffing and care [26]. Staffing based solely on nurse-to-patient ratios or paid hours per visit is limited in scope without consideration of the variables that affect the consumption of nursing resources [10,18]. To identify safe, effective, realistic best practice staffing in EDs, the ENA identified six key factors that were critical in the projection of staffing requirements, the development of staffing models, and accurate budget preparation [18]. These factors include patient census, patient acuity, patient length of stay, nursing time for nursing interventions and activities by patient acuity, skill mix for providing patient care based on nursing interventions that can be delegated to a non-registered nurse, and an adjustment factor for the non-patient care time included in each FTE [18]. The staffing guidelines and tools that were developed are applicable in all types of EDs, flexible and dynamic, and easy to use and understand [18]. The ENA staffing guidelines represent a new and innovative method to predict nurse staffing needs in US EDs [12]. Continued research is needed to determine patient, nurse, and organizational outcomes in relation to predicted staffing [18]. Triage Triage is a process used to determine severity of illness or injury for each patient who enters the ED. An RN should fulfill this role. The Joint Commission on Accreditation of Healthcare Organizations standards identifies the RN as the appropriate person to perform patient assessment, which is essential for the triage process. The triage process was introduced in EDs in the late 1950s and early 1960s. The primary goal of a triage system is rapid identification of patients with urgent, life-threatening conditions. Most EDs in the United States use some type of triage system. There are two systems most commonly used throughout the country. The first system is a spot check system. This type of system is appropriate for low volume EDs where patients do not wait for ED bed space and it is not cost effective to have an RN at triage 24/7. The most advanced system is comprehensive triage and it is supported by the ENA’s Standards of Emergency Nursing Practice [28]. A comprehensive triage system uses four or more classifications. The emergency nurse triages each patient and determines the priority of care based on physical, developmental, and psychosocial needs and factors influencing access to health care and patient flow through the emergency care system. Triage is to be performed by an experienced ED nurse who has demonstrated competency in the triage role. The goal is to rapidly gather sufficient information to determine triage acuity [1].
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In 2001, the ENA surveyed US EDs about the type of triage acuity scale used by their department [9]. Sixty-nine percent of the respondents indicated that they used a three-level triage scale, 12% used a four-level scale, 3% used either the Australasian or Canadian five-level scale, and 16% did not answer the question or used no triage acuity rating scale. The most commonly used three-level scale included the acuity levels of emergent, urgent, and non-urgent. Several studies, however, have evaluated the reliability of triage rating systems and found poor inter-rater reliability, whereas, five-level triage classification systems have been shown to have better inter-rater and test-retest reliability than three-level or four-level classification systems [29]. Three countries, Australia, the United Kingdom, and Canada have implemented standardized five-level triage classification systems. Recently a five-level scale called the Emergency Severity Index (ESI) emerged and is used in several academic institutions in the United States. This scale stratifies adult patients into defined exclusive categories. Patient acuity, expected resource intensity, and timeliness define categories. Research by Wuerz has demonstrated reliability and validity of the ESI [30]. The ENA and the American College of Emergency Physicians believe that a standardized triage system would provide a point of reference with which to benchmark triage acuity for staffing, resource allocation, research, and educational needs. These two associations have formed a collaborative workgroup charged with the task of evaluating the existing triage systems in the United States and to recommend a standardized system for use by our nation’s EDs. Patient throughput and customer satisfaction The primary challenge for many health care organizations is to identify cost-effective strategies to enhance clinical outcomes and provide for the highest level of patient safety. These strategies have to be practical. Patient throughput has been studied extensively. Several factors have been identified that affect patient throughput in the ED. These factors include census, facility size and design, ambulance traffic, number of trauma cases, case mix, number of admissions, average time an admitted patient waits in the ED, laboratory and radiology throughput times, and seasonal data. Six primary bottlenecks to patient throughput have been defined by the Advisory Board Company [31] and include triage, registration, emergency physician, laboratory, radiology, and inpatient admission. At some point, every ED manager is confronted with the two central concerns of structure: determining if problematic conditions are being generated by inadequate structure and if so, understanding the precise nature of the structural issues. Every nursing unit and health care system has a structure that is the key factor in system performance. The overall perspective notes, ‘‘Every system and organization has an architecture, or structure broadly defined, which largely determines what the system can and cannot do’’ [31]. System
