Although hospitals have been striving to cut the cost, the problem of unscheduled return visits to the Four Corner emergency department has not been completely addressed. Most hospitals in the state of Florida have been concentrating on reducing 30-day readmission with a few activities and intercessions (CDC, 2017). In Florida, it is estimated that 28% of the acute care visit and half of the hospital admissions emerge from the ED per Center of Disease and Control (2017). The authorization of Patient Protection and Affordable Care Act has shown the requirement for coordinating patient care voice in structuring the conveyance of social insurance (Rising et al., 2014). The clarifications for patients to come back to the ED, the plausibility of future return, and the rehashed return can be inspected from the administrative information. Some basic variables have been related with high rates of readmission of patients to the ED. They incorporate low follow up care and language boundary that bars patients from understanding the discharge guidelines. Other variables include old age, non-ambulatory status, and absence of family support.
Patients returning to the emergency department have medical issues that have either failed to go away or improve or have gotten worse. Being an important metric to measure the quality of healthcare, the problem of unscheduled return visits to the emergency department is very important to healthcare or nursing since it provides the healthcare personnel with essential information regarding their performance or health output. A reduction in the rate of return visits to the ED is a marker of high-quality care, while an increase in the rate signifies poor healthcare performance and poor patient outcomes.
Needs Assessment
The daily number or volume of patient received in the Four Corner ED is 72-98, with 35% of these patients returning back to the ED because they did not have instructions for follow up, diagnoses explained, or test results given so they can provide to their primary care provider which has cause the PCP to referred the patient back to ED for further treatments. From that 35%, 12% end up being admitted due to their failure to complete treatment and to the lack of instructions in care after they had been discharged. There are several information gaps which occur due to the unavailability of patient information that were previously collected by a physician. Information gaps were present in around one-third of the visits to the emergency department. These gaps therefore meant that the physicians were not able to provide high quality care to the patients upon their first visit, increasing the chances of an unscheduled return visit to the emergency department (Hayward et al., 2018).
Return visits to the ED is presently a metric of the adequacy of Emergency Department discharge activities. The short returns to the Emergency Department intently gets checked. This metric additionally mirrors the emergency care quality, particularly in situations where patients need hospitalization in their return to the ED. Nonetheless, there are issues to embracing return visits as proportions of value since it is unsure and connected with unpredictable results. ED offers care for a blend of the patient populace. A considerable lot of the patients get released home after treatment without legitimate training or directions. This analysis distinguished the issue in relation with the adult population in Four Corner ED. This investigation recognizes the gap that is to address the challenges that address the difficulties related with ED return visits. ED doctors must realize how to adjust expected hospitalization benefits against costs related with hospital stay and clinical vulnerability when settling on choices concerning patient hospitalization.
Target Population/Community
The Florida state is populous, which makes it an ideal spot to create and execute the intervention. ED information in this state is robust, and it is anything but difficult to follow return visits. The study population is adults in the state of Florida at Four Corner ED. They have differing social foundations, which are primarily dictated by race. Among the social or cultural perspectives that prevail in the American culture can be ordered into whites, African Americans, Hispanic, Asians, Native Americans, and individuals with a mix of two races. The way of life of the objective populace impacts their wellbeing, convictions about ailments and demise, ways of life as well as health advancement. The psychosocial measurements can be ordered into three. Restorative measurements identify with the sort of treatment, the impression of misery, and the clinical course. Mental variables spread the interruption of life objectives and the capability of modifying life plans utilizing coping strategies and emotional stability. The social variables contain the accessibility of help from close partners, for example, companions, family, and colleagues.
The ecological elements for the target population are critical in impacting the nature of their wellbeing and characterizing the fundamental preventive measures. It is evaluated that 23% of all deaths in the world, just as 26% of deaths in kids under the age of 5, are contributed by natural factors that can be prevented (Healthy People 2020, 2019). A portion of the elements that effect the target population incorporate environmental change, exposure to toxins in food, water, air and soil, the contamination of their habitats, and occupational dangers.
