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All Publications

2015

Discharge Alternative Non-Urgent Care Education (D. A.N.C.E.) Protocol: Addressing Emergency Department Misuse Samantha Leon West Kendall Baptist Hospital, [email protected]

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DISCHARGE ALTERNATIVE NON-URGENT CARE EDUCATION (D.A.N.C.E)

PROTOCOL: ADDRESSING EMERGENCY DEPARTMENT MISUSE

SCHOLARLY PROJECT

Presented in Partial Fulfillment of the

Requirements for the Degree of

Doctorate of Nursing Practice

Barry University

Samantha C. Leon

2015

DISCHARGE ALTERNATIVE NON-URGENT CARE EDUCATION (D.A.N.C.E)

PROTOCOL: ADDRESSING EMERGENCY DEPARTMENT MISUSE

Samantha C. Leon

2015

APPROVED BY:

____________________________________ Corvette V. Yacoob, DNP, ARNP, FNP-BC

Chairperson, DNP Project Committee

____________________________________ Mureen L. Shaw, DNP, ARNP, FNP-BC

Member, DNP Project Committee

____________________________________ Terri Rocafort, MSN, ARNP-BC

Director, NP and DNP Specializations

____________________________________ John McFadden, PhD, CRNA

Dean, College of Nursing and Health Sciences

Abstract

Background: The misuse of the Emergency Department (ED) creates a substantial

problem for the health care system, generating gaps in continuity of care, leaving little

room for preventative care, and forcing a financial strain on the system. An increasing

number of patients are using hospital EDs for non-urgent care despite the availability of

alternative care sites such as retail clinics (RCs) and urgent care centers (UCCs).

Purpose: The project’s aim was to educate patients who utilize ED services as a source

of care for non-urgent complaints with the use of the D.A.N.C.E. protocol. Enhancing the

public’s knowledge of the ED’s purpose and the services available at alternative care

sites could provide a potential solution to ED misuse and subsequent overcrowding.

Theoretical Framework: The Andersen Framework of Health Utilization Services was

used to guide this project, as it uses a systems perspective to integrate individual,

environmental, and provider-related variables associated with decisions to seek care.

Methods: The D.A.N.C.E. protocol was implemented in a pilot project with the use of an

educational protocol delineating functions of alternative care sites and EDs. Face validity

was established by a staff consensus panel, and the protocol was then distributed to lower

acuity patients discharged from the ED. At the completion of the patient’s review of the

protocol, a survey card was provided evaluating which care site would be selected for the

same or similar non-urgent complaint in the future and whether the protocol influenced

this decision.

Results: A sample size of 22 completed surveys were returned with 55% (12) selecting

the ED, 36% (8) selecting UCC/RC, and 9% (2) selecting their PCP for future care site.

The majority of the surveys showed that 91% (20) of the participants found the protocol

influential and 9% (2) selected the protocol had no influence on their future care site

decision.

Conclusion: Despite more than half of the patients selecting the ED as their next

potential source of non-urgent care, a post discharge intervention did seem to influence

care site selection. Several factors presented during this project requiring further

examination to better address these patients’ health care seeking behaviors.

ACKNOWLEDGMENTS

I’d like to thank the staff of West Kendall Baptist Hospital Emergency

Department for their help and support during the project and throughout the program. It

was greatly appreciated. A huge thank you to the Research Department at the hospital as

well as to my committee Chair, for their guidance and sound advice on this journey.

Finally, I’d like to acknowledge my classmates who are the only small group of people

who know firsthand what it was like to complete this DNP program and survive.

vii

DEDICATION

This work is dedicated to the awe inspiring world of nursing that has played such

a central role in my life. To all those who have strived to better themselves and refine the

art and practice of nursing.

I also would like to dedicate this to my loving family-- the foundation that has

kept me standing since day one. For all the family gatherings my laptop attended, for

every living room rehearsal of a presentation my sister endured, even to the dogs who

were up all night on my lap for every paper and study session; I love you all more than I

could ever express.

Finally, I dedicate this work to my mother, Barbara. All that I am I owe to you. I

attribute all my success in life to the moral, intellectual and physical education I received

from you. Your support, encouragement, and constant love have sustained me throughout

my life and always will. I love you.

viii

TABLE OF CONTENTS

TITLE PAGE.…………………………………………………………………….………..i

SIGNATURE PAGE……………………………………………….…………………..…ii

ABSTRACT ....................................................................................................................... iv

ACKNOWLEDGMENTS ................................................................................................. vi

DEDICATION .................................................................................................................. vii

LIST OF TABLES ............................................................................................................ xii

LIST OF FIGURES ......................................................................................................... xiii

SECTION ONE: INTRODUCTION ................................................................................. 1

Background ..................................................................................................................... 1

Problem Statement .......................................................................................................... 5

Purpose Statement ........................................................................................................... 5

Definitions ....................................................................................................................... 6 Emergency Departments.............................................................................................. 6 Urgent Care Centers .................................................................................................... 7 Retail Clinics ............................................................................................................... 8 Primary Care Providers ............................................................................................... 8 Emergency Severity Index (ESI) Acuity Levels ......................................................... 9

Project Objectives ......................................................................................................... 11

Project Questions .......................................................................................................... 11

Theoretical Framework ................................................................................................. 12

Significance to Nursing ................................................................................................. 14

DNP Essentials .............................................................................................................. 16

Significance of the Project ............................................................................................ 19 Health Care Practice .................................................................................................. 20 Health Care Delivery ................................................................................................. 20

Health Care Outcomes ............................................................................................... 21 Health Care Policy ..................................................................................................... 21

Summary ....................................................................................................................... 22

SECTION TWO: REVIEW OF THE LITERATURE ..................................................... 23

Introduction ................................................................................................................... 23

Emergency Department Overutilization ........................................................................ 24 Non-Urgent ................................................................................................................ 26

Who’s Responsible? ...................................................................................................... 28

Access ............................................................................................................................ 29

Clinician vs. Patient ....................................................................................................... 31

Promise of Alternative Care Sites ................................................................................. 32

Summary ....................................................................................................................... 36

SECTION THREE: METHODS ...................................................................................... 37

Introduction ................................................................................................................... 37

Design............................................................................................................................ 37

Setting............................................................................................................................ 38

Project Phases ................................................................................................................ 38 Phase One: The Protocol ........................................................................................... 38 Phase Two: The Consensus Panel ............................................................................. 39 Phase Three: D.A.N.C.E Protocol Pilot..................................................................... 40 Phase Four: Data Analysis ......................................................................................... 41

Sample ........................................................................................................................... 41 Inclusion Criteria ....................................................................................................... 43 Exclusion Criteria ...................................................................................................... 44

Protection of Human Subjects ....................................................................................... 45

Data Collection Methods ............................................................................................... 47

Outcomes Measures ...................................................................................................... 48

Proposed Budget ........................................................................................................... 49

Summary ....................................................................................................................... 49

SECTION FOUR: RESULTS AND DISCUSSIONS ...................................................... 50

Introduction ................................................................................................................... 50

Findings ......................................................................................................................... 50 Phase One: The Protocol ........................................................................................... 51 Phase Two: The Consensus Panel ............................................................................. 51 Phase Three: D.A.N.C.E Protocol Pilot..................................................................... 53 Phase Four: Data Analysis ......................................................................................... 54

Discussion ..................................................................................................................... 56

Strengths and Limitations of the Project ....................................................................... 57 Sample Size ............................................................................................................... 57 Project Setting............................................................................................................ 58 The D.A.N.C.E. Protocol ........................................................................................... 60 Patient Observations .................................................................................................. 61

Implications of the Project ............................................................................................ 62 DNP Essentials .......................................................................................................... 62 Implications for Practice ............................................................................................ 66 Implications for Health Care Delivery ...................................................................... 67 Implication for Health Care Outcomes ...................................................................... 67 Implications for Health Care Policy .......................................................................... 68 Suggestions for Future Research ............................................................................... 68

Summary ....................................................................................................................... 70

REFERENCES ................................................................................................................. 71

APPENDIX A: BARRY UNIVERSITY IRB APPROVAL LETTER ............................ 77

APPENDIX B: STUDY SITE IRB APPROVAL LETTER............................................. 79

APPENDIX C: COVER LETTER – THE CONSENSUS PANEL.................................. 80

APPENDIX D: COVER LETTER – PATIENT PARTICIPANTS- ENGLISH AND

SPANISH VERSION ...................................................................................................... 81

APPENDIX E: PROTOCOL AND SURVEY CARD – ENGLISH AND SPANISH

VERSION ......................................................................................................................... 83

APPENDIX F: TRANSLATING SERVICE CERTIFICATE ......................................... 87

APPENDIX G: THE CONSENSUS PANEL RECRUITMENT FLYER ........................ 88

APPENDIX H: PATIENT PARTICIPANT RECRUITMENT FLYER- ENGLISH AND

SPANISH VERSION ....................................................................................................... 90

VITA ................................................................................................................................. 93

xii

LIST OF TABLES

Table 1 The Consensus Panel .......................................................................................... 52

Table 2 D.A.N.C.E. Protocol Pilot Results……………..………………...…...………...54

xiii

LIST OF FIGURES

Figure 1. Emergency Severity Index (ESI) algorithm. ..................................................... 10

Figure 2. The Andersen Framework of Health Utilization Services (Andersen, 1995). .. 12

Figure 3. The Andersen Framework of Health Utilization Services expanded population

characteristics behavioral model of health services (Andersen, 1995). ............................ 14

Figure 4. Emergency department charges across payer groups for the 10 most frequent

outpatient conditions (Caldwell et al., 2013). ................................................................... 35

Figure 5. D.A.N.C.E. protocol pilot survey results: Question #1..................................... 55

Figure 6. D.A.N.C.E. protocol pilot survey results: Question #2..................................... 55

SECTION ONE:

INTRODUCTION

The ongoing misuse of the Emergency Department (ED) is creating a substantial

problem for the health care system, as it creates gaps in continuity of care. Equally

significant, the misappropriation of the ED often leaves little room for preventative care

and forces a financial strain on the health care system at both a systems level and an

individual level. Enhancing the public’s knowledge of the ED’s purpose and the services

available at alternative care sites, such as retail clinics (RCs) and urgent cares centers

(UCCs) can provide a potential solution to ED misuse and help alleviate subsequent

overcrowding. By examining the reasons for ED utilization, health care providers can

not only understand individual patients’ health care needs but also explore and highlight

needed changes in the health care system that would more effectively address these needs

(Ragin et al., 2005). RCs, UCCs, and EDs share several relevant characteristics and are

capable of treating a wide array of patients; however, patients must be made aware of

these valuable resources and when to use them in order for a more suitable and safe

substitution to take place.

Background

The delivery of modern health services is a complex activity that increasingly

relies on multi-professional and multi-service teamwork. An emergency department, also

known as an emergency room (ER), is generally part of a hospital or medical center and

is required by federal law to provide care to all individuals, regardless of insurance,

monetary or legal status. A vital component of the health care system, EDs specialize in

the acute care of patients who arrive without an appointment and are open 24 hours a day,

7 days a week, 365 days a year. Demanding by nature, the ED is often staffed with

physicians, nurse practitioners, physician assistants, nurses, and technicians working

around the clock to provide care to those in dire need of lifesaving interventions. Yet

despite the ED’s commitment to acute and emergency treatment, many people utilize the

ED erroneously expecting immediate treatment no matter the acuity level of the

complaint. Often, many of these patients can be helped at other places so that ED

providers can concentrate on those who really need help (McFadden, 2008). It is the one-

stop-shop, quick comprehensive work-up notion that is dangerously upsetting the health

care delivery system today. Patients can receive care in the ED any time—regardless of

the severity of their condition—and in view of the wide array of services available in the

ED, patients can receive immediate feedback about their condition. These factors

contribute to the fact that all payer groups and age groups contribute to the issue of non-

urgent care in the ED (Rosof, 2010).

A common misconception regarding primary responsibility for the misuse, and

subsequent overcrowding of EDs, is that uninsured minority populations are most at fault.

Anecdotal evidence suggests that this population considers services at a primary care

office unavailable to them due to lack of insurance coverage and therefore resort to the

ED for care regardless of the acuity of their presenting complaint. According to the

Centers for Disease Control and Prevention (CDC), Americans made 136.1 million visits

to one of the country’s nearly 3,900 emergency rooms in 2012 (Fay, 2014). As of 2010,

emergency department overuse costs $38 billion in wasteful health care spending with the

average cost of an ED visit being $580 more than the cost of an office health care visit

(National Priorities Partnership [NPP], 2010). It is estimated that more than $18 billion

could be saved annually if those patients whose medical problems are considered

“avoidable” or “non-urgent” were to take advantage of primary or preventive health care

and not rely on ERs for their medical needs (Fay, 2014).

A significant modifier to these statistics is the recent health care reform and

enactment of the Patient Protection and Affordable Care Act and its potential impact on

ED misuse and overcrowding. The Patient Protection and Affordable Care Act (PPACA)

is a federal statute signed into law by President Obama in March 2010. It is designed to

take effect in stages over 8 years and includes reforms such as prohibiting insurers from

denying coverage for pre-existing conditions, expanding Medicaid eligibility, subsidizing

insurance premiums, and providing incentives for businesses to provide health care

benefits. The Congressional Budget Office estimates that the number of uninsured

persons will drop by 32 million people after all the provisions of the PPACA are in effect

in 2019—the Act will still leave 23 million people uncovered, including illegal

immigrants and those who choose not to enroll in health insurance policies (American

College of Emergency Physicians [ACEP], 2011). With the number of both insured and

uninsured patients predicted to fluctuate at a rate unseen in the United States for over a

decade, the EDs are undoubtedly at risk for collapse by virtue of their structure unless

major health care reform is scrutinized and initiated.