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structure is critical to improving the effectiveness of the operation. Starting at patient entrance to the ED, a thorough analysis of patient throughput can take place. According to Salluzzo et al, patient entrance to registration should not exceed 10–12 minutes; the registration process should not exceed 5–8 minutes, and comprehensive triage should be completed in 2–5 minutes [32]. Focusing on front end activities are often not sufficient to provide faster bed access for all patients. If bottlenecks continue to contribute to length of stay, then other factors, such as wait time to see a physician and discharge process, should be evaluated. It is in everyone’s best interest to implement change on area at a time so that the implementation and the related outcome can be effectively measured. Managers must realize that often the most critical access/throughput issue is bed availability and facility design. It is estimated that for every bed available in the ED, 2000 patients can be evaluated. This number does not factor patient acuity or length of stay, however; therefore, it provides an extremely rough estimate of capacity. On average, 80% of a patient’s time in an ED is spent waiting [31]. Wait times exert the highest influence on the patient’s likelihood to recommend the ED to others and is considered the biggest problem in EDs by patients [33]. The inability of an ED to evaluate, treat, and make a disposition for a patient in a reasonable amount of time is the most scrutinized aspect of ED care [32]. The ENA Position Statement on Customer Service and Satisfaction in the ED notes that, ‘‘Patients and their families are influenced by the actual care and conditions that they encounter during their ED visit. Their satisfaction with care also may be influenced by the increasing media coverage concerning the quality of health care in the United States, particularly in EDs. Although many patients and families are more informed about health care services, for some, an ED visit is a frightening experience [34]. In addition, the patient’s ED experience also may influence the overall satisfaction with the institution, because the ED serves as the link between the community and the in-patient facility [33].’’ In the ENA National Benchmark Guide: Emergency Departments [9], 1380 ED managers reported that 88% of their patients rated their satisfaction with the ED as good to excellent. Formal patient satisfaction surveys were used by 76% of the EDs. In addition, 96% of patients rated the quality of their ED care as good or excellent. Quality of care was measured using a formal survey by 59% of the EDs. Ongoing monitoring is needed to determine if quality and satisfaction are improving, remaining stable, or declining. Distributing surveys and encouraging staff to ‘‘be nicer and work harder’’ are sometimes the only steps taken by institutions to address customer service [35]. Improving customer service and satisfaction often requires staff training programs and process improvement programs [33,35]. In a 72,000visit ED, an 80% reduction in patient complaints and a 100% increase in patient compliments was achieved following a training program on
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customer service [35]. Following training, another ED reported a 100% increase in compliments and a 70% reduction in patient complaints (from 2.6 to 0.6 per 1000), well below the national average of 3–5 per 1000 visits [34]. After initiating a customer-oriented approach, an ED reported improved patient satisfaction scores for the first time in 3 years [33]. Fast tracks Patient satisfaction can be greatly enhanced by appropriately shortening the turnaround time in the delivery of simple, uncomplicated health care. Studies have shown that 20%–60% of all patients presenting to EDs have urgent yet simple and uncomplicated problems that can be cared for quickly and efficiently in lower intensity settings [35]. Many departments have established alternative delivery sites to care for this patient population. These areas are commonly called fast tracks. Fast track programs allow these patients to be seen separately in an efficient and continuously flowing area set aside in or adjacent to the ED. Depending on acuity of the patient population, approximately one third of the ED’s volume can be evaluated in the fast track area. On average, 3–4 patients can be seen per hour if the triage of patients to the fast track area is appropriate. An accurate triage assessment is a pivotal point in the success of a fast track program. The fundamental requirement for a fast track program is a dedicated treatment area for the care of the appropriately triaged fast track patient. Ideally, this location should allow for the sharing of triage, supplies and equipment, and non-ancillary personnel. Providers and nursing staff, however, should be assigned to the area. Nursing staff should not be pulled back to the main ED. Often, inexperienced nurses are assigned to staff the fast track area because it has a lower patient acuity; however, this could decrease the overall productivity of the fast track, leading to longer patient waits and decreased patient satisfaction. A physician or midlevel provider can staff a fast track. The lower acuity of the fast track correlates well with the scope of practice of midlevel providers. Over the last decade, EDs have seen an increasing presence of nurse practitioners and physician assistants. Dowling and Dudley [36] have identified the benefits of using a nurse practitioner as: increased quality and cost-effective patient care decreased malpractice costs and risks increased ED physician corporate profitability reduced actual contact time physicians must spend with non-urgent patients increased patient satisfaction Nurse practitioners providing emergency care have functioned under either an implicit scope of practice or the scope of practice for the area in which their education was obtained.
