Capstone

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Title of your Capstone Project

Olivia Timmons

Department of Nursing. St. Johns River State College

NUR 4949: Nursing Capstone

Dr. C. Z. Velasco

November 14, 2021

Title of your Capstone Project

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Statement of the Problem

Timing is essential in the nursing field and the Emergency Room is notorious for its long wait times. The goal of a clinical laboratory is to deliver medically useful results for patients on a timely basis. This goal can be hindered by the new paradigm of the modern laboratory – “do more with less" (Lopez, 2020). When implementing new care models for patients, the patient perspective is critical. Objective of this study was to describe and develop an understanding of the information needs of patients in the ED waiting room with respect to ED wait time notification (Calder, 2021). As a patient arrives to the ER waiting area, its critical to have lab results for the provider to evaluate. I can give you an example of a patient that waited in the waiting room for over 3 hours, no labs were completed because they were waiting for the patient to go back into a room. The patient was suffering from a heart attack and his troponins were elevated and no one knew until 3 hours later. If POC labs were done on all patients as soon as they arrived, mistakes like these can be avoided. Completed POC blood can cut the wait times in half and the laboratory also won't be backed up on resulting lab specimens.

PICOT Question

Question: Is there a significant decrease in Emergency Department patient length of stay (LOS) for those whose blood was analyzed using POC testing versus those whose blood was analyzed using laboratory testing?

· P-Population= emergency room patients

· I-Intervention or Exposure= POC testing of blood specimens

· C-Comparison= Laboratory blood specimens

· O-Outcome= Decrease patient stay in the emergency room

· T-Time = N/A

History of the Issue

The length of patient stay in emergency department (ED) is an issue that not only increases the severity of illnesses but also reduces the quality of patient care. Serious health conditions including diabetes and hypertension can worsen while patients are still waiting to be tested through the conventional laboratory approaches thereby leading to adverse events. Crowding in the ED is a great threat to public health given that the number of ED visits is more than 130 million and is increasing (Chang et al., 2018). Many countries including the US and have reported alarming and unsustainable increase in ED visits in which population growth is not enough to explain the trend (Chang et al., 2018). Emergency department crowding is an obstacle to the provision of timely patient care due to the backlog of work. Additionally, it increases the likelihood of rise in HAI due to the prolonged length of patient stay in crowded ED waiting bays thereby exposing patients to infectious diseases (Chang et al., 2018). The issue of ED crowding can be reduced by adopting the point-of-care testing (POC) testing in place of the conventional laboratory testing in which patients are required to wait for lengthy durations of time in wait for laboratory test results in crowded waiting bays.

Current Data on the Issue

Overcrowding in hospitals is measured by the occupancy rates. Occupancy rate refers to the ratio between the number of inpatients and the number of hospital beds (Jobé et al., 2018). Similarly, ED occupancy ratio that indicates overcrowding is measured by the total number of ED visits and the number of ongoing ED treatment beds (Jobé et al., 2018). According to the Centers for Disease Control and Prevention (2021), 43.5% of patients in the ED are seen within 15 minutes time while the number of ED visits is 16.2 million people annually. Given that 57.2% of ED patients are seen in more than 15 minutes, the rate of crowding in EDs is high at 9.72 million, which is rising with increasing annual ED visits (CDC, 2021). In a study conducted by Jobé et al. (2018), all the EDs of the three hospitals in the study were found to be clinically crowded. During the day, the hospitals were overcrowded especially the ones whose subsidiaries that were in urban settings and institutions.

The measure for clinical ED overcrowding was 100 or more patients in the ED. Crowding was measured by the presence of 99 patients and below, who were waiting to be treated in the ED (Jobé et al., 2018). A significant fraction of the patients in the crowded ED were sitting in wait for laboratory test results and waiting for their results to be provided. The average length of time taken for the laboratory results to be produced was between 30 minutes to 2 hours (Jobé et al., 2018). While most laboratory results typically take minutes, delays in releasing laboratory test results are a common but worrying trend that is mainly caused by administrative formalities and procedures (Chang et al., 2018). In another study conducted by Rowe et al. (2020), all the EDs of the 16 hospitals in Alberta County, Canada, that were included in the study were found to be overcrowded during the day. In the study, overcrowding in the ED was defined as the situation that occurs when patients seeking treatment in the ED exceeds the number of patients receiving treatment. Rowe et al. (2020) also found that 63% of the ED presentation stayed longer than the recommended median 1 hour in the EDs, which significantly contributed to overcrowding in the EDs. Overcrowding was found to be at alarming rates in teaching or academic settings and urban areas.

Current Organizational Practices or Activities

Different strategies have been applied by healthcare organizations to manage the issue of crowding in ED depending on the nature of the healthcare facilities. They include public education initiatives on appropriate use of ED (Morley et al., 2018). While the backlog of work in hospitals significantly contributes to crowding in EDs, patient behaviors can also lead to crowding. Therefore, healthcare facilities often educate and guide inpatients and the public at large on the proper use of EDs including decongesting the waiting bays to avoid possibilities of transfer of contagious diseases. Hospitals also manage ED crowding by redirecting non-emergency visits to the ED to appropriate departments. In this regard, healthcare facilities have established units that are aimed at addressing ED visits that are can be estimated to take less than four hours to examine (Morley et al., 2018). Additionally, some healthcare facilities have assigned senior nurses in EDs to continuously monitor the EDs to intervene in situations in which patients have stayed in the EDs for 2-3 hours. The assigned senior nurses identify the cause of delays and facilitate treatment and departure of the patients within 4 hours (Morley et al., 2018). Most of such cases occur due to a backlog of work due to administrative formalities that reduce the rate of patient care processes in the EDs.

Another effective strategy that is currently being applied to ease crowding in the ED is performance of diagnostic testing arrangements in the waiting bays for stable patients. Following quick medical assessment upon arrival, patients can be tested and referred to appropriate departments for further treatment instead of overstaying in the ED (Morley et al., 2018). Further afield, some hospitals have opened a monitored unit with appropriate number of beds and other medical resources located at proximity to the ED (Morley et al., 2018). These facilities are meant to accommodate ED patients that need observation and management for more than 4 hours and are staffed by ED professionals.

Proposed Interventions and Implementations

The proposed intervention for reducing crowding in ED is to introduce point-of-care testing (POCT) in addition to laboratory testing. The POCT is an easy and effective method for testing diseases using special machines that produce results rapidly (Egilmezer et al., 2018). This method is simple and can be used by medical professionals who are not laboratory technicians including nurses. In this regard, nurses will be assigned the role of testing ED patients using the POCT methods for patients with stable condition, and when the number of ED visitors is high and likely to lead to crowding. The approach has the potential to significantly manage crowding in EDs, which will in turn reduce patients’ length of stay (LOS) in hospitals thereby increasing the quality of patient care, and hospitals’ effectiveness regarding time management.

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