A preexisting form of legal binding within the United States health care system,

particularly in EDs, is seen in the Emergency Medical Treatment and Active Labor Act

(EMTALA). In 1986, Congress enacted EMTALA to ensure public access to emergency

services regardless of ability to pay. Section 1867 of the Social Security Act imposes

specific obligations on Medicare-participating hospitals that offer emergency services to

provide a medical screening examination when a request is made for examination or

treatment for an emergency medical condition, including active labor, regardless of an

individual's ability to pay (Centers for Medicare and Medicaid Services [CMS], 2012).

Hospitals are then required to provide stabilizing treatment for patients with emergency

medical conditions, and if the hospital is unable to stabilize a patient within its capability,

or if the patient requests, an appropriate transfer should be implemented. Essentially,

EDs are to provide services and care to all patients in a nondiscriminatory and consistent

manner, paralleling the aim of the PPACA. Prior to the PPACA as a national universal

health benefits program, hospitals EDs were predominantly the only place in the health

care system in which all patients were guaranteed medical care. Incidentally, policy

makers in favor of the enactment of the PPACA are also in favor of EMTALA and the

notion of universal coverage for individuals.

With EMTALA and PPACA theoretically enhancing access to care, the argument

of whether those seeking care are doing so at an appropriate site and utilizing health care

resources correctly is still at the forefront of public policy discussion. In the midst of

several controversial debates regarding universal health care coverage, however, many

policymakers agree with the practice of redirecting non-urgent patients to more

appropriate alternative sites in efforts to decrease overcrowding in the ED. Advocates for

deferral of care site advantages that include improved ED performance through improved

throughput times, decreased wait times, and decreased financial debt with other potential

advantages of the deferral of care including the appropriate location for non-urgent care

for non-urgent conditions, shorter wait times, and improved patient satisfaction (ACEP,

2011).

RCs and UCCs are most typically freestanding physicians’ offices with extended

hours, onsite x-rays and laboratory testing, and an expanded treatment range, including

care for fractures and lacerations (Weinick, Burns, & Mehrotra, 2010). RCs, UCCs, and

EDs share several relevant characteristics. They provide walk-in care focused on acute

conditions and acute exacerbations of chronic conditions. For any given patient, the

possibility of safely substituting RC or UCC care for an ED depends on the severity of

the condition, the equipment and level of provider training required to care for the

patient, and the patient’s ability to self-triage to the most appropriate site (Weinick et al.,

2010).

Problem Statement

The problem is an increasing number of patients are using hospital EDs for non-

urgent care despite the availability of alternative care sites such as RCs and UCCs. The

aim of this project is to address the non-urgent use of the ED by increasing awareness of

alternative care sites available to these individuals. Addressing these factors can serve as

a framework for more effective utilization of health care resources, potentially bridging

the gap in continued and appropriate care and improving the health care system overall.

Purpose Statement

The implementation of an educational protocol to address ED misuse was chosen

for this project. The purpose of this project was to educate patients who utilize ED

services as a source of care for non-urgent complaints with the use of the Discharge

Alternative Non-urgent Care Education (D.A.N.C.E.) protocol. The project also intends

to examine the protocol’s influence on future care site decisions. Enhancing the public’s

knowledge of the ED’s purpose and the services available at alternative care sites, such as

RCs and UCCs, could provide a potential solution to ED misuse and subsequent

overcrowding.

Definitions

The following sections defines the terms emergency departments, urgent care

centers, retail clinics, primary care providers and Emergency Severity Index (ESI) acuity

levels as they were used throughout this project.

Emergency Departments

The terms emergency department (ED) and emergency room (ER) are used

interchangeably throughout this project. With the terms being synonymous, emergency

department is defined as a hospital room or area that is used for treating people who need

immediate medical care (Merriam-Webster, 2015). This department is open 24 hours a

day, 7 days a week, 365 days a year, and is required by federal law to care for anyone

who arrives, regardless of insurance or ability to pay. EDs/ERs generally treat people in

order of severity and not by time of arrival. At typically higher costs and co-pays

independent of severity, this area of the hospital treats medical issues that are life-

threatening or limb-threatening or issues that can quickly become so without immediate

medical intervention. According to the Centers for Disease Control and Prevention

(CDC), Americans made 136.1 million visits to one of the country’s nearly 3,900

emergency rooms in 2012 (CDC, 2012). Because of its convenient hours of operation,

comprehensive resources, and inability to decline care, EDs have become the safety net

of the health care system and are facing structural and financial strain due to overuse and

misuse.

Urgent Care Centers

Urgent care centers are freestanding, walk-in medical facilities that offer extended

hours and provide services for less or non-acute illnesses or injuries on a no-appointment

basis and are often open for extended hours, including nights and weekends. They are a

cost-effective alternative to emergency rooms for the treatment of non-life-threatening

medical situations such as cuts, sprains, simple bone fractures, flus and fevers, insect

bites, infections, etc. (Fay, 2012). Some centers provide basic laboratory and radiological

services, and most can run diagnostic tests and dispense prescriptions. These centers can

be owned by doctors, hospitals, or corporations, and many urgent care centers are staffed

by nurse practitioners and physician assistants, in addition to at least one board-certified

physician (Fay, 2012). They often provide services that are beyond the scope of a retail

clinic, when you cannot get an appointment to see your primary-care doctor, but they are

not appropriate for emergencies (Consumer Reports, 2009). The Annals of Internal

Medicine study found that the average cost of an urgent care visit for three common

illnesses—middle ear infection, pharyngitis, and urinary tract infection—was $155, with

other estimates that place the average urgent care visit at anywhere from $71 to $125

(Fay, 2012). On average, the costs of services at these centers are considerably lower

than an ER visit.

Retail Clinics

Located inside drugstores, supermarkets, and big-box retailers such as Wal-Mart,

these clinics treat a limited range of common illnesses and provide some preventive

services, such as vaccinations and medication refills (Consumer Reports, 2009). They,

like urgent care centers, are open nights and weekends, do not require appointments, and

are generally in places where prescriptions can be filled and are usually staffed by nurse

practitioners and registered nurses who have advanced training. Unlike urgent care

centers, most retail clinics do not have the available resources, such as imaging services,

for more urgent conditions. Their accessibility and low cost—$55 to $75 on average if

you pay out of pocket or a regular office visit co-pay if your insurance covers it—have

made the clinics a popular choice for people who lack health insurance and need basic

health maintenance (Consumer Reports, 2009).

Primary Care Providers

A primary care provider (PCP) is a health care practitioner who sees people that

have common medical problems (National Institutes of Health [NIH], 2013). This person

is usually a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) but may be a

physician assistant (PA) or a nurse practitioner (NP). The PCP is often involved in the

care of the individual for a long period of time and is responsible for an individual’s

continued care throughout the lifespan. A PCP is the main health care provider in non-

emergency situations, and his or her role is to provide preventive care and teach healthy

lifestyle choices, identify and treat common medical conditions, assess the urgency of

medical problems, and direct the patient to the best place for that care, as well as make

referrals to medical specialists when necessary (NIH, 2013). These providers often work

in an outpatient setting and have varying hours of operation and rates depending on

insurance coverage.

Emergency Severity Index (ESI) Acuity Levels

According to Agency for Healthcare Research and Quality (2013), the Emergency

Severity Index (ESI) is a five-level ED triage algorithm that provides clinically relevant

stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the

basis of acuity and resource needs— inclusion of resource needs in the triage rating is a

unique feature of the ESI in comparison with other triage systems. This algorithm and

rating system is used in the United States to differentiate between emergent, urgent, and

non-urgent patient complaints presenting to the ED. The purpose of triage in the ED is to

prioritize incoming patients and to identify those who cannot wait to be seen. The ESI is

intended for nurses with triage experience or those who have attended a separate,

comprehensive triage educational program. The triage nurse performs a brief, focused

assessment and assigns the patient a triage acuity level, which is a proxy measure of how

long an individual patient can safely wait for a medical screening examination and

treatment (Agency for Healthcare Research and Quality [AHRQ], 2011). Acuity is

determined by the stability of vital functions and the potential threat to life, limb, or

organ. The triage nurse then estimates resource needs based on previous experience with

patients presenting with similar injuries or complaints and national guidelines for

emergency care.

The ESI level also assists in determining which patients presenting to the ED can

in fact be more safely and effectively treated in a fast-track area, which some EDs have

opted for to expedite lower acuity care. The ESI retains the traditional foundation of

initially evaluating patient urgency and then seeks to maximize patient streaming: getting

the right patient to the right resources at the right place and the right time (AHRQ, 2011).

Version 1 of the ESI was originally implemented at two university-based EDs in 1999

and has been revised to its current Version 5 in 2004 (Figure 1).

Figure 1. Emergency Severity Index (ESI) algorithm.

Project Objectives

This project sought to achieve the following objectives:

1. To develop an educational protocol entitled D.A.N.C.E protocol to address non-

urgent use and overcrowding issues in the ED.

2. To present the protocol, constructed from national evidence-based data on

services available at non-urgent care sites and the ED to a staff consensus panel

for review and face validity.

3. To initiate a pilot test of the D.A.N.C.E. protocol over a 1-day period at a local

hospital to evaluate the effectiveness of the protocol.

4. To analyze the D.A.N.C.E. protocol’s influence on the patient’s future care site

decision for the same or similar non-urgent complaint by evaluating a post

intervention survey card completed by the patient after complete discharge from

the ED.

Project Questions

The project’s questions included the following:

1. Will the D.A.N.C.E. protocol affect patients’ health-seeking behavior when

determining appropriate care sites for non-urgent, lower acuity health complains?

2. What is the likelihood the D.A.N.C.E. protocol can be an effective educational

protocol on a system wide level to reduce the misuse and overcrowding of the ED

by non-urgent patients?

Theoretical Framework

The Andersen Framework of Health Utilization Services was utilized to guide this

project as it uses a systems perspective to integrate individual, environmental, and

provider-related variables associated with decisions to seek care. The Health Services

Utilization Framework can be used for the purpose of discovering conditions that either

facilitate or impede utilization of health care (Andersen, 1995). Developed as a

sociology model, the most current version of the Andersen model describes four

components that interact and assist in understanding utilization of care: Environment,

Population Characteristics, Health Behavior, and Outcomes (Figure 2).

Figure 2. The Andersen Framework of Health Utilization Services (Andersen, 1995).

The model proposes that the combination of these characteristics enables or

impedes the use of health care services with this decision being highly individualized and

interactive with and/or dependent on certain components. While all four components are

important to the framework, for the purpose of this project, the Population Characteristics

segment was the area of concentration, as it is unique to the individual. The focus was on

the three main characteristics of the component Population Characteristics: predisposing

characteristics, enabling resources, and need (Figure 3).

Predisposing characteristics are the socio-cultural characteristics of individuals

that exist prior to their illness and encompass social structure, health beliefs, and

demographics (Andersen, 1995). These factors are facets such as race and age, with

social structure including education, occupation, ethnicity, social networks, interactions,

and culture. Health beliefs are further defined to include attitudes, values, and knowledge

individuals have regarding disease processes and the health care system in general.

Demographics include age and gender.

Enabling factors incorporate family and community resources and accessibility of

those resources. Financing and organizational factors are considered to serve as

conditions enabling services utilization (Andersen, 1995). These factors include income,

transportation, health insurance, and a primary source for health care. They also include

means of transportation, travel time to the health care facility, and waiting time for health

care. Social relationships are also potentially an enabling resource, overlapping slightly

with predisposing characteristics. The community is a reflection of available health

resources, such as facility space, wait times, and adequate staffing levels (Andersen,

1995).

Finally, perhaps the most individualized aspect of the model is need. Essentially,

this factor includes functional and health problems that generate the need for health care

services. Needs are divided into two aspects: perceived need and evaluated need.

Perceived need in this framework is defined as how people view their own general health

and functional state, as well as how they experience symptoms of illness, pain, and

worries about their health and whether they judge their problems to be of sufficient

importance and magnitude to seek professional help (Andersen, 1995). Evaluated need

falls on the decision and expertise of the health care professional acting as the source of

care and ultimately fulfilling an individual’s health care need. Evaluated need represents

professional judgment about people's health status and their need for medical care

(Andersen, 1995).

Figure 3. The Andersen Framework of Health Utilization Services expanded population characteristics behavioral model of health services (Andersen, 1995).

Significance to Nursing

Historically, nursing’s underpinnings have been rooted in increasing the

individual’s awareness of health in order to foster independence and empowerment

through enhanced knowledge. As a result, efficient utilization of health care provisions

takes place and ultimately allows for a more feasible and fluid health care system. In

2006, the Institute of Medicine (IOM) called for improved operations management to

support ED efficiencies and mitigate the effects of overcrowding (IOM, 2006). Recently,

the IOM consensus report called for changes across the nursing profession that will

benefit patients, families, and the global community. According to this report, nurses

should practice to the full extent of their education and training; nurses should achieve

higher levels of education and training through an improved education system that

promotes seamless academic progression; and nurses should be full partners with

physicians and other health care professionals in redesigning health care systems in the

United States (IOM, 2010).

A major advantage of nurse practitioners (NPs) is that they possess an advanced

breadth of knowledge and expertise in health care and nursing which renders them

capable of managing a broad spectrum of clinical issues, despite their specialty or setting.