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Nurse practitioners in the emergency department Emergency nurses have continuously been at the forefront of health care in providing high quality care to those in need. The current trend in nursing is toward an expanded, advanced practice role in which highly educated nurses take a leadership position in the emergency care environment delivering quality care to all people. The ENA notes in their paper Scope of Practice for the Nurse Practitioner in the Emergency Care Setting [37] that the practice environment for nurse practitioners in emergency care contains the same dimensions as those for emergency nursing in general. These dimensions consist of responsibilities, functions, roles, and skills that are related to and evolve from the specific body of emergency care knowledge [37]. Many features that are unique to emergency care characterize the practice environment. These features have been identified in the Emergency Nursing Scope of Practice as: assessment, analysis, nursing diagnosis, planning, implementation of interventions, outcome identification, and evaluation of human responses of individuals in all age groups whose care is made difficult by the limited access to past medical history and the episodic nature of their health care triage and prioritization emergency operations preparedness stabilization and resuscitation crisis intervention for unique patient populations, such as sexual assault survivors provision of care in uncontrolled and unpredictable environments consistency as much as possible across the continuum of care Practice arrangements vary according to state regulations for advanced practice nursing. Each state controls how and in what circumstances nurse practitioners may practice. Some states require that the nurse practitioner practice collaboratively with a physician, whereas other states allow nurse practitioners to practice independently. When physician involvement is mandated for practice, the nurse practitioner usually follows agreed upon protocols or guidelines for the medical management of patient conditions. Practice arrangements also vary by whether the nurse practitioner is an employee of the hospital or a physician group. With either employer, the nurse practitioner most often has a contract that specifies the arrangements for practice, such as types of patients that may be cared for, the area in which services are provided, such as fast track, main ED, or both, the types of patient conditions that the nurse practitioner can manage according to guidelines without consultation of the physician, and the types of diagnostic or treatment procedures that the nurse practitioner can perform. Advanced practice nursing, including the role of nurse practitioner in emergency care, is regulated to assure public safety. Each state, through its
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government, has the authority to regulate nursing practice through nurse practice acts. These acts vary from state to state and define the limits of practice for nursing and advanced practice nursing. Nurse practitioners in all 50 states have prescriptive privileges; however, they vary according to the types of medications that can be prescribed and the degree to which physicians are involved in the prescription process [38,39]. Some states allow nurse practitioners to dispense drug samples and others do not [38]. The title of nurse practitioner is protected in some states and not in others [38]. The board of nursing in some states is the sole authority for nurse practitioner practice, whereas other states require physician collaboration or supervision [38]. National certification as a nurse practitioner is another requirement that varies among states. National certification as a nurse practitioner is required for practice in some states and not in others. Some states do not recognize all of the areas of certification available and other states limit the practice of the nurse practitioner based on the type of certification obtained. For example, a nurse practitioner with certification as an acute care nurse practitioner is prohibited from caring for children in some states and the age ranges defining a child also vary by state. These examples demonstrate the variability in regulations affecting the practice of nurse practitioners in different states. In addition to advanced practice regulations, nurse practitioners must be registered nurses in the state in which they practice and are, therefore, also held to the standards of the state nurse practice act. Additionally, other mechanisms exist to regulate the education and practice of nurse practitioners. National standards and the requirements of the specialty regulate the educational requirements for nurse practitioners. Certification as a nurse practitioner indicates that the individual has obtained a specific body of knowledge and serves as a measure of competency. Certification is important in the regulation of nurse practitioners and a certification examination for nurse practitioners in emergency care is supported. Other areas of practice also have certification examinations related to specific skills or abilities. The emergency nurse practitioner should be certified in the area of emergency nursing and have specific verifications within the specialty, including Advanced Cardiac Life Support, Trauma Nursing Core Course, Emergency Nurse Pediatric Course, and Basic Cardiac Life Support. A written scope of practice for nurse practitioners in emergency care sets standards and helps to regulate practice. Nurse practitioners in emergency care use their experience in emergency nursing and their expert knowledge to establish a personal standard that serves to self-regulate through accountability, commitment, and prudence. Peer reviews by nurse practitioners, medical reviews by physicians, and self-reviews examining patient responses are performance improvement activities that help assure quality through meeting standards of care. Collaborative practice in the ED optimizes patient care and benefits all stakeholders.
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Although EDs vary in shape, size, and technology, similarities in responsibilities exist. The primary responsibility is to provide quality health care to the communities served. The ED constitutes a substantial business in any hospital. Because of changing acuity levels and patient volume and mix, success in the ED requires effective management to coordinate the many facets of this ever-changing environment. The ED nurse manager must have an understanding of how outside influences affect the operational aspect of the ED. Having this body of knowledge enhances the viability of the department and positively affects the quality of care.