The estimated demographic descriptors of the population are 49.1% male and 50.9% female and a median age of 35 for both genders. The population has an average family size of 3.14. The health literacy of the target population varies significantly according to race. For example, 14% of the whites are proficiency in health literacy; the rate literacy rate for Hispanics is 4%, with that of the African American being only 2% (Rikard et al., 2016). The intermediate literacy rate for the three races is 58%, 31%, and 41 %, respectively. The proficiency level implies that individuals can clearly read, write, understand, and solve problems. The intermediate level suggests that people can experience a problem, such as solving problems. Health literacy has direct impacts on health outcomes. Literate people have better outcomes than illiterate ones. In 2016, the life expectancy of the target population was 78.8 (Rikard et al., 2016). Diabetes and stroke caused 21.3 and 37.6% of all deaths in this population. The adults that smoke cigarette makes 15.1% of the entire population. It is further estimated that 21.8% of the people visit the emergency room at least once a year.
Project Purpose/Goal
The purpose of this project is to enable the implementation of a clinical intervention to ensure a reduction in the unscheduled return visits to the emergency department. The proposed intervention is to use the skill of medical attendants in limiting congestion in the ED. These experts are at a perfect situation of reducing the crowding since they are in direct contact with patients. They, subsequently, have specific errands, which are the main drivers of overcrowding. The issue of the patients to comprehend release guidelines can be tended to effectively by medical attendants (Sayah et al., 2014). They handle all the vital techniques of guaranteeing that patients are released from the hospitals, which incorporates all the desk work that should be shown to the patients, their parents, or relatives. Nurses can grasp this opportunity to clarify in detail every one of the inquiries that the patients of guardians pose and, in any event,, asking them questions to guarantee that they understand the data they are given in detail. They can also step up to the plate by ensuring the transportation of the patients from the ED to their destinations, particularly when utilizing the ambulatory services. Nurses are in a better position to partake in clarifying the concerns of the patients as well as their diseases. This intervention can guarantee that patients stick to every one of the mandates of the directives of the care providers to maintain a strategic distance from occurrences arising from wrong medication. It ought to be fortified with legitimate ED training on patient management to prevent future returns. Intensive training can concentrate on improving the role of nurses and incorporating patient engagement. The efforts can guarantee that patients don't go to the ED again and, thus, reducing congestion.
Concepts and Definitions Used in The Project
Some of the main concepts of this project include the problem, which is unscheduled return visits to the emergency department, clinical interventions for the problem, DNP essentials, and advanced nursing practice. The clinical interventions to the problem of unscheduled return visits to the emergency department entail the utilization of the expertise of nurses in minimizing overcrowding in the ED. Nurses are the ideal group of healthcare personnel to reduce congestion in the emergency department because they have a direct connection or interaction with the patients. The DNP Essentials detail all the curricular elements required by DNP programs. Published by the AACN, they address the complex needs that apply to the modern healthcare system. Advanced nursing practice refers to a level of nursing practice which applies the use of experience, comprehensive skills, and knowledge in nursing care.
Relationship of Project to Advanced Nursing Practice
This project has a close connection with Advanced Nursing Practice in that it provides nurses with an opportunity to perform their duties regarding patient discharge and patient care. Nurses assume a key role in transforming care. They can offer nitty gritty clarifications concerning patient discharge to the patients. It will involve the factors that will emerge while the patient will be at home, and how to move toward circumstances that may force them to return to the ED (Rafnsson & Gunnarsdottir, 2010). This will help keep the patients from heading off to the ED once more. Another transient arrangement includes the doctors examining itemized data about the diseases affecting their patients. The doctors can likewise appropriately address worries that their patients may need to lessen their vulnerability. Over the long haul, the doctors and attendants ought to guarantee they make an ED-based care program that will integrate the care teams in the ED. The program should offer more trainings on taking care of patients at the ED including the parts of release to prevent the return cases (Rushforth, 2015). Intensive training should point towards upgrading the nurses and doctor roles that incorporates patient engagement. Developing a discharge checklist that when patients are going to be released from the ED they can check out and sign affirming that providers examined what is on the agenda with the patients before they leave the ED. Doctors can fill in as a contact to different partners who practice by helping them discover the patients fittingly. Doctors ought to likewise work intimately with distinguished drug specialists associated to the hospital, to offer medication counselling. This will cultivate patient self-management and diminish vulnerability from patients (Schrader et al., 2019).
The DNP Essential Aligned with The Project
The project that I’m working on is supported by the essentials I, II and III. Essential I is the scientific underpinnings of this education which reflect the