Two hallmarks of the NP profession are proficiency in cross-cultural competencies and

proficiency in caring for patients with non-emergent problems of an acute or chronic

nature (Abbot, 2012). Furthermore the NPs’ emphasis on health promotion and disease

prevention is integral in today’s evolving health care climate. NPs are expanding on their

education to the doctoral level as they are expected to be involved in system-wide and

nationwide improvements in health care policy. This education also incorporates the

appropriate use of important health care resources including EDs, UCCs, and RCs.

Commonly employed at RCs and UCCs, nurse practitioners continue to be a great

resource for these alternative care sites as they are highly skilled, highly trained, well

accepted by the general public, and cost effective professional providers (American

Academy of Nurse Practitioners [AANP], 2006). With the expansion of advance nursing

education to a doctoral level, NPs, or Doctorate of Nursing Practice (DNP), continue to

demonstrate a progressive and profound knowledge in practice that will undoubtedly

serve as a impressive asset in our shifting health care system.

DNP Essentials

The American Association of Colleges of Nursing outlines expectations for

advanced nursing practice in The Essentials of Doctoral Education for Advanced Nursing

Practice, henceforth referred to as DNP Essentials (American Association of Colleges of

Nursing [AACN], 2006). The significance of this project can be directly identified and

justified by the eight DNP Essentials. These essentials are: Essential I: Scientific

Underpinnings for Practice; Essential II: Organizational and Systems Leadership for

Quality Improvement and Systems Thinking; Essential III: Clinical Scholarship and

Analytical Methods for Evidence-Based Practice; Essential IV: Information

Systems/Technology and Patient Care Technology for the Improvement and

Transformation of Health Care; Essential V: Health Care Policy for Advocacy in Health

Care; Essential VI: Interprofessional Collaboration for Improving Patient and

Population Health Outcomes; Essential VII: Clinical Prevention and Population Health

for Improving the Nation’s Health and Essential VIII Advanced Nursing Practice.

Under Essential I, the DNP is expected to use scientific-based theories and

concepts to evaluate outcomes as well as develop and evaluate new practice approaches

based on nursing and theories from other disciplines (AACN, 2006). The project itself is

the essence of this Essential—not just in the approach to scientific inquiry itself but in the

topic being examined as well. By use of scientific theories and procedures, the project

examines a population’s health-seeking behaviors and knowledge deficits in awareness of

the role of alternative care sites.

Essential II expects the DNP to be able to develop and evaluate care delivery

approaches that meet current and future needs of populations based on scientific findings

in nursing and other clinical sciences, as well as organizational, political, and economical

science (AACN, 2006). This Essential also expects the DNP to develop, evaluate,

design, and direct quality improvement methods that include addressing ethical, financial,

and patient-centered care. All of these expectations are met through the aim, which is

implementing an educational protocol that enhances public’s knowledge of available

alternative sites more appropriate for care.

With scholarship and research being the hallmarks of doctoral education,

Essential III focuses on the translation of new science, its application, and evaluation

(AACN, 2006). It is expected of the DNP to generate evidence through practice to guide

improvements in practice and outcomes of care. The entire process of this project, from

beginning to end, allows the DNP to use analytical methods that critically appraise

existing literature in a scholarly attempt to determine and implement the best evidence-

based practice for a set population. In doing so, it simultaneously showcases a

fundamental understanding of the relationship between research and practice. In

conducting this study, the DNP is applying relevant findings to develop practice

guidelines and ultimately improve practice. Under this essential, it is also expected of the

DNP to design evidence-based interventions, predict and analyze outcomes, examine

patterns of behavior and outcomes, and identify gaps in evidence for practice (AACN,

2006). This essential certainly stands at the core of this project.

Under Essential IV, the project allows for the DNP to design, select, use, and

evaluate programs that evaluate and monitor outcomes of care, care systems, and quality

improvement including consumer use of health care information systems (AACN, 2006).

Through this project, analysis and identification of significant elements involved in

patient’s health-seeking behaviors can be examined and the use of patient care

technology can potentially be further explored. Findings could present an opportunity to

explore the use and evaluation of health care information systems dependent on further

study on related variables associated with decisions to seek care.

Essential V exemplifies that the DNP’s engagement in the process of policy

development is central to creating a health care system that meets the needs of its

constituents (AACN, 2006). This project could serve as a platform from which the DNP

can educate others, including policy makers at all levels, regarding nursing, health policy,

patient care outcomes, and related issues from the perspective of consumers in health care

behaviors and needed reform. The project serves as the groundwork that can facilitate

the delivery of health care services and address health care needs in this particular

population.

Essential VI stresses the importance of effective communication and collaborative

skills in the development and implementation of practice models, peer review, practice

guidelines, health policy, standards of care, and/or other scholarly products (AACN,

2006). The project exemplifies a collegiality among a community of highly skilled and

knowledgeable individuals from multiple professions of the health care system in

attempts to better serve this population and utilize health care resources as effectively as

possible.

Under Essential VII, the DNP is expected to evaluate care delivery models and/or

strategies using concepts related to community, environment and occupational health, and

cultural and socioeconomic dimensions of health (AACN, 2006). The project itself

embraces the community at large as it adds to the current body of knowledge supporting

strategies aimed at improving all dimensions of health. Further supporting this is the

theoretical framework to be used to guide the project on the community as a whole.

Finally, under Essential VIII, the DNP is expected to design, implement, and

evaluate therapeutic interventions based on nursing science and other sciences (AACN,

2006). The project focused on the already established strengths of the NP and applies

them to the investigator’s ability to effectively assess and educate individuals on the

proper alternative provision of health care. This Essential showcases the ability of the

DNP to demonstrate advanced levels of clinical judgment, systems thinking, and

accountability in designing, delivering, and evaluating evidence-based care to improve

patient outcomes. The DNP’s conceptual and analytical skills in evaluating the links

between practice, organizational, population, fiscal, and policy issues are showcased in

the implementation of the project.

Significance of the Project

It was anticipated that this study will be significant in the areas of not only

nursing but in health care practice, health care delivery, health care outcomes, and health

care policy as well.

Health Care Practice

Studies have shown that the utilization of NPs in the ED is a practice that has

evolved to address the non-urgent needs of patients at a lower cost. According to Abbot

(2012), a comparative study showed that utilizing NPs in the ED for non-emergent cases

reduced wait times, lengths of stay, and the number of patients who leave without being

seen compared to ED without NPs. While there is a need for further studies to confirm

and extend these findings, there is compelling evidence to suggest that increasing the use

of NPs in other realms of the health care system may be as advantageous especially in

areas of non-urgent care. As our health care system shifts to accommodate the needs of a

rapidly growing nation and different areas of health care accept NPs as key stakeholders

in the provision of quality care, alternative care sites present a promising opportunity for

advanced nursing practice as NPs are well suited to care for the majority of patients with

non-urgent problems.

Health Care Delivery

ED overcrowding is recognized as a national problem that hinders the delivery of

emergency medical services. Overcrowding in the ED has been linked to decreased

quality of care, increased costs, and patient dissatisfaction (Abbot, 2012). Delivery of

acceptable patient care under such circumstances requires a fundamental reordering of

ED priorities, policy, and procedures. Yet in the face of a much-needed redesign in the

delivery of care, few interventions that are in place target the education of patients

responsible for ED misuse and subsequently overcrowding. Solutions to the complex

problem of inappropriate ED use will require payers and hospital systems to work

together to design and invest in novel, targeted interventions (McWilliams, Tapp, Barker,

& Dulin, 2011). By enhancing an individual’s knowledge of available alternative care

sites, which are generally less time consuming and less costly, the delivery of health care

can focus on more tactful utilization of resources.

Health Care Outcomes

By educating these individuals on alternative care sites, the patient’s ability to

self-triage to the most appropriate site fundamentally impacts health care outcomes by

seeking suitable and equivalent care. Expanding on this concept and tailoring

interventions to the individual, which in turn affect the overall health care system, the

implementation of a discharge educational protocol showcases the NP’s astute clinical

judgment and evaluation of evidence-based care to improve health care outcomes. Most

importantly, once individuals have been educated on the appropriate site of care for their

non-urgent complaints, it can be assumed that they will continue to seek care accordingly

and eventually the dynamics of the proper application of provision will positively affect

health care at multiple levels.

Health Care Policy

Nurses can play a vital role in helping realize the objectives set forth in the 2010

Affordable Care Act, legislation that represents the broadest health care overhaul since

the 1965 creation of the Medicare and Medicaid programs (IOM, 2010). Although NPs

as a group have been employed in emergency care for more than 35 years, few studies

have been conducted to ascertain how they—and their skills and experience—can best be

utilized; the multifaceted problems that emergency medical service is facing deserve

further investigation into the utilization of NPs and demand urgent attention from

researchers and policymakers (Abbot, 2012). With the advent of NPs at the forefront of

educating individuals on appropriate health-seeking behaviors, a consistent and effective

health care system can be reconstructed. If health plans, policy makers, and providers

want to reduce use of the ED for non-urgent problems, they must ensure that their

interventions are tailored to address the needs of the populations they are designed to

serve (Uscher-Pines, Pines, Kellermann, Gillen, & Mehrotra, 2013). Emerging into

health care as a key element to reform, NPs are rapidly being placed at the political

forefront to policy changes that embrace better care of these patients.

Summary

An increasing number of patients are using hospital EDs for non-urgent care

despite the availability of alternative care sites such as RCs and UCCs. Enhancing the

individual’s knowledge of available alternative care sites for non-urgent complaints was

fundamental to this project. Having significant impacts on health care practice,

outcomes, delivery, and policy, the project served to explore an intervention tailored to a

specific group with dynamic characteristics. With the expansion of advance nursing

education and practice, NPs are proving to be an even larger asset to our shifting health

care system as they enter greater roles as DNPs. Increasing patients’ awareness of

available alternative care sites, such as UCC and RC, over the use of the ED for a non-

urgent complaint can help identify needed changes in our health care system in order to

better serve the community.

SECTION TWO:

REVIEW OF THE LITERATURE

Introduction

An increasing number of patients are using hospital EDs for care of non-urgent

conditions that can be treated in alternative care settings. The individual’s understanding

of appropriate alternative care sites for care of non-urgent complaints should be

addressed in order to streamline a more efficient treatment of these patients and reduce

the misuse of the ED. Non-urgent ED use is at the forefront of medico-political agendas,

and diversion of these patients has been entertained as a management strategy (Afilalo et

al., 2004). Because non-urgent ED users are likely a diverse group, the better approach

might be to try to break up non-urgent ED users into different strata with the precise

issues or challenges identified so that the correct intervention(s) can be applied (Uscher-

Pines et al., 2013). Identifying these factors can also serve as a framework for the

implementation of a discharge alternative non-urgent care education protocol for these

patients and potentially bridge the gap in the misappropriation of health care resources.

A review of the literature reveals that the use of EDs for non-urgent care has been

examined for the past three decades. Yet, despite the growing and consistent evidence of

its detrimental effects, little use has been made of this information regarding

implementing strategies that encourage or enable patient’s health-seeking behaviors

appropriately. A search of relevant literature across disciplines was conducted to explore

the phenomenon of overcrowding and non-urgent care in the ED. Using First Search,

Lilinet Online, and ProQuest Direct search engines, the following computerized

databases were used for this search: the Cumulative Index to Nursing and Allied Health

Literature (CINAHL); Dissertation Abstracts; Educational Resource Information Center

(ERIC); Health Reference Center – Academic; Medicine, Modern Language Association

(MLA); and Periodical Abstracts (PerAbs: Covering business, economics, literature,

religion, psychology, and women studies). The key words used in the search were

emergency department overcrowding, ED overcrowding, ED overuse, ER abuse,

motivating factors, alternative non-urgent care, perceptions of care, barriers to ED care,

Nurse Practitioners in ED, and retail clinics versus emergency rooms cost. Citations

were limited by language to English and by subject to exploration of the concepts. A

limitation was imposed to find literature published since 2009 with classics sought by

reviewing citations in the published works. A random selection process delimited the

profusion of theoretical references that were found. Additionally, over 10 research

studies were reviewed in which the occurrences of ED overcrowding and non-urgent use

of the ED were explored. Synthesis of the literature reveals what is known and not

known about ED overcrowding and patients’ understanding of alternative care sites.

Emergency Department Overutilization

An international phenomenon, overcrowding in EDs is described in emergency

medicine literature as a major public health problem because of its consequences:

degradation of the quality of care (e.g., prolonged waiting times, delays to diagnosis and

treatment, and delays in treating seriously ill patients); increased costs (e.g., insurance

coverage and unnecessary diagnostic investigations); and patients’ dissatisfaction

(Gentile et al., 2010). The number of these non-urgent visits continues to rise, and their

reduction requires a system wide reform. ED overcrowding is a serious and well-

documented problem—of an estimated 14 million visits to hospital emergency

departments, only 12.9% are considered emergent cases; with 62% of all emergency

departments described themselves as over capacity (Twanmoh & Cunningham, 2006) in

the United States.

An extensive, international literature review reported that 4.8% to 90% of ED

patients were potentially non-urgent cases, with a median of 32.1% (Gentile et al., 2010).