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Nursing perspectives on the emergency department Sherri-Lynne Almeida, Dr PH, MSN, MEd, RN, CENa,b,c,* a
Team Health Southwest, 6750 West Loop South, Suite 460, Bellaire, TX 77401, USA b Division of Acute and Continuing Care, University of Texas–Houston, Graduate School of Nursing, 1100 Holcombe Blvd., Houston, TX 77030, USA c Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016, USA
Emergency nursing Emergency nursing is the care of individuals of all ages with perceived or actual physical or emotional alterations of health that are undiagnosed or that require further interventions. The care is episodic, primary, and usually acute. The profession of emergency nursing has evolved over the last 30 years, nurses have become more responsible and accountable for their practice. Emergency nursing practice is defined through specific role functions as delineated in the Emergency Nurses Association’s (ENA) Standards of Emergency Nursing Practice, Scope of Practice Statement, and Emergency Nursing Core Curriculum. Nursing roles include patient care, research, education, consultation, advocacy, and management. Emergency department (ED) management is one of the most challenging fields in health care today. Over the last 30 years, we have experienced dramatic changes in the provision of emergency care within the United States. We have seen the implementation of managed care, the closure of many hospitals and inpatient beds, the downsizing of nursing and other ancillary staff, nursing shortages, strike actions, decreased reimbursement to hospitals and providers, diversion, and physician work stoppages; yet through all of these changes, one thing remained: patients in need of care. Emergency departments nationwide are experiencing an exponential growth in patient visits while simultaneously feeling the impact of a sluggish economy.
* Team Health Southwest, 6750 West Loop South, Suite 460, Bellaire, TX 77401. E-mail address: [email protected] 0733-8627/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0733-8627(03)00099-3
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The ED is the only provider many people ever know. It serves not only as a receiving center for critically ill and injured people, but also as a 24-hour shelter for the walking well, worried, and wounded. Increasing visits and admissions have led to the development of diversion policies and a common state of ED crowding. To balance all the issues facing EDs today, the ED nurse manager must use strong organizational skills and effective interpersonal communication skills and must implement sound financial principles. Emergency department nurse manager The title of ED Nurse Manager has undergone many changes in the last several years and varies across the country. No matter the title, however, the roles and responsibilities are similar. The roles and responsibilities of the ED nurse manager are more complex than they were a decade ago. Because of the dramatic changes that have occurred in health care, the ED has seen an increase in visibility, responsibility, and delivery. Increases at a time when resources are being decreased can present the ED nurse manager with daily challenges and opportunities. As the ED evolves into the major diagnostic and resuscitation site of the health care system, the ED manager has been forced to evolve to keep pace and make this possible. The body of information required to be an ED nurse manager has grown considerably in mass and complexity. In the best of all worlds, the ED nurse manager possesses a strong background in the practice of emergency nursing, management, and leadership. They uphold the standards of professional performance as outlined by the Emergency Nurses Association [1]. Box 1 lists the ENA’s Standards of Professional Performance. These standards provide an excellent framework for practice; however, it is incumbent on each institution to develop more refined qualifications and a position description to include responsibilities. The author briefly discusses the most common responsibilities placed on today’s ED nurse manager. Box 1. ENA standards of professional performance Quality Performance appraisal Education Collegiality Ethics Collaboration Research Resource use
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Administrative management Being an administrative leader requires flexibility, openness, innovation, proficiency, and patience. Managers in the twenty-first century are involved in and often direct financial and strategic planning, business development, and outcomes management. There is a complex list of issues that fall under each of these categories. These issues affect the daily operations of an ED. Those which have the greatest impact on patient care are addressed in this article. The ED nurse manager plays a vital role in the development and enhancement of programs that are designed to address the issues set forth. Outcomes management There are two areas the ED nurse manager must focus on when measuring outcomes. They are clinical and organizational. As the administrative leader, the ED nurse manager is charged with the tasks of measuring, monitoring, and evaluating each outcome assessed. The data obtained during this process should be compared with standards, protocols, and guidelines. The final analysis should correlate process to outcomes. Changes in the health care delivery system have greatly affected patient care in the ED. Increasing numbers of ED patient visits, delays at discharge, longer ED stays, overcrowding, and diversion to other ED facilities may lead to decreased quality of care and patient dissatisfaction [2,3]. The national shortage of nurses also is creating a perception that EDs may have difficulty providing quality care [3]. The ED nurse manager must ensure that quality indicators identify expected outcomes of care and are specific to the plan of care. In many facilities, clinical pathways or practice policies have been implemented. The purpose of these pathways/policies is to move the patient’s care along a delineated timeline that allows for specific standards of care and a method by which data can be obtained to determine compliance. The use of such guidelines affects clinical outcomes and organizational outcomes. Organizational outcomes are measured by improvements in the health care and well being of the population served relative to costs incurred [4]. Cost containment is an ever-prevailing theme that affects the clinical and the business side of managing an ED. The ED nurse manager and the medical director should collaborate and develop operational systems that lend efficiencies and consistencies to departmental operations. There are many factors in an ED that significantly affect overall financial status. These factors include salary cost and staffing, health care delivery systems (eg, triage, fast tracks), use of diagnostic testing, and the use of supplies/equipment. A well managed ED should consider incorporating cost containment practices into the everyday practice environment, and collaboration between the ED nurse manager and the medical director is essential to this goal.