Despite exceptionally long wait times documented, much of the literature has found that

patients are willing to wait extended periods of time for care, regardless of acuity. In

their French study, Gentile et al. (2010) found that when given the option of being treated

in the ED or a nearby facility for their non-urgent complaints, nearly one-third of patients

refusing reorientation would be willing to pay an extra fee to be treated in the ED

(Gentile et al., 2010). This finding is significant in that it points to motivations behind

seeking care despite lower acuity complaints. The aim of this study was to assess the

willingness of non-urgent patients to be reoriented to primary care units (PCUs)—

alternative structures located near hospitals—and to collect the reasons that prompted

them to accept or refuse. In this cross-sectional study, patients were interviewed at a

single French hospital where 85 patients considered non-urgent by a triage nurse were

asked to respond to a questionnaire. The results showed that most patients went to the

ED autonomously (76%) with the main reasons for using the ED were difficulty to get an

appointment with a general practitioner (22.3%), feelings of pain (68.5%), and the

availability of medical services in the ED, such as imaging, laboratory tests, and drug

prescriptions (37.6%). Traumatisms and wounds were the main medical reasons for

going to the ED (43.5%). More than two-thirds of responders (68%) were willing to be

reoriented towards PCUs (Gentile et al., 2010). Despite a small sample size, the study

provides significant data regarding patients’ willingness to be reoriented to a more

appropriate care site based on urgency and actualizes the possibility of policy change

involving these sites.

Non-Urgent

Interestingly, a common limitation seen in the majority of the literature is the lack

of an official definition to the term “non-urgent.” While all the studies reviewed

explicitly explain the acuity designation of their patients, that is a level 4 or 5 based on a

five-level triage algorithm, and no two studies used the same definition of the term non-

urgent. According to Agency for Healthcare Research and Quality (2013), the

Emergency Severity Index (ESI) is a five-level emergency department triage algorithm

that provides clinically relevant stratification of patients into five groups from 1 (most

urgent) to 5 (least urgent) on the basis of acuity and resource needs. Inclusion of

resource needs in the triage rating is a unique feature of the ESI in comparison with other

triage systems. Yet, the literature incongruently describes the same system. Other

severity indexes exist and are used at the discretion of the hospital system as well as the

country or region the emergency department is located. A well-recognized and validated

triage system is the Canadian Emergency Department Triage and Acuity Scale (CTAS)

which has five acuity levels consisting of - Resuscitation, Emergent, Urgent, Less Urgent

and Non Urgent (Elkum, Barrett, & Al-Omran, 2011). While all systems are quite

similar and facilities generally responded with a comparable level of care and use of

resources, there is still no evidence of a universal designation of levels of acuity.

With no uniformity in a definition of the term, greater confusion was found in

categorizing the motivating factors for seeking care in the ED. Thus, non-urgent became

the standard term while the care of these patients continues to be a major point of

controversy. Further studies revealed that the patients’ perception of appropriateness in

seeking care had less to do with the level of medical urgency and more with the

convenience of the ED services. In a secondary analysis from a cross-sectional study

with sequential sampling in the EDs of five Quebec tertiary care hospitals. Afialo et al.

(2004) found that the reasons given by non-urgent patients for not seeking primary care

provider care were accessibility (32%), perception of need (22%), referral/follow-up to

the ED (20%), familiarity with the ED (11%), trust of the ED (7%), and no reason (7%).

Similar studies have acknowledged that the term non-urgent is poorly defined, and its

clarification is essential in determining a solution to their unfitting use of the ED. They

often defined a non-urgent visit according to medical criteria such as calling it a “minor

medical problem that is non-acute, non-life-threatening” (Durand et al., 2012).

Identifying these factors potentially plays a pivotal role in the designing of diversion

interventions that incorporate the multifaceted dynamics of the populations seen in the

ED and their equally multidimensional reasons for utilizing it.

Fueling a portion of this controversy is the cost of treating these non-urgent

patients in the ED. In the United States, 56%, or roughly 7 million visits, are potentially

avoidable; reducing this trend represents a significant opportunity to improve quality and

lower costs in health care (NPP, 2010). In an effort to reduce these costs and

overcrowding, numerous alternative sites, such as Urgent Care Centers (UCCs) and

Retail Clinics (RCs) have been created to provide non-urgent care. One study found that

between 13.7% and 27.1% of all emergency department visits could be treated at one of

these alternative sites with a potential cost savings of approximately $4.4 billion annually

(Weinick et al., 2010). With roughly 2% of national health care spending potential saved

with the use of these alternative sites there is stirring initiative to determine responsible

parties for the improper use of the ED. In their study, Weinick et al. (2010) compared

care at the three sites (RCs, UCCs, and EDs) in attempts to examine the extent of which a

safe substitution could be made and found that overall, a total of 27.1% of all ED visits

could be managed at a RC or UCC. This study reinforces the capacity of these

alternative sites to care for these non-urgent patients and help reduce ED misuse and

overcrowding.

Who’s Responsible?

Public perception often point to the uninsured individual as the responsible party

for ED misuse. Yet, despite the compelling statistical evidence found in multiple studies

over the past decades stating differently, the blame for misuse of the ED is still being

placed on the uninsured populations. In tracking this trend over the years, there now is

evidence to support that it is not only the uninsured but the insured and newly termed

underinsured, who are at fault for the misuse of the ED. While the uninsured still partake

in the misuse, a study shows that the increased use of the ED over a decade (119 million

U.S. visits in 2006, compared with 67 million in 1996) is actually driven by more visits

from insured, middle-class patients who usually get their care from a doctor's office

(Meisel & Pines, 2008). It appears the uninsured misuse the ED comparatively

proportionately to those with insurance according to the studies reviewed. While

uninsured adults were more likely than those with private health insurance or a public

health plan to visit the emergency room due to having no other place to go, adults with

public health plan coverage were twice as likely as those with no health insurance to visit

the emergency room because their doctor’s office was not open (CDC, 2012). It is clear

that interventions should be aimed at not just the uninsured population but the insured as

well.

Interestingly, another study found that the communities with high ED usage do

not necessarily have the highest number of uninsured, low income, racial/ethnic

minorities, or immigrants (Cunningham, 2006). Moreover, the most recent evidence

suggests that younger age, convenience of the ED compared with alternatives, referral to

the ED by a physician, and negative perceptions about alternatives, such as primary care

providers, all play a role in driving non-urgent ED use (Uscher-Pines et al., 2013).

Sufficient evidence suggests that a reform in the health care system should be aimed

specifically to the population responsible for the overall misuse of the ED and not toward

an anecdotal offender. In short, attributing the increase in visits to the uninsured

oversimplifies a complex problem and thereby subverts meaningful debate on how best to

develop innovative and appropriate solutions to the problem of ED crowding (Weber et

al., 2008).

Access

The increase in ED use may be attributable to lack of ready access to primary care

and other structural problems in the health care system (Weber et al., 2008). The

numerous studies reviewed highlighted other factors that affect patient’s decisions when

seeking care. The New England Healthcare Institute notes that lack of timely

appointments and after-hours care also drive patients to the ED (Rosof, 2010). Multiple

studies noted that patients often reported anticipating that their primary care providers

would refer them to the ED, and so they preemptively make the choice to go to the ED.

With the prioritization of cost containment, many offices rely on staff with less training

to answer phone calls, and studies have shown that office staffs often refer patients with

non-urgent conditions to the ED (Adesara, Spencer, & Bost, 2011). There is noted

liability in allowing office staff members who are often inexperienced in medical care or

nursing to perform their own version of phone triaging, specifically in combination with

observable conflicts of interest of scheduling an unexpected patient to the office. Seeing

additional patients may result in additional work or hours for the staff (Adesara et al.,

2011). A main theme noted throughout many of the studies was the perceived

convenience of the ED by otherwise unknowing office staff as well.

Acknowledged in virtually all of the reviewed literature is the ED’s role as a

safety net in the current health care system. Required by law to care for all patients

regardless of ability to pay, EDs have fallen into the “safety net for safety nets” role, and

overcrowding threatens public health by compromising patient safety and jeopardizes the

reliability of the entire health care system (Rivers, 2003). Insurance status had a

particularly solid presence throughout the research of the ED, being often the only access

to health care for some individuals. As mentioned in an earlier section, visits to the ED

are due to having no other place to go. These binding legal obligations coupled with

patient’s misuse unconsciously subject the ED to an exploitation that will not be able to

sustain itself unless significant reform occurs. However, studies have shown that patients

are acting as rational consumers when choosing the ED for care. One study points out

that even after being interviewed and made fully aware of all alternative health structures

available, patients continued to choose treatments and services provided in the ED. A

common limitation in several studies was the patient’s reluctance to utilize a more

appropriate alternative site despite education for unjustifiable reasons. Interviews

showed that patients are able to use this information to make their own choice when

selecting care providers and yet continued to choose the ED. For them, among all health

care resources available, the ED is the most suitable place and the most efficient provider

that can fulfill their medical needs immediately (Durand et al., 2012). Therefore,

although their acuity and self-triage is not appropriate for the ED setting, the patient’s

progression of thoughts can be seen as a rational decision when seeking fulfillment of

their needs.

Clinician vs. Patient

A growing trend noted in the literature is the interest in the opinions of the health

care professionals in the ED and why they feel patients are using the ED for non-urgent

care. A result of interviews with physicians and nurses working in the ED revealed that

the “rational consumer” notion was not shared by these health care professionals. These

health care professionals stigmatized patients as “abusive and irresponsible consumers”

of health care resources and felt patients use EDs to be seen earlier and faster than their

medical condition warrants (Durand et al., 2012). They also felt their training on

handling life-threatening emergencies was being wasted on these patients. Interestingly,

studies found reverse ranking on level of importance between patients and health care

staff. There will always be a certain disconnect between what patients perceive as

appropriate use and what clinicians see as appropriate, but the reasons given by patients

make such good sense that they call in to question the whole issue of using the term

inappropriate to describe some ED attendances (Masso, Bezzina, Siminski, Middleton, &

Eagar, 2007).

Potential solutions offered by health care professionals were also examined.

Among these solutions was patient education regarding appropriate use of health care

services. Others consisted of improving the continuity of care by extending PCP office

hours as well as imposing a penalty fee for those patients deemed non-urgent. A

compelling suggestion was to integrate a gatekeeper in the ED who would require

authorization from patients’ PCPs for admission to the ED in an attempt to filter patients

through or away from the ED. While some suggestions can be interpreted as biased or

unreasonable because of the varying definitions of an emergency between clinicians and

the patients, enhancing patient education was a mutual theme throughout the literature.

Promise of Alternative Care Sites

The ED is not the ideal health care resource for non-urgent or chronic conditions,

and patients receive better care at sites capable of managing these conditions in a timely,

efficient, and ethical manner (ACEP, 2011). ED costs are difficult to quantify and are

most often unknown to a patient when he or she walks in. Other than knowing the

standard co-pay amount for those who have private medical insurance, which can be

several hundred dollars, it is impossible to determine how much the final ER bill will be

until it is received in the mail a few weeks after treatment (Fay, 2014). A cost-effective

alternative to EDs for the treatment of non-life-threatening medical situations such as

cuts, sprains, simple bone fractures, flus and fevers, insect bites, and infections lies in the

use of alternative care sites.

ED costs correspond to the severity of a patient’s illness or injury, the number of

diagnostic tests and/or treatments performed, physicians’ fees (typically about 20-25

percent of the total charges), radiology or specialist services, and any pharmacy or other

hospital expenses (Fay, 2014). The similar services available at alternative care sites

compared to ED services have proven to be substantially less costly throughout the

literature. According to the Agency for Healthcare Research and Quality, average

expenses for all people who had one or more visits to an ER in 2009 were $1,318 (Fay,

2014). In a study by Mehrotra, et al. (2009), the authors found that overall costs of care

for episodes initiated at retail clinics were substantially lower than those of matched

episodes initiated at physician offices, urgent care centers, and emergency departments

($110 vs. $166, $156, and $570, respectively). The authors compared the cost and

quality of care and the delivery of preventive services for patients who received care for

three conditions commonly treated in retail clinics (otitis media, pharyngitis, and urinary

tract infection) with that received in physician offices, urgent care centers, and

emergency departments over 1 year. The authors also recognized that the majority of

provisions at these sites were administered by NPs and correlated with other studies

reinforcing patient satisfaction and positive patient outcomes following care with these

providers.

An Annals of Internal Medicine study found that the average 2009 cost of an ER

visit for three common illnesses—middle ear infection, pharyngitis, and urinary tract

infection—was $570 (Mehrotra, et. al., 2009). According to Kiplinger’s Personal

Finance magazine, a multi-award winning publisher of business forecasts and personal

finance advice, in 2011, the average in-network cost of an emergency room visit for

someone with private health insurance was about $933 (Lankford, 2010). Despite

varying totals for care at each site, it is unmistakable that non-urgent care at an alternative

care site is substantially cheaper than an ED visit. The most recent study discovered was

a cross-sectional study performed by Caldwell, Srebotnjak, Wang, Hsia, and Zhang

(2013) where they examined the charges, variability, and respective payer group for

diagnosis and treatment of the 10 most common outpatient conditions presenting to the

ED. The 10 most common outpatient conditions being sprains and strains, other injuries,

open wounds of extremities, pregnancy, headaches, back problems, upper respiratory

infections (URI), kidney stones, urinary tract infection (UTI), and intestinal infection

(Figure 4). Median charges ranged from $740 for an upper respiratory infection to

$3,437 for a kidney stone. The median charge for all 10 outpatient conditions in the ED

was $1,233, with a high degree of charge variability (Caldwell et al., 2013).

Figure 4. Emergency department charges across payer groups for the 10 most frequent outpatient conditions (Caldwell et al., 2013).