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Emergency department nurse staffing Staffing an ED has always been a challenge to ED managers and hospital administrators. Fluctuating patient volumes and acuity prohibit the accurate assignment of staff to the workload; however, managers and administrators have the responsibility of ensuring effective and efficient emergency care delivery systems. Staffing and productivity are critical components of those systems. In the past several years, concern has grown about inadequate nurse staffing, possible adverse outcomes, and the frequency and impact of medical errors. Inadequate nurse staffing may reflect insufficient numbers of nursing personnel in response to an increase in nursing care needs, the replacement of licensed nurses with unlicensed personnel, or the mandate of excessive overtime [5,6]. Many states have passed legislation that mandates nurse staffing in the ED. There is varying opinion, however, as to whether this approach is safe and effective. Staffing with qualified professional registered nurses and ancillary staff is needed to deliver optimal patient care, achieve an operationally efficient department, and maintain a qualified and satisfied nursing staff [7,8]. According to the ENA, for more than a decade health care cost containment, institutional restructuring, nursing staff downsizing, and nursing shortages have resulted in a system that threatens the quality and safety of patient care and the quality of work life for nurses [7–10]. In 1994, the American Nurses Association (ANA) recognized the need for empiric data to drive staffing decisions [10]. Subsequently the ANA identified nine outcomes that were sensitive to nursing intervention as the basis for new research studies [11]. The outcomes included adverse drug events, patient falls and injuries, nosocomial infections, skin breakdown, pain management, educational information, patient satisfaction with care, nursing job satisfaction, and total nursing care hours provided per patient day [11]. In 1996 the Institute of Medicine’s report showed significant work-related injuries and stress for nurses but was unable to demonstrate a relationship between hospital quality of care and staffing patterns in part because of the lack of empiric data on quality of care [7,8]. Nurses continued to report their concerns for patient safety in an environment of inadequate numbers of qualified staff, high workloads, mandatory overtime, and fatigue [12–14]. Occupational injury, job dissatisfaction, burnout, and departure from the nursing profession also were reported. Health care providers’ concerns for quality of care and patient safety and the impact on nurses, however, was largely dismissed without the presence of empiric data [11,13]. Investigators are now able to support what health care providers had been saying, that is, nurse staffing influences patient outcomes. The ANA commissioned a study examining the amount and skill mix of nursing care, patient length of stay, and preventable morbidities, including pneumonia, postoperative infections, pressure ulcers, and urinary tract infections [15].
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Patient data from nine states, 2500 hospitals, and approximately 13 million patients were sampled. The findings showed that morbidity was lower in hospitals with higher registered nurse skill mixes and greater staffing levels [15]. Shorter lengths of stay were associated with greater staffing levels [15]. In a study of 232 acute care hospitals and 124,204 surgical patients, an increase in 1 hour of registered nurse staffing per patient day produced a significant 8.9% decrease in the risk for pneumonia [16]. Adverse events were associated with longer patient stays, and for some events a greater probability of death during hospitalization [16]. Similarly, a study of 168 hospitals, 10,184 nurses, and 232,342 surgical patients showed that in hospitals with higher patient-to-nurse ratios there were higher risk-adjusted 30-day mortalities and 30-day mortalities for patients with complications [12]. In addition, nurses were more likely to experience burnout and job dissatisfaction [12]. To help determine nurse staffing and improve patient safety, workforce measures, such as hours per patient visit and nurse-to-patient ratios, were proposed and have generated considerable debate [17–25]. In EDs, the hours per patient visit method for calculating staffing was based on historic or benchmark data. The previous year’s actual paid hours are divided by the total number of ED visits. The limitation of this method is that it considers patient volume and available nursing hours without consideration of factors such as patient acuity, length of stay, and nursing interventions and activities [10,17]. In addition, decision making based on the prior year’s data may not be accurate for today’s rapidly changing emergency care environments with increased patient acuity, increased lengths of stays, delays in discharge, overcrowding, diversions, and nursing staff shortages. The ANA stated that hours per patient day was a ‘‘one size fits all’’ strategy whose usefulness is questionable [10]. In 2002, California was the first state to propose specific nurse-to-patient ratios [19–25]. Other states are also considering the use of ratios [26]. For EDs, the California Department of Health and Human Services (DHHS) proposed one nurse to four general ED patients, one nurse to two critical care ED patients, and one nurse to one ED trauma patient. No ratios were assigned to triage or radio-dedicated nurses [19–26]. Although supporting the use of ratios to determine nurse staffing, the California Nurses Association was concerned that the ratios should only apply to professional registered nurses [26]. The California DHHS proposal categorizes nurses as licensed practical/vocational nurses and registered nurses [26]. A critical limitation in the use of ratios is that ratios do not take into account the variability found in institutions, available internal and external resources (eg, inpatient beds, equipment, other staff), individual and aggregate patient needs (eg, volume, intensity, demographics, length of stay), and the nursing expertise required by the patient population (eg, knowledge, skills, licensure) [10,18,27]. The use of ratios also was challenged because some investigators [24,27] believed that mandated staffing may be