According to Ashwood et al. (2011), the 11 “retail clinic–sensitive” conditions

were URIs, sinusitis, bronchitis, pharyngitis, otitis media, otitis externa, conjunctivitis,

UTIs, allergic rhinitis, influenza, and unspecified viral infection, which correspond with

the top-presenting complaints seen in other studies investigating ailments presenting to

these alternative care site. RCs and UCCs are comparable in the spectrum of non-urgent

conditions they treat and their reduced pricing. Charges for the same diagnoses were

found to be 69% to 86% lower in primary care clinics than in EDs, with potentially

significant savings. Reasonably, hospital margins for ED visits were much higher for

emergency care than non-urgent related care ($187/patient vs. $68/visit); this finding

suggests that hospitals benefit more when EDs are focused on providing emergency care

(McWilliams et al., 2011). Collectively, all studies reviewed corroborate that these

alternative care sites were both appropriate for care of a non-urgent nature and less costly

to all parties involved regardless of insurance status. Ultimately, the possibility of safely

substituting RC or UCC care for an ED depends on the severity of the condition, the

equipment and level of provider training required to care for the patient, and the patient’s

ability to self-triage to the most appropriate site (Weinick et al., 2010).

Summary

Both the science and practice of health care have changed dramatically over the

past decades along with the role and management of EDs worldwide. Use of the ED as

source for non-urgent care or primary care is episodic and fragmented yet continues to

occur. Additionally, with the uninsured and insured populations misusing the ED

equally, an ominous tension in placed on the safety net of the health care system. With

RCs and UCCs commonly being operated by NPs as principal providers, the potential

benefits of more useful utilization of these sites by patients seeking non-urgent care

carries twofold gains for improved patient outcomes and employment opportunities for

NPs. Reducing the educational deficit of these individuals may help to improve the

misuse of the ED.

SECTION THREE:

METHODS

Introduction

The purpose of this project was to educate lower acuity patients after discharge

from the ED on use of alternative care sites, such as RCs and UCCs, for future non-

urgent complains. Taking place at a single ED in Miami Dade County, FL the

implementation of a Discharge Alternative Non-urgent Care Education (D.A.N.C.E)

protocol to address the misuse of the ED was chosen for this project. Enhancing the

individual’s knowledge of available alternative care sites, and assessing the protocol’s

influence on future decisions to use these sites, is central to the study and could be

instrumental in future health care reform.

Design

A descriptive post survey design was chosen for this project with a cross-sectional

pilot intervention by use of the D.A.N.C.E protocol on lower acuity patients presenting

the ED. A descriptive project is one in which information is collected without changing

the environment. This design was chosen because descriptive studies can yield rich data

on the naturally occurring health status and behavior of a particular group that could lead

to important recommendations in practice. A pilot design was selected, as these are

small, preliminary clinical projects whose primary objective is to prove that further

studies need to be done.

Setting

The setting for this project was a single ED in Miami-Dade County, FL open 24

hours a day and 7 days a week. The department is professionally staffed with emergency

department physicians (EDPs), nurse practitioners (NPs), physician-assistants (PAs), and

registered nurses (RNs). The average amount of patients seen in this ED on a given shift

is over 100 patients, with a shift equating to 12 hours. Provisions for lower acuity

patients are primarily under the direction of an NP or PA with higher acuity patients

being under the care of an EDP. Provider designation can also be dependent on patient

volumes and provider work hours. EDPs usually are on shift from 7 a.m. to 7 p.m. and 7

p.m. to 7 a.m. in this ED, with PAs and NPs on duty between 9 a.m. to 9 p.m. and/or 3

p.m. to 3 a.m., respectively. After 3 a.m. all patients, regardless of acuity level

designation, are under the care of the EDPs. The primary languages spoken by the

patients who presented to this hospital during the implementation of this project were

English followed by Spanish.

Project Phases

The project progressed through four phases.

Phase One: The Protocol

The D.A.N.C.E. protocol was implemented in a pilot project with the use of an

educational protocol constructed from national evidence-based data on the scope of care

available at non-urgent care sites and the ED. An exhaustive appraisal of accredited

medical and nursing agencies as well as insurance companies’ data was reviewed during

the constructing of the D.A.N.C.E. protocol. Studies performed in the past that examined

the non-urgent use of the ED the statistical data of the most commonly sought and treated

complaints in the ED was also reviewed and utilized in the construction of the protocol.

A single-page protocol was drafted to represent the data collectively and concisely. All

symptoms and conditions listed on the protocol pertaining to non-urgent complaints

could be cared for at local UCCs and RCs. In attempt to refrain from prolonging physical

length of stay in the ED, which differs from the length of stay (LOS) documented by

health care facilities, the protocol and survey card were tailored to be brief yet effective.

Face validity was then established by a staff consensus panel.

Phase Two: The Consensus Panel

The consensus panel consisted of five ED health care providers from the selected

facility who met inclusion criteria to participate. A meeting date and time were

determined after all members had accepted to contribute to the project. Each panel

member was provided with a cover letter describing the project and the role expected of

the panel member. The D.A.N.C.E protocol and survey was then provided to the

consensus panel for review of face validity. A review of the information on the protocol

took place in a face-to-face workshop in the ED conference room of the selected facility

over a 2-hour time period with all members of the panel present. Face validity was

determined by the panel as they reviewed the protocol based on professional practice

experiences, relevance, readability, and population characteristics seen and treated in this

ED. The overall appearance of the protocol and survey card was appraised by the panel

as well. Panel commentary was considered for future revisions of the project and will be

discussed further in the Results section of this project.

Phase Three: D.A.N.C.E Protocol Pilot

The D.A.N.C.E protocol and survey card (Appendix E) were offered to lower

acuity patients after their complete discharge from the ED. The protocol was available in

English and Spanish. Translating services were employed (Appendix F) and included

back-translation, in which all text was translated into another language then translated

back in the first language to ensure that it equated so that results could be compared. The

protocol was administered individual by individual after discharge from the ED. Along

with the protocol, a cover letter introducing the project as well as an explanation of

voluntary involvement was attached for the patient’s review. The DNP student also

provided each participant with a short verbal introduction to the project, which included

explanation of voluntary involvement, a brief personal introduction of the DNP student,

navigation of the protocol, and instructions upon completion of survey card. This was the

only involvement the DNP student had with each participant in efforts to enhance

comprehension of protocol’s aim. It was expected that the protocol would not take more

than 10 minutes to complete; nevertheless, each participant was allotted individual time

with the protocol for review after their complete discharge from the ED.

At the completion of the patient’s review of the protocol, a survey card was

completed by each participant. Participants were free to review the protocol and

complete the survey card anywhere on hospital premises. A locked drop box was visibly

located at the front desk of the ED waiting area for collection of the surveys. Only cards

returned to the drop box were included in the analysis at the completion of the project.

At the completion of the visit and project participation, each participant was allowed to

take the educational protocol home for further review and future use.

Phase Four: Data Analysis

In order to analyze the D.A.N.C.E. protocol’s effectiveness and influence on the

patient’s health-seeking decisions, a post intervention survey card was utilized. The

survey card consisted of two questions. The first question being, Where would you seek

care next time you have the same or similar health care problem? followed by four

checkboxes listing The Emergency Room, Urgent Care Center/Retail Clinic, and Primary

Care Provider as options for selection. Participants were asked to select one of these

options from the list. The second question was Did the D.A.N.C.E. protocol help you

make your choice above? followed by checkboxes indicating Yes or No. Participants

were again asked to only select one option from the list of possible response. The date

and time were also included on the survey card. Evaluating a post intervention survey

card for the protocol’s influence on care seeking decisions may help guide policy changes

in determining what interventions need to be made when catering to the health care needs

of this community. Further discussion on this concept can be found in the Results section

of this project.

Sample

The sample obtained for the consensus panel were those ED staff members who

met inclusion criteria and volunteered their involvement in the project. A flyer created

by the DNP student (Appendix G) was posted in the ED employee lounge area and other

employees-only areas announcing the project and inviting those who met inclusion

criteria to participate in and/or inquire about the project. The target sample size for this

consensus panel was a minimum of three and a maximum of five staff members. The

first five staff members who met inclusion criteria to accept involvement in the project

formed the consensus panel. All inquiries from prospective participants were addressed

as they were received by the DNP student and as needed by each member throughout the

project in order to maintain full disclosure of the requirements of each panel member.

A convenience sampling technique was used in the selection of patient

participants arriving by their own means to the ED, deemed non-urgent based on ESI

acuity level, and met inclusion criteria. A flyer created by the DNP student (Appendix

H) was posted throughout the ED discharge area announcing the project and inviting

those who met inclusion criteria to participate in and/or inquire about the project. The

D.A.N.C.E protocol was distributed to individuals who met inclusion criteria after all

hospital documentation had been completed and all care provisions had been

administered. The target sample size for this portion of project was approximately 20

patient participants. It was felt by the DNP student that this sample size was large

enough to provide useful information about the aspects that were being assessed at this

stage of the project, as had been demonstrated in similar pilot projects on this area of

study.

The Emergency Severity Index (ESI) acuity level is used at this facility. If a

patient does not meet high acuity level criteria (ESI level 1 or 2), the triage nurse then

evaluates expected resource needed to help determine a lower acuity designation level

(ESI level 3, 4, or 5). Generally, ESI level 4 or 5 conditions are those that may be acute

but non-urgent as well as conditions which may be part of a chronic problem with or

without evidence of deterioration. Based on composite review of current literature, the

interventions for some of these illnesses or injuries could be delayed or even referred to

other area of the hospital or health care system. Sample participants in this project were

selected based on the assignment of acuity established by the ED RN assessment with a

designation of an ESI level of 4 or 5, indicating lower acuity. It is important to note that

because ESI levels incorporate both objective and subjective patient findings, the ESI

number designation can change after certain immediate, non-life-saving provisions are

provided to enhance the patient’s overall comfort and health state (e.g., an ice pack for a

minor limb injury). For this reason, in the event of an insufficient amount of participants,

some ESI level acuity 3 patients qualified for this project. As a result, the DNP student

considered the expertise of the RN involved in the triage, direct care, and discharge of the

patient in order to verify the patient’s qualification for the project. Providing the protocol

at the end of the ED visit allowed for better identification of qualifying patients and the

decision to include ESI level 3 patients.

Inclusion Criteria

Requirements to participate on the consensus panel included voluntary

involvement, educational level of a Master’s degree in health care (e.g. nursing and/or

medicine) or higher, and/or a minimum of 5 years of emergency room and/or urgent care

center experience. Current employment in the emergency department at the participating

facility was also required.

Inclusion criteria for pilot project participation included being a patient

discharged from the ED on the day the project was implemented, ESI acuity level 4 or 5

(some ESI level 3 were considered), and English and/or Spanish speaking individuals.

The project only included patients 18-64 years of age. As mentioned in the review of

literature, this age group was found to frequently misuse the ED for non-urgent

complaints. Voluntary involvement was also required of D.A.N.C.E. pilot project

participants.

Exclusion Criteria

Exclusion criteria for the staff consensus panel included employees who did not

meet any of the inclusion criteria.

Exclusion criteria for pilot project participation included patients younger than 18

years of age and older than 64 years of age. Patients suspected to be intoxicated as well

as patients with cognitive disabilities involving comprehension and expression of clear

thought, whether or not related to their reason for the visit, were also excluded.

Languages other than English and/or Spanish were not included in this project due to

limited availability of translation of the protocol in more than one foreign language and

time constraints. Any person suspected to be a victim of abuse or any person who

presented as part of hospital required ED evaluation (such as employees or prisoners)

were excluded to avoid interference with legally required documentation and policies.

Patients who as a result of their visit were admitted to the hospital were also excluded as

their condition warranted the use of ED and later inpatient services. Patients who were

referred to the ED from an alternative care site for further evaluation were excluded along

with patients who were told by a provider at this facility to return to the ED for follow-up

care. Patients who received a protocol but did not wish to complete a survey card were

excluded due to partial participation. Finally, any participants who refused to volunteer

were excluded for obvious reasons. All patient participants were allowed to keep the

protocol for future use regardless of participation level after recruitment.

Protection of Human Subjects

Protection of human subjects was incorporated and maintained throughout the

entirety of this project. Prior to data collection, the Institutional Review Board of Barry

University approved the project as an exempt project (Appendix A). Also prior to data

collection, the Institutional Review Board of the local hospital in which the pilot project

took place also approved this project as exempt (Appendix B).

Each panel member received a cover letter identifying him or her as an official

member of the consensus panel as well as describing his or her role in the project

(Appendix C). Panel members were informed that any information provided would be

kept confidential—that is, no names or other identifiers were collected on any of the

instruments used during this project. Any discussion or revisions made to the protocol

were maintained by only the DNP student. This project was of minimal risk. There may

have be some anxiety about establishing face-validity of a protocol that would be

distributed to patients for educational purposes for each member of the consensus panel.

This risk was minimized through voluntary involvement and face-to-face dialogue on

material allowing for open discussion that did not harm subjects. There was no direct

benefit or compensation to the members of the consensus panel for participating in the

educational project. Panel members may have gained awareness of patient’s health-

seeking behaviors including the patient’s increased awareness of alternate care sites and

emergency departments by participating in this project.

A cover letter for patient participants (Appendix D) was attached to each

D.A.N.C.E protocol introducing the project as well explaining voluntary involvement.

No patient identifiers were collected during the project to preserve patient privacy. It is

also important to note that the DNP student did not have access to any participants’

medical records or ED charting for this project. There may have also been some anxiety

for the patient participants about completing the protocol. This risk was minimized

through voluntary involvement, anonymity of responses, and the use of non-invasive

project processes that did not harm subjects. Patient participants were made aware that,

although unlikely, should they experience overwhelming anxiety related to being in this

project, they were welcome leave the project at any time and use the ED or a care site of

their choice, to treat this anxiety.

All participants, staff and patient, were asked to not provide any identifiable

information including but not limited to name, age, or sex on the forms collected. During

the collection of data, all information and documents were kept in a locked locker, which

was only accessible by the DNP student and was located at the selected facility. Any

information provided electronically was kept on a password-protected computer system,

which was also only accessible by the DNP student, at the selected facility. All collected

data is to remain kept in a locked cabinet at the home of the DNP student for a minimum

of 5 years and will only be accessible by the DNP student.

Data Collection Methods

Data collection took place at a single facility within a large health care system.

The management team was notified of the project’s time frame through a series of emails

and meetings detailing ED staff and patient involvement. ED staff was then notified of

the project and its aim through pre-start-of-shift-huddle announcements. Panel members

were recruited approximately 1 week prior to the collection of survey cards from the

D.A.N.C.E. protocol pilot. This time frame allowed for adequate review of the protocol

and any cosmetic changes to be done to the document if needed. No formal notes were

documented at this workshop; however, comments and suggestions were considered for

future study. These ideas and recommendations are discussed further in the Results

section of this project.

Patient participants were recruited between the hours of 9 a.m. to 9 p.m. on one

date. Due to the hours of operation of the ED selected, the DNP student distributed the

D.A.N.C.E protocol after the complete discharge of the patient from the ED between the

hours of 9 a.m. to 11 a.m. in the main area of the ED. After 11 a.m., recruitment took

place from within the section of this ED titled the Rapid Care Unit (RCU). This area is

involved in the care of non-urgent patients that present to the ED and is staffed by a

single RN and ED technician as well as an NP or PA. Patients are seen in this separate

area of the ED after being deemed non-urgent by the triage RN. This area was created by

this facility in response to an increase of lower acuity patients presenting to the ED; its

aim is to free rooms in the main ED for higher acuity patients. The secure drop box was

made available to participants until 9:30 p.m. for convenience and allowance of protocol

review. This time frame was chosen, as it is considered one of the peak hours of

operation in this ED. The protocol was provided after complete discharge from the ED in

efforts to avoid patient sentiment involving discrimination or singling out for project

participation. Furthermore, post-discharge intervention was chosen in efforts to avoid

patient’s viewing participation as an impediment or delay to care.

Outcomes Measures

Each objective of this four-phase project was evaluated following the procedures

in Phases One through Four. The measure of meeting these objectives was defined for

each objective:

1. To present a draft of the D.A.N.C.E. educational tool, constructed from

national evidence-based data on services available at non-urgent care sites and

the emergency department to a consensus panel for review of face validity

2. To initiate a pilot project of the D.A.N.C.E. protocol over a 1-day period at a

local hospital to evaluate the protocol’s effectiveness

3. To describe the D.A.N.C.E. protocol’s influence on the patient’s future

decision to use an alternative care site over the ED for the same or similar

complaint by evaluating the post intervention survey cards completed by the

patients. The survey cards will be reviewed and analyzed to determine the

feasibly of such a protocol implementation in the future and possibly on a

system-wide level. The Results section of this final project explains this

concept further.

Proposed Budget

The cost of this project was $453.58. The cost was allotted to the printing cost of

50 copies of the three-page protocol including the cover letter, protocol, and survey card

in both languages (100 copies total) as well as the cost of the locked drop box. Translator

and editing services were also aggregated to this total.

Summary

This section discussed the methodologies of the project. As the United States

population continues to grow, so will the strain on our health care resources if a

fundamental redesign of our nation’s health care provisions is not addressed

appropriately. An advent to the expanding population is the rise in scientific inquiry to

determine innovative methods to improve health care. Alternative care sites may

potentiate this impetus as more tactful utilization of health care resources is part of the

solution to alleviate ED misuse. In order for non-urgent care to be sought at a reciprocal

site, patients must be made aware of the valuable resources these clinics and centers offer

and when to use them.

SECTION FOUR:

RESULTS AND DISCUSSIONS

Introduction

The aim of this project was to increase awareness among lower acuity patients

presenting to the ED with non-urgent complaints of the care and services provided by

alternative care sites. The D.A.N.C.E. educational protocol, constructed from national

evidence-based data on services available at non-urgent care sites and the emergency

department, was presented to a consensus panel for review of face validity. With the use

of the D.A.N.C.E. protocol, lower acuity patients (ESI acuity level 4 and/or 5) were

presented with the single-page protocol for review and a post intervention survey card

examining the protocol’s influence on future decisions. The setting was a local South

Florida ED in Miami Dade County, FL, and surveys were collected on a single day

between the hours of 9 a.m. to 9 p.m. Results from the study were analyzed by the DNP

student, with percentage calculations performed in and displayed graphically with the use

of Excel spreadsheet.

Findings

Overall, project objectives were met at the competition of the project. While the

findings were not expected, project aims were performed and delivered as intended.

Thankfully, there were no adverse events associated with this project. The findings will

be discussed through each phase of the project.

Phase One: The Protocol

The primary objective of Phase One was to construct an educational protocol

from national evidence-based data on the scope of care available at alternative care sites

and the ED. The single-page educational protocol listed common illness and conditions

that could be treated at alternative care sites on the left side of the paper and reasons to

call 9-1-1 or seek care in the ED on the right. The protocol also included visual aids such

as small icons depicting each of the common illness and conditions listed for the

alternative care site side. A short narrative was included at the bottom section of the page

depicting ED flow based on severity and the comparable benefits these alternative sites

offer. With information obtained from reputable sources such as: Agency for Healthcare

Research and Quality (AHRQ), National Institutes of Health (NIH), Centers for Disease

Control and Prevention (CDC), major United States insurance companies, consumer

reports, health care analyst writers, and similar scholarly works on the topic, the objective

to construction the D.A.N.C.E. protocol was accomplished.

Phase Two: The Consensus Panel

The objective in this phase was to present the protocol to a staff consensus panel

for review and face validity. After initiating the recruitment process with flyers in the ED

employee areas, the final panel consisted of five nursing professionals. This consensus

panel consisted of: one RN with a Master’s of Science in nursing (MSN) in education and

9 years of ED nursing experience; one RN with an MSN and 8 years of ED nursing

experience; one RN with a Bachelor’s of Science in Nursing (BSN) but 10 years of ED

nursing experience; one RN with a BSN and enrolled in her third year of a Doctorate of

Nursing Practice (DNP) program but with 7 years of ED nursing experience; and one NP

with a Doctor of Philosophy (PhD) in Nursing and 10 years total of nursing experience

with 6 years of ED nursing experience and 4 years of UCC experience. The all RN staff

consensus panel is represented in the table below (Table 2). The protocol was overall

accepted by the group, and face validity was established fairly quickly. After further

review, the panel agreed that the protocol maybe too wordy, and this may deter

participants from reading it entirely. Other suggestions from the panel included that more

distinguishing images of what are considered an emergency could potentially help drive

the protocol’s point more effectively. The panel also suggested that a future version

include this health system’s alternative care site addresses on the protocol so the patient

can have these readily available. Ultimately, face validity was established by the staff

consensus panel, meeting the objective for this phase. It is interesting to note that there

was a unanimous agreement in that the project had merit and boundless potential for

future investigations into health care changes after the establishment of face validity.

Table 1 The Consensus Panel

Phase Three: D.A.N.C.E Protocol Pilot

The main objective of this phase was to initiate a pilot test of the D.A.N.C.E.

protocol over a 1-day period at a local hospital to evaluate the effectiveness of the

protocol. Regular hospital services were provided throughout the patient’s emergency

department visit by the ED staff prior to participant involvement in the project. At the

request of the selected facility, the DNP student scripted a brief narrative for the primary

ED RN and the ED Patient Care Supervisor to follow if their involvement was needed in

the study. This script, brief in length and available in English and Spanish, only

introduced the DNP student and assessed the patient’s initial willingness to participate in

the project. The RN assigned to the RCU area on the day of the project utilized the

scripting with no difficulties. Overall, there was a receptive and cooperative welcoming

of the protocol and survey collection process from the ED and RCU staff.

After discharge from the RCU area, participants were recruited as they exited

back into the ED waiting area. Each potential participant was asked to participate and

informed that he or she could complete the survey anywhere on the hospital premises and

return the card to the drop box in the ED waiting room area. All patients completed the

survey in the ED waiting room area. On average, each participant took approximately 5

to 10 minutes reviewing the protocol and completing the survey card. All participants

were admittedly open to the prospect of the doctoral work being conducted, and several

comments were volunteered by participants during the project to the DNP student. These

comments and their implications are discussed in further detail in the section titled

Patient Observations of this final project. A total of 23 surveys were collected by the end

of the day. Of these 23 surveys, only 22 were included in the final analysis due to

multiple answers being selected in question one on one survey collected. Exceeding the

sample size of a minimum of 20 participants, the main objective of this phase was met.

The following table depicts the final tally of surveys completed:

Table 2. D.A.N.C.E. Protocol Pilot Results

Care Site Options D.A.N.C.E. Protocol Influence Yes No Emergency Room 11 1 Urgent Care/Retail Clinic 8 0 Primary Care Provider 1 1 20 2

Phase Four: Data Analysis

The primary objective of this phase was to analyze the D.A.N.C.E. protocol’s

survey results and describe its influence on future care site decisions made by the

patients. This objective was met by use of percentage calculations in an Excel

spreadsheet to analyze the survey results. After evaluating the post intervention survey

cards, the protocol was found to have significant influence over a future care site choice;

however, the care site itself seemed to remain at the discretion of the patient. Of the 22

completed surveys returned, 55% (12) selected the ED, 36% (8) selected RC/UCC, and

9% (2) selected their PCP as the future care site for the same or similar complaint as

reported on the day of the pilot project. The majority of the surveys showed that 91%

(20) of the participants found the protocol influential, and 9% (2) selected the protocol

had no influence on their future care site decision. Results from each question were

calculated separately and are represented graphically below:

Figure 5. D.A.N.C.E. protocol pilot survey results: Question #1.

Figure 6. D.A.N.C.E. protocol pilot survey results: Question #2.

Where would you seek care next time you have the same or similar health care

problem?

Emergency Room

Urgent Care/ Retail Clinic

Primary Care Provider 55% 36%

Did the D.A.N.C.E Protocol help you make your choice?

Influenced by D.A.N.C.E Protocol

Not Influeced by D.A.N.C.E Protocol91%

Discussion

It was expected that the D.A.N.C.E. protocol would influence patients to choose

an alternative care site over the ED in the future for the same or similar non-urgent

complaint. Results of this project show that future care site choice incorporates more

than a knowledge deficit of available care sites. Despite more than half of the patients

selecting the ED as their next potential source of non-urgent care, a post discharge

intervention did seem to influence future care site selection. Of the patients surveyed in

this project, it stands to reason that 45% of these patients can be and are willing to be

treated for their non-urgent complaints elsewhere. Applying these results to a larger

scale, an argument can be made that of an estimated 1,000 patients arriving to an ED with

a non-urgent complaint, 450 of those patients could be treated at an alternative care site.

Moreover, 910 of those 1,000 patients would choose the alternative care site having been

influenced by the protocol. This finding is especially significant when savings on health

care resources and finances are factored into these calculations as well.

These results effectively answer the project questions. Recall from Section One,

these project questions were: Will the D.A.N.C.E. protocol affect patient health-seeking

behavior when determining appropriate care sites for non-urgent, lower acuity health

complains? and What is the likelihood the D.A.N.C.E. protocol can be an effective

educational protocol on a system wide level to reduce the misuse and overcrowding of

the Emergency Department by non-urgent patients?. Based on the survey results, a post

discharge intervention did seem to influence future care site selection however it appears

that modification of the information on the protocol may be required in order for an

appropriate and reciprocal site to be chosen and better address the needs of these patients.

While a future system-wide protocol does appear to be promising, there were several

factors and significant limitations that presented during this project that require further

examination in order to determine the feasibly of implementing such a protocol on a

system-wide level. Among these inquiries, a financial analysis of the expenditures of the

project date on the treatment of these non-urgent patients in the ED may be useful as well

as investigation of annual costs for the treatment of these patients at this particular

hospital.

Strengths and Limitations of the Project

Despite the limitations identified, the project findings did reinforce and build on

existing investigation found on non-urgent use and misuse of the ED. The main strengths

and limitations found are addressed below.

Sample Size

At the request of the selected facility, the minimum sample size was kept at 20

participants, but a maximum sample size of 50 participants was added to the project. Due

to time constraints in executing this project, a small sample size was achieved. It was

recognized by the DNP student that the sample size, although sufficient for a pilot

project, may have benefited from reaching the larger sample target. Although the final

sample size was found to be reproducible and applicable on larger scale, a small sample

size may not serve as a total representation of these non-urgent patients and impacts the

ability to generalize these findings to other EDs, populations, and health care systems.

Moreover, as in any survey, results are subject to sampling and non-sampling errors.

Non-sampling errors include reporting and processing errors as well as biases due to

nonresponse and incomplete response. Only 22 of the 23 surveys returned were

completed correctly, so the already small sample size results were affected pointedly

even by the one error. Another significant limitation was that despite a growing volume

of patients, this facility, being the newest of the hospitals within this health care system,

has yet to meet a consistently large minimum number of patients seen daily through the

ED as its counterparts have. The reported total number of patients seen this day was 217,

per the management team. Therefore, the sample size reached during the project

represents only 10% of the population seen in the ED that day. Thus, an assertive sample

size was difficult to predict. However, because of the unpredictability in patient volume

at this facility, there is weakened defense against the sample size obtained not being

sufficient to generalize.