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interpreted by institutions as the maximum required staffing, when in fact it is the minimal mandated staffing standard. Further, ratios may lead to an acceptance of minimally safe staffing and patient care instead of best practice staffing and care [26]. Staffing based solely on nurse-to-patient ratios or paid hours per visit is limited in scope without consideration of the variables that affect the consumption of nursing resources [10,18]. To identify safe, effective, realistic best practice staffing in EDs, the ENA identified six key factors that were critical in the projection of staffing requirements, the development of staffing models, and accurate budget preparation [18]. These factors include patient census, patient acuity, patient length of stay, nursing time for nursing interventions and activities by patient acuity, skill mix for providing patient care based on nursing interventions that can be delegated to a non-registered nurse, and an adjustment factor for the non-patient care time included in each FTE [18]. The staffing guidelines and tools that were developed are applicable in all types of EDs, flexible and dynamic, and easy to use and understand [18]. The ENA staffing guidelines represent a new and innovative method to predict nurse staffing needs in US EDs [12]. Continued research is needed to determine patient, nurse, and organizational outcomes in relation to predicted staffing [18]. Triage Triage is a process used to determine severity of illness or injury for each patient who enters the ED. An RN should fulfill this role. The Joint Commission on Accreditation of Healthcare Organizations standards identifies the RN as the appropriate person to perform patient assessment, which is essential for the triage process. The triage process was introduced in EDs in the late 1950s and early 1960s. The primary goal of a triage system is rapid identification of patients with urgent, life-threatening conditions. Most EDs in the United States use some type of triage system. There are two systems most commonly used throughout the country. The first system is a spot check system. This type of system is appropriate for low volume EDs where patients do not wait for ED bed space and it is not cost effective to have an RN at triage 24/7. The most advanced system is comprehensive triage and it is supported by the ENA’s Standards of Emergency Nursing Practice [28]. A comprehensive triage system uses four or more classifications. The emergency nurse triages each patient and determines the priority of care based on physical, developmental, and psychosocial needs and factors influencing access to health care and patient flow through the emergency care system. Triage is to be performed by an experienced ED nurse who has demonstrated competency in the triage role. The goal is to rapidly gather sufficient information to determine triage acuity [1].
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In 2001, the ENA surveyed US EDs about the type of triage acuity scale used by their department [9]. Sixty-nine percent of the respondents indicated that they used a three-level triage scale, 12% used a four-level scale, 3% used either the Australasian or Canadian five-level scale, and 16% did not answer the question or used no triage acuity rating scale. The most commonly used three-level scale included the acuity levels of emergent, urgent, and non-urgent. Several studies, however, have evaluated the reliability of triage rating systems and found poor inter-rater reliability, whereas, five-level triage classification systems have been shown to have better inter-rater and test-retest reliability than three-level or four-level classification systems [29]. Three countries, Australia, the United Kingdom, and Canada have implemented standardized five-level triage classification systems. Recently a five-level scale called the Emergency Severity Index (ESI) emerged and is used in several academic institutions in the United States. This scale stratifies adult patients into defined exclusive categories. Patient acuity, expected resource intensity, and timeliness define categories. Research by Wuerz has demonstrated reliability and validity of the ESI [30]. The ENA and the American College of Emergency Physicians believe that a standardized triage system would provide a point of reference with which to benchmark triage acuity for staffing, resource allocation, research, and educational needs. These two associations have formed a collaborative workgroup charged with the task of evaluating the existing triage systems in the United States and to recommend a standardized system for use by our nation’s EDs. Patient throughput and customer satisfaction The primary challenge for many health care organizations is to identify cost-effective strategies to enhance clinical outcomes and provide for the highest level of patient safety. These strategies have to be practical. Patient throughput has been studied extensively. Several factors have been identified that affect patient throughput in the ED. These factors include census, facility size and design, ambulance traffic, number of trauma cases, case mix, number of admissions, average time an admitted patient waits in the ED, laboratory and radiology throughput times, and seasonal data. Six primary bottlenecks to patient throughput have been defined by the Advisory Board Company [31] and include triage, registration, emergency physician, laboratory, radiology, and inpatient admission. At some point, every ED manager is confronted with the two central concerns of structure: determining if problematic conditions are being generated by inadequate structure and if so, understanding the precise nature of the structural issues. Every nursing unit and health care system has a structure that is the key factor in system performance. The overall perspective notes, ‘‘Every system and organization has an architecture, or structure broadly defined, which largely determines what the system can and cannot do’’ [31]. System
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structure is critical to improving the effectiveness of the operation. Starting at patient entrance to the ED, a thorough analysis of patient throughput can take place. According to Salluzzo et al, patient entrance to registration should not exceed 10–12 minutes; the registration process should not exceed 5–8 minutes, and comprehensive triage should be completed in 2–5 minutes [32]. Focusing on front end activities are often not sufficient to provide faster bed access for all patients. If bottlenecks continue to contribute to length of stay, then other factors, such as wait time to see a physician and discharge process, should be evaluated. It is in everyone’s best interest to implement change on area at a time so that the implementation and the related outcome can be effectively measured. Managers must realize that often the most critical access/throughput issue is bed availability and facility design. It is estimated that for every bed available in the ED, 2000 patients can be evaluated. This number does not factor patient acuity or length of stay, however; therefore, it provides an extremely rough estimate of capacity. On average, 80% of a patient’s time in an ED is spent waiting [31]. Wait times exert the highest influence on the patient’s likelihood to recommend the ED to others and is considered the biggest problem in EDs by patients [33]. The inability of an ED to evaluate, treat, and make a disposition for a patient in a reasonable amount of time is the most scrutinized aspect of ED care [32]. The ENA Position Statement on Customer Service and Satisfaction in the ED notes that, ‘‘Patients and their families are influenced by the actual care and conditions that they encounter during their ED visit. Their satisfaction with care also may be influenced by the increasing media coverage concerning the quality of health care in the United States, particularly in EDs. Although many patients and families are more informed about health care services, for some, an ED visit is a frightening experience [34]. In addition, the patient’s ED experience also may influence the overall satisfaction with the institution, because the ED serves as the link between the community and the in-patient facility [33].’’ In the ENA National Benchmark Guide: Emergency Departments [9], 1380 ED managers reported that 88% of their patients rated their satisfaction with the ED as good to excellent. Formal patient satisfaction surveys were used by 76% of the EDs. In addition, 96% of patients rated the quality of their ED care as good or excellent. Quality of care was measured using a formal survey by 59% of the EDs. Ongoing monitoring is needed to determine if quality and satisfaction are improving, remaining stable, or declining. Distributing surveys and encouraging staff to ‘‘be nicer and work harder’’ are sometimes the only steps taken by institutions to address customer service [35]. Improving customer service and satisfaction often requires staff training programs and process improvement programs [33,35]. In a 72,000visit ED, an 80% reduction in patient complaints and a 100% increase in patient compliments was achieved following a training program on
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customer service [35]. Following training, another ED reported a 100% increase in compliments and a 70% reduction in patient complaints (from 2.6 to 0.6 per 1000), well below the national average of 3–5 per 1000 visits [34]. After initiating a customer-oriented approach, an ED reported improved patient satisfaction scores for the first time in 3 years [33]. Fast tracks Patient satisfaction can be greatly enhanced by appropriately shortening the turnaround time in the delivery of simple, uncomplicated health care. Studies have shown that 20%–60% of all patients presenting to EDs have urgent yet simple and uncomplicated problems that can be cared for quickly and efficiently in lower intensity settings [35]. Many departments have established alternative delivery sites to care for this patient population. These areas are commonly called fast tracks. Fast track programs allow these patients to be seen separately in an efficient and continuously flowing area set aside in or adjacent to the ED. Depending on acuity of the patient population, approximately one third of the ED’s volume can be evaluated in the fast track area. On average, 3–4 patients can be seen per hour if the triage of patients to the fast track area is appropriate. An accurate triage assessment is a pivotal point in the success of a fast track program. The fundamental requirement for a fast track program is a dedicated treatment area for the care of the appropriately triaged fast track patient. Ideally, this location should allow for the sharing of triage, supplies and equipment, and non-ancillary personnel. Providers and nursing staff, however, should be assigned to the area. Nursing staff should not be pulled back to the main ED. Often, inexperienced nurses are assigned to staff the fast track area because it has a lower patient acuity; however, this could decrease the overall productivity of the fast track, leading to longer patient waits and decreased patient satisfaction. A physician or midlevel provider can staff a fast track. The lower acuity of the fast track correlates well with the scope of practice of midlevel providers. Over the last decade, EDs have seen an increasing presence of nurse practitioners and physician assistants. Dowling and Dudley [36] have identified the benefits of using a nurse practitioner as: increased quality and cost-effective patient care decreased malpractice costs and risks increased ED physician corporate profitability reduced actual contact time physicians must spend with non-urgent patients increased patient satisfaction Nurse practitioners providing emergency care have functioned under either an implicit scope of practice or the scope of practice for the area in which their education was obtained.