Project Setting

The facility in this project is the current place of employment for the DNP

student. This facility was chosen for its convenience as well as for the organization’s

renowned enthusiasm to participate in and improve nursing research efforts. This interest

in nursing inquiry paired with the system’s backing for advancement of the nursing

profession, has resulted in the overall improvement of patient care for this health care

system in the four years of its existence. With the facility being the newest hospital to be

built in South Florida for over 30 years and the youngest of the hospitals within this

health care system, its appeal to the public maybe clouded by its innovation instead of its

services and capacities. Additionally, this health care system is partnered with a

performance improvement company that focuses on the overall patient experience and

satisfaction with care. As a result, customer service plays a large role in delivery of care

within this health care system, as patient satisfaction scores dictate certain allocations of

funds for the staff and department. While ideal for the patients, once again, the facility’s

organization and novelty may have created a bias in the patients’ decisions on where to

seek care.

Another limitation realized was the established RCU area in this ED from 11 a.m.

to 11 p.m. Due to the growing number of non-urgent patients presenting to this ED over

the 4 years it has been open, this area was created approximately 2 years ago in effort to

decompress an overcrowded main ED. Although this area served as an advantage to the

project for lower acuity patient selection, the established rapid care area seemed to have

gained fame among the lower acuity patients, as many were aware that they could be seen

faster in this ED because of this area. With patients being unable to differentiate the

services being provided by the RCU as services that could be received at alternative care

sites, conducting the protocol pilot in this area may have stirred confusion among

participants. Finally, the health care system selected currently operates a number of

UCCs throughout Miami Dade County, and although not explicitly included, directly

mentioned or favored in this project, these UCCs were often referred to by patients as an

interchangeable name for alternative care sites. This instinctive substitution of the word

presented an additional bias to the project for participants.

The D.A.N.C.E. Protocol

A strength in the project was that the protocol itself was generally well accepted,

visually appealing, and easy to navigate. The survey card’s succinctness was also a

strength as patient engagement was easier to maintain with a brief and simple survey. The

consensus panel, however, did note some limitations of the protocol. One of these

limitations was that the narrative portion located at the bottom section of the protocol

may have been visually daunting for some participants, especially when health care

literacy was considered. It was also found that the icons depicting common alternative

care site conditions may not have conveyed the difference in severity. The panel

recommended visual representation for the ED portion of the protocol, within reason and

censorship, to better distinguish the differences in severity. Interestingly, both the panel

and some patients recommended that the addresses to local alternative care site be

included on the protocol. Although the protocol and survey card were well received by

the panel and patients alike, the results of the survey lead the DNP student to believe that

there was a disconnect between the participants recognizing the relationship between the

two questions on the survey card. This conclusion was drawn after multiple observations

were volunteered by participants during the pilot project.

A final limitation of the protocol was the limited data gathered. With no

demographic data collected, such as age, sex, ethnicity or racial group, level of education,

socioeconomic status, generational or immigrant status and/or disability status, there was

no real method of truly defining this population. Similarly useful would have been topic-

specific characteristics like achievement level or retainment level of information in this

educational intervention. These characteristics can serve as important elements to

understand of the nature of the sample and the degree to which the results can be

generalized to other EDs, populations, and health care systems. Collection and

evaluation of these characteristics could also prove to be useful in meta-analytic studies

that could incorporate this project’s results.

Patient Observations

Bonus insight from the project was found in patient observations while interacting

with them after their completion of the survey. Many were intrigued by the scholarly

work and asked questions about the function and role of an NP and, moreover, a DNP.

Many recognized and applauded the aim of the project stating that the protocol was

seemingly influential on future use; however, many of those same patients recognized

that their complaints were not life-threating but would still choose this ED over an

alternative care site. Other comments showcased that an educational deficit had less to

do with care site choice and more to do with personal preference and convenience.

Several patients commented that they would gladly fill out a survey because of their

adoration for this facility and that they would always return to it for care. Others

commented on how they do not like the customer service at the local UCCs and prefer

this ED. Other participants mentioned that they prefer the hospital because is close to

their home. One patient commented that he had not been in this country for more than 16

days, did not know how the health care system works, and did not know of anywhere else

to go for health care treatment. Another participant refused to participate as he simply

wanted to leave in order to fill the prescriptions as soon as possible. Interestingly, a

recurrent comment made by several participants was their lack of a PCP as well as a lack

of trust in their established PCP. Anecdotal evidence suggests that lack of insurance or

changes in insurance is responsible for this factor however; more investigation would

have to take place to determine this. Finally, multiple patients commented that this ED is

fast compared to the other EDs in this health care system, and the staff is always pleasant.

It is important to note that no patient observations were documented in any form during

the project pilot. These observations provided insight on several limitations to project

regarding personal preference when choosing care sites. They also point to factors that

drive decisions to seek care that are multifaceted and fall beyond an educational deficit.

Implications of the Project

The consistent delivery of appropriate patient care requires a fundamental

reordering of priorities and redesign in the delivery of health care in order to be more

efficient. Nursing as a practice profession requires both practice experts and nurse

scientists to expand the scientific basis for patient care. Doctoral education in nursing is

designed to prepare nurses for the highest level of leadership in practice and scientific

inquiry (AACN, 2006). DNP projects focus heavily on practice that is innovative and

evidence-based, reflecting the application of credible research findings. This project

proved to be significant in the areas of nursing, specifically the DNP Essentials, as well

as in practice, health care delivery, health care outcomes, and health care policy.

DNP Essentials

Doctoral education, whether practice or research, is distinguished by the

completion of a specific project that demonstrates synthesis of the student’s work and

lays the groundwork for future scholarship (AACN, 2006). The completion of this

change initiative, presented as a pilot project, embodies this expectation. Major

advantages of the DNP-prepared nurse include the enhanced focus on providing requisite

specialty knowledge and care for patients across the spectrum and playing a pivotal role

in the larger health care system. While all doctoral nursing graduates demonstrate the

competencies delineated in DNP Essentials I through VIII, further DNP preparation falls

into two general categories: roles that specialize as an advanced practice nurse with a

focus on care of individuals and roles that specialize in practice at an aggregate, systems,

or organizational level (AACN, 2006). As previously discussed in Section One, the DNP

Essentials document outlines and defines the eight foundational Essentials and provides

some introductory comments on specialty competencies/content. Examining the results,

it is evident that the Essentials are embedded throughout the project.

Essential I: Scientific Underpinnings for Practice is apparent in project’s

approach to scientific inquiry and in the topic being examined. By use of scientific

theories and procedures, the project successfully examines a population’s health-seeking

behaviors and knowledge deficits in awareness of the role of alternative care sites for

non-urgent healthcare complaints. The project showcases the development and

evaluation of new practice approaches based on nursing theories as well as theories from

other disciplines and in doing so successfully incorporates this essential.

The expectations of Essential II: Organizational and Systems Leadership for

Quality Improvement and Systems Thinking, were met through the project aim, which

was implementing an educational protocol that enhances public’s knowledge of available

alternative sites more appropriate for care. The project effectively develops and

evaluates a care delivery approach to meet the current and future needs of a population

based on scientific findings in nursing, as well as organizational science. The results of

this project can be further explored to more firmly address ethical, financial and quality

improvement issues surrounding the improper use of the ED.

With the focus of Essential III: Clinical Scholarship and Analytical Methods for

Evidence-Based Practice being on the translation of new science, its application, and

evaluation, the project affirmatively generates evidence through practice to guide

improvements in practice and outcomes of care. The implementation of this project and

its results showcase the DNP student’s ability to use analytic methods to critically

appraise existing literature on a current issue in healthcare. In conducting this project, the

DNP student applied relevant findings to develop a potential practice protocol that could

ultimately improve practice and care.

Under Essential IV: Information Systems/Technology and Patient Care

Technology for the Improvement and Transformation of Health Care, the project allowed

for the DNP student to design, use, and evaluate a protocol that serves to assess consumer

use of health care information and health seeking behaviors. Through this project,

analysis and identification of significant elements involved in patient’s health-seeking

behaviors were examined and the results hold potential for further study on the use of

patient care technology and how it relates to their healthcare decisions.

Perhaps most evident in the project, Essential V: Health Care Policy for

Advocacy in Health Care was demonstrated as policy development and creating a health

care system that meets the needs of its constituents was central to the project. This is

evident by the abundant potential the results yield that can be used to educate others,

including policy makers, regarding nursing, health policy, patient care outcomes, and

related issues from the perspective of consumers in health care.

Essential VI: Interprofessional Collaboration for Improving Patient and

Population Health Outcomes stresses the importance of effective communication and

collaborative skills in the development and implementation of practice models, peer

review, practice guidelines, health policy, standards of care, and/or other scholarly

products (AACN, 2006). The project showcased a collegiality among a community of

highly skilled and knowledgeable individuals from multiple professions of the health care

system in attempts to better serve a population and utilize health care resources as

effectively as possible.

Under Essential VII: Clinical Prevention and Population Health for Improving

the Nation’s Health, the DNP is expected to evaluate care delivery models and/or

strategies using concepts related to community, environment and occupational health, and

cultural and socioeconomic dimensions of health (AACN, 2006). The project serves to

identify and examine health seeking behaviors and its results provide an array of possible

further exploration of these choices. The project embraces the community and adds to

the current body of knowledge supporting strategies aimed at improving all dimensions

of health. Overall the project’s aim points to improving the general health of the nation

overtime with the implementation of a refined system wide protocol in the future.

Lastly, Essential VIII Advanced Nursing Practice was evident throughout the

entirety of the project. Focused on the already established strengths of the NP, the

project showcases the ability of the DNP student to demonstrate advanced levels of

clinical judgment, systems thinking, and accountability in designing, delivering, and

evaluating evidence-based care to improve patient outcomes. The DNP student’s

conceptual and analytical skills in evaluating the links between practice, organizational,

population, fiscal, and policy issues is fundamental to the project; these skills are the

essence of advanced nursing practice. Overall, this project serves as an example of

advanced understanding in a group of individuals as well as platform for future practice

reform and system change. The project also supports the concept of NPs functioning as

assets to our shifting health care system as they enter greater roles as DNPs.

Implications for Practice

The theme that links scholarly experiences is the use of evidence to improve

either practice or patient outcomes (AACN, 2006). As our health care system shifts to

accommodate the needs of a rapidly growing nation and different areas of health care

accept NPs as key stakeholders in the provision of quality care, alternative care sites

present a promising opportunity for NPs. Well suited to care for the majority of patients

with non-urgent problems, the project extends and reinforces the compelling evidence to

suggest that increasing the use of NPs in other realms of the health care system may be

advantageous and profitable. With the expansion of advance nursing education to a

doctoral level, DNP-prepared nurses demonstrate a progressive and profound knowledge

in practice that serves as an impressive asset in translating and redefining advance

nursing practice.

Implications for Health Care Delivery

This project serves as a novel and targeted intervention necessary in the face of a

much-needed redesign in the delivery of health care. With the project results indicating

that a post-discharge intervention can influence an individual’s future care site decision,

the delivery of health care can focus on more tactful utilization of resources through

similar protocols. Additional study must first be conducted in order to properly address

the multifactorial causes of ED misuse. With the advent of NPs working and flourishing

in many of these alternative care sites, the project served as a practical starting point for

NPs to lead scientific actions geared at addressing this population’s health care needs and

improving the overall delivery of health care.

Implication for Health Care Outcomes

The results of this study potentially prove that educational deficit is only a partial

motive in selecting the ED for non-urgent care. The patient’s ability to self-triage to the

most appropriate care site fundamentally impacts health care outcomes. The project

validates this and has determined that interventions require additional modification.

Tailoring interventions to the individual is among one of the many advantages the NP’s

astute clinical judgment and evaluation. This advanced understanding of individual

needs as they relate to the community assists in improving health care outcomes and

affects the overall health care system. The implementation of a discharge educational

protocol has apparent influence over individuals’ care site choices. Applying this

finding, NPs should design and utilize such protocols when tailoring interventions geared

toward care non-urgent complains. Implementing such a protocol can prompt patients to

seek care accordingly based on their level of acuity and resources required to care for

them. The proper application of provision will affect the dynamics of health care, which

will, in turn, positively affect health care outcomes.

Implications for Health Care Policy

Health care policy—whether it is created through governmental actions,

institutional decision making, or organizational standards—creates a framework that can

facilitate or impede the delivery of health care services or the ability of the provider to

engage in practice to address health care needs (AACN, 2006). This project

demonstrates engagement in the process of policy development by creating a change

initiative to meet the demands of the health care system and the needs of its constituents.

From the inception to completion of this project, the DNP student servers as a leader in

the practice arena and provides a critical interface between practice, translation of

research, and policy. Evolving in health care as a key element to reform, NPs are rapidly

being placed at the political forefront to policy changes that embrace better care options

for patients. Involvement in this project provides the DNP student with essential

competencies to assume a leadership role in the development of health policy as well as

opportunities to contrast the major contextual factors and policy triggers that influence

health policy-making at the various levels.

Suggestions for Future Research

This project’s findings demonstrated the potential influence of a post discharge

protocol on future care site choices by non-urgent patients in the ED. Despite more than

half of the patients selecting the ED as their next potential source of non-urgent care, the

project results supplied an abundance of strengths and limitations to be considered for

future adaptations to patient’s needs. Future study should examine the use of an edited

protocol validated by experts in the field of emergency care, urgent care and retail clinic

as well as primary care offices. Inquiry into primary care and reasons for lack of a steady

provider would also be useful as it may lead to further changes throughout the healthcare

field and open other subjects to scientific investigation. A larger sample size may be

beneficial as well as collecting data at more than one facility for an extended period of

time. An extended collection time frame may provide for a more robust sample and

analysis of results. Examining more than one facility, whether from the same healthcare

system or varying, could provide rich data on this topic as well as identify other barriers

and possible solutions to the problem of ED misuse. Moreover, future studies should

exam hospital EDs with and without already established RCUs to reduce bias and further

exam the presenting population and their impact in the ED. A useful adaptation to this

project could be surveying those patients who present to UCCs and RCs with non-urgent

complaints and examining their reasons for choosing an appropriate site. A comparison

between appropriate use and misuse of these care sites may prove to be useful in better

identifying key factors that could lead patients to choose reciprocal sites for their

complaints. Additionally, the survey content should be expanded to collect more

information that would be useful in understanding the nature of the target population and

the degree to which the results can be generalized to other EDs, UCCs, RCs, primary care

settings and populations. Lastly, supplementary study into NP roles and the public’s

perspective of NPs, more specifically DNPs, would serves as solid groundwork for

further defense of their use in alternative care sites and on a system-wide level.

Summary

The use of the ED for non-urgent care continues to place a strain on our health

care system. Presenting a single solution for a multidimensional topic oversimplifies a

complex problem. With the expansion of advance nursing education and practice, the

DNP-prepared NP holds infinite potential in delivering innovative and tangible solutions.

Increasing patients’ awareness of available alternative care sites, such as retail clinics and

urgent care centers, over the use of the emergency department for a non-urgent complaint

can help identify needed changes in our health care system in order to better serve the

community. The project serves as a foundation for future scholarly inquiry and practice.

Further development and analysis of this project and its findings can serve as a

framework in establishing a system-wide change initiative to address the non-urgent use

of the emergency department and the proper use of alternative care sites.

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APPENDIX A

BARRY UNIVERSITY IRB APPROVAL LETTER

APPENDIX B

STUDY SITE IRB APPROVAL LETTER

APPENDIX C

COVER LETTER – THE CONSENSUS PANEL

BARRY UNIVERSITY

COVER LETER

Dear Project Participant:

Your participation in an educational research project is requested. The title of the project is Discharge Alternative Non-Urgent Care Education (D.A.N.C.E) Protocol Addressing Emergency Department Misuse. The project is being conducted by Samantha C. Leon, BSN, RN, CEN, a student in the Doctorate of Nursing Practice program in the College of Nursing and Health Sciences at Barry University, and is seeking information that will be useful in the field of Nursing. The aims of the project are to increase awareness of and educate patients on emergency room use and alternative care sites. In accordance with these aims, the following procedures will be used: you will be assigned as a member on a panel of experts who will be presented with the D.A.N.C.E protocol and asked to determine the face-validity of the protocol and comment card.

We anticipate the number of participants for this panel to be 5 employees in the medical and/or nursing field with a Master’s Degree or higher and/or at least 5 years of emergency room or urgent care experience. Your participation time will not exceed 4 hours.

Participation is strictly voluntary and should you decline to participate, there will be no adverse effects on your employment at this facility. There is no direct benefit or compensation for participating in the educational research project. Participants may gain awareness of patient’s health seeking behaviors.

This is a minimal risk project. There may be some anxiety about establishing face-validity of a tool that will be distributed to patients for educational purposes. This risk may be minimized through voluntary involvement and face-to-face discussion on material allowing for open discussion that will not harm subjects.

Information you provide will be kept confidential, that is, no names or other identifiers will be collected on any of the instruments used. Any discussion or revisions made to the protocol will be maintained by the DNP student and the research team only.

If you have any questions or concerns regarding the educational project, you may contact me, Samantha C. Leon BSN, RN, CEN at (786) 223- 5922, my supervisor, Corvette Yacoob, DNP, MSN, BC at (305) 899- 3100, or the Institutional Review Board point of contact, Barbara Cook, at (305) 899-3020 or the BHSF Institutional Review Board point of contact, Maria Arnold at (786) 527-9282.

Thank you for your participation.

Sincerely,

APPENDIX D

COVER LETTER – PATIENT PARTICIPANTS- ENGLISH AND SPANISH

VERSION

BARRY UNIVERSITY

COVER LETER

Dear Project Participant:

You are being asked to participate in an educational research project. The title of this project is Discharge Alternative Non-Urgent Care Education (D.A.N.C.E) Protocol Addressing Emergency Department Misuse. The project is being conducted by Samantha C. Leon, BSN, RN, CEN, a student in the Doctorate of Nursing Practice program in the College of Nursing and Health Sciences at Barry University. This project is collecting information that will be useful in the field of Nursing. The goal of this project is to educate patients on the proper use of emergency rooms and alternative care sites. We expect the number of participants to be about 20.

If you decide to join in this educational research project, you will be asked to read the D.A.N.C.E protocol and complete a brief two question comment card. Your participation time should not take longer than 10 minutes.

Participation is strictly voluntary and if you decide not to participate, there will be no harmful effects on your healthcare or any change in services provided at this facility.

There is no direct benefit or compensation for being involved in this educational project but you may improve your awareness of alternate care sites and emergency rooms. There are minimal risks in this project that may include some anxiety about completing the protocol. This risk may be reduced by your involvement being completely voluntary and your identity being kept anonymous. Although it is highly unlikely to happen, if you experience anxiety related to being in this project, you are welcome leave the project and use the emergency department or a care site of your choice to treat this anxiety.

Information you provide will be kept confidential, that is, no names or other identifiers will be collected on any parts of the information collected. You will place your comment card in an assigned locked drop box when you have finished with the protocol. The cards will be kept by the DNP student and the research team only.

If you have any questions or concerns about the educational project, you can contact me, Samantha C. Leon BSN, RN, CEN at (786) 223- 5922, my supervisor, Corvette Yacoob, DNP, MSN, BC at (305) 899-3100, or the Barry University Institutional Review Board point of contact, Barbara Cook, at (305) 899-3020, or the BHSF Institutional Review Board point of contact, Maria Arnold at (786) 527-9282.

Thank you for your participation.

Sincerely,

BARRY UNIVERSITY

PORTADA

Estimado/a participante del proyecto:

Se le invita a participar en un proyecto educativo de investigación. El título de este proyecto es Protocolo de Educación sobre Cuidados No Urgentes Alternativos al Alta (D.A.N.C.E.). Cómo abordar el mal uso del Departamento de Emergencias. El proyecto está a cargo de Samantha C. Leon, BSN, RN, CEN, estudiante del programa de Doctorado sobre Prácticas de Enfermería en el Colegio de Enfermería y Ciencias Médicas de Barry University. Este proyecto recopila información que será útil en el campo de la Enfermería. El objetivo de este proyecto es educar a los pacientes en el correcto uso de las salas de emergencias y de las áreas de cuidado alternativas. Esperamos un número de participantes de aproximadamente 20 personas.

Si decide unirse a este proyecto educativo de investigación, se le pedirá que lea el protocolo D.A.N.C.E. y complete una breve tarjeta de comentarios de dos preguntas. Su tiempo de participación no será de más de 10 minutos.

La participación es estrictamente voluntaria y si decide no participar, no se producirá ninguna consecuencia negativa en su atención médica ni ningún cambio en los servicios prestados en estas instalaciones.

No habrá ningún beneficio directo o compensación relacionado con su participación en este proyecto educativo pero puede mejorar sus conocimientos sobre las áreas de cuidado alternativas y las salas de emergencias. Los riesgos de este proyecto son mínimos, los cuales pueden incluir cierta ansiedad al completar esta herramienta. Este riesgo se puede reducir ya que su participación es completamente voluntaria y su identidad se mantiene anónima. Aunque es muy poco probable que ocurra, si usted experimenta ansiedad relacionada con su participación en este proyecto, usted esta bienvenido(a) a abandonar el proyecto y utilizar el servicio del departamento de emergencias o cualquier otro sitio de atención médica de su elección para el tratamiento de esta ansiedad.

La información que proporcione tendrá un carácter confidencial, es decir, no se guardarán ni nombres ni ningún otro dato identificativo como parte de ninguna de las informaciones que se recopilen. Usted introducirá su tarjeta de comentarios en una caja cerrada asignada una vez haya acabado de completar la herramienta. Únicamente los estudiantes de DNP y el equipo de investigación guardarán las tarjetas.

Si tiene alguna pregunta o duda sobre el proyecto educativo puede ponerse en contacto conmigo, Samantha C. Leon, BSN, RN, CEN, en el (786) 223- 5922, mi supervisora, Corvette Yacoob, DNP, MSN, BC en el (305) 899-3100, o punto de contacto de la Junta de Revisión Institucional de Barry University, Barbara Cook, en el (305) 899-3020, o punto de contacto de la Junta de Revisión Institucional de BHSF, Maria Arnold en el (786) 527-9282.

Gracias por su participación.

Atentamente,

APPENDIX E

PROTOCOL AND SURVEY CARD – ENGLISH AND SPANISH VERSION

Retail Clinics

Located inside drugstores and supermarkets, these clinics treat a limited

range of common illnesses and also provide some preventive services, such as

vaccinations and prescription refills.

Emergency rooms tend to treat the patients with the most serious conditions first. So unless it’s a true emergency, you will likely get quicker medical care at

other care settings such as urgent care centers or retail clinics.

Use these locations when you need medical care quickly, but can’t see your regular health care provider. They are usually staffed with doctors, nurses,

physician assistants and nurse practitioners.

Get quality care quicker and pay much less than you would in the emergency department. Hours of operations may vary but they are usually open

nights, weekends and holidays and do not require appointments.

Date: _______ Time:_______

D.A.N.C.E Protocol Survey Card

Where would you seek care next time you have the same or similar health care problem? Please check ONE care site from the list below:

The Emergency Room Urgent Care Center/ Retail Clinic

Primary Care Provider

Did the D.A.N.C.E. Protocol help you make your choice above? Please circle ONE.

YES NO

When you have finished with your survey card, please fold and place the card in the locked drop box located at the front desk of the Emergency Room waiting room area.

Thank you.

Las salas de emergencia tratan primero a los pacientes con las condiciones más graves. Así que a menos quese se trate de una verdadera emergencia, es

probable que reciba una atención más rápida en otro sitio de atención médica, como en centros de atención de urgencia o en clínicas minoristas.

Utilice estos establecimientos, donde disponible, cuando necesite una atención médica rápidamente pero no pueda visitar a su proveedor de atención

médica habitual. En ellos suele haber personal como médicos, enfermeros, asistentes médicos y enfermeros profesionales.

Consiga una atención de calidad más rápida y pague mucho menos de lo que haría en el departamento de emergencias. Los horarios de operación pueden variar, pero son generalmente abierto por la noche, los fines de semana y los

días festivos, y no requieren citas previas.

Clínicas Minoristas

Ubicadas en las farmacias o en los supermercados, estas clínicas tratan una

gama limitada de enfermedades comunes y también prestan algunos servicios

preventivos, como vacunas o reposiciones de medicamentos con receta.

Fecha: _______ Hora:_______

D.A.N.C.E Protocolo Tarjeta de Encuesta

¿Dónde buscara atención médica la próxima vez que tenga el mismo problema de salud? Por favor seleccione UNO de los siguiente opciones:

La sala de emergencia Centro de atención de urgencia/ clínicas minoristas

Médico de cabecera

¿El protocolo ha sido de ayuda en la selección de la respuesta anterior? Seleccione UNO.

SI NO

Cuando haya terminado con su tarjeta de encuesta, por favor doblar y colcar la tarjeta en el buzón situado en la recepción en la sala de espera de la sala de emergencia.

Gracias.

APPENDIX F

TRANSLATING SERVICE CERTIFICATE

APPENDIX G

THE CONSENSUS PANEL RECRUITMENT FLYER

APPENDIX H

PATIENT PARTICIPANT RECRUITMENT FLYER- ENGLISH AND SPAISH

VERSION

VITA

Samantha C. Leon, BSN, RN, CEN

EDUCATION

Barry University, Miami Shores, FL Doctorate of Nursing Practice in Family Practice 2015 Post Baccalaureate to Doctorate Program

Florida International University, Miami, FL Bachelors in Science in Nursing 2011 Honors: Dean’s List

Miami Dade College, Miami, FL Associate in Science in Nursing 2009 Miami Dade College, Miami, FL 2007 Associate in Arts Honors: Associate degree awarded with Honors Hialeah Senior High School, Hialeah, FL 2005 High School Diploma Honors: Superintendent’s Diploma of Distinction

LICENSES/ CERTIFICATIONS

Registered Nurse License# 9295674 (State of Florida Department of Health) Certified Emergency Nurse (CEN) # 981106324 (Board of Certification for Emergency Nursing) Trauma Nursing Core Course (TNCC) Verification (Emergency Nurses Association) Air Medical Crew Course (Department of Transportation)

EMPLOYMENT HISTORY

Trinity Air Ambulance International, LLC Emergency Medical Air Transport- Flight Nurse- on call West Kendall Baptist Hospital- Miami, FL Emergency Department- Clinical Staff Nurse/ Charge Nurse Relief- Full-time/ Per Diem

2014- Present 2011- Present

Jackson North Medical Center, North Miami Beach, FL Emergency Department- Clinical Staff Nurse- Full-time

2009-2011

PUBLICATIONS

Lambda Chi Chapter Sigma Theta Tau International “Translating Evidence Into Practice” Poster Presenter West Kendall Baptist Hospital Quality Improvement Research Poster Presenter

2014 2012

Baptist Health South Florida
Scholarly Commons @ Baptist Health South Florida

2015

Discharge Alternative Non-Urgent Care Education (D.A.N.C.E.) Protocol: Addressing Emergency Department Misuse

Samantha Leon

Citation

Microsoft Word - DANCE Protocol to Address ED Misuse- RePRINT July 2015