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Nurse practitioners in the emergency department Emergency nurses have continuously been at the forefront of health care in providing high quality care to those in need. The current trend in nursing is toward an expanded, advanced practice role in which highly educated nurses take a leadership position in the emergency care environment delivering quality care to all people. The ENA notes in their paper Scope of Practice for the Nurse Practitioner in the Emergency Care Setting [37] that the practice environment for nurse practitioners in emergency care contains the same dimensions as those for emergency nursing in general. These dimensions consist of responsibilities, functions, roles, and skills that are related to and evolve from the specific body of emergency care knowledge [37]. Many features that are unique to emergency care characterize the practice environment. These features have been identified in the Emergency Nursing Scope of Practice as: assessment, analysis, nursing diagnosis, planning, implementation of interventions, outcome identification, and evaluation of human responses of individuals in all age groups whose care is made difficult by the limited access to past medical history and the episodic nature of their health care triage and prioritization emergency operations preparedness stabilization and resuscitation crisis intervention for unique patient populations, such as sexual assault survivors provision of care in uncontrolled and unpredictable environments consistency as much as possible across the continuum of care Practice arrangements vary according to state regulations for advanced practice nursing. Each state controls how and in what circumstances nurse practitioners may practice. Some states require that the nurse practitioner practice collaboratively with a physician, whereas other states allow nurse practitioners to practice independently. When physician involvement is mandated for practice, the nurse practitioner usually follows agreed upon protocols or guidelines for the medical management of patient conditions. Practice arrangements also vary by whether the nurse practitioner is an employee of the hospital or a physician group. With either employer, the nurse practitioner most often has a contract that specifies the arrangements for practice, such as types of patients that may be cared for, the area in which services are provided, such as fast track, main ED, or both, the types of patient conditions that the nurse practitioner can manage according to guidelines without consultation of the physician, and the types of diagnostic or treatment procedures that the nurse practitioner can perform. Advanced practice nursing, including the role of nurse practitioner in emergency care, is regulated to assure public safety. Each state, through its
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government, has the authority to regulate nursing practice through nurse practice acts. These acts vary from state to state and define the limits of practice for nursing and advanced practice nursing. Nurse practitioners in all 50 states have prescriptive privileges; however, they vary according to the types of medications that can be prescribed and the degree to which physicians are involved in the prescription process [38,39]. Some states allow nurse practitioners to dispense drug samples and others do not [38]. The title of nurse practitioner is protected in some states and not in others [38]. The board of nursing in some states is the sole authority for nurse practitioner practice, whereas other states require physician collaboration or supervision [38]. National certification as a nurse practitioner is another requirement that varies among states. National certification as a nurse practitioner is required for practice in some states and not in others. Some states do not recognize all of the areas of certification available and other states limit the practice of the nurse practitioner based on the type of certification obtained. For example, a nurse practitioner with certification as an acute care nurse practitioner is prohibited from caring for children in some states and the age ranges defining a child also vary by state. These examples demonstrate the variability in regulations affecting the practice of nurse practitioners in different states. In addition to advanced practice regulations, nurse practitioners must be registered nurses in the state in which they practice and are, therefore, also held to the standards of the state nurse practice act. Additionally, other mechanisms exist to regulate the education and practice of nurse practitioners. National standards and the requirements of the specialty regulate the educational requirements for nurse practitioners. Certification as a nurse practitioner indicates that the individual has obtained a specific body of knowledge and serves as a measure of competency. Certification is important in the regulation of nurse practitioners and a certification examination for nurse practitioners in emergency care is supported. Other areas of practice also have certification examinations related to specific skills or abilities. The emergency nurse practitioner should be certified in the area of emergency nursing and have specific verifications within the specialty, including Advanced Cardiac Life Support, Trauma Nursing Core Course, Emergency Nurse Pediatric Course, and Basic Cardiac Life Support. A written scope of practice for nurse practitioners in emergency care sets standards and helps to regulate practice. Nurse practitioners in emergency care use their experience in emergency nursing and their expert knowledge to establish a personal standard that serves to self-regulate through accountability, commitment, and prudence. Peer reviews by nurse practitioners, medical reviews by physicians, and self-reviews examining patient responses are performance improvement activities that help assure quality through meeting standards of care. Collaborative practice in the ED optimizes patient care and benefits all stakeholders.
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Although EDs vary in shape, size, and technology, similarities in responsibilities exist. The primary responsibility is to provide quality health care to the communities served. The ED constitutes a substantial business in any hospital. Because of changing acuity levels and patient volume and mix, success in the ED requires effective management to coordinate the many facets of this ever-changing environment. The ED nurse manager must have an understanding of how outside influences affect the operational aspect of the ED. Having this body of knowledge enhances the viability of the department and positively affects the quality of care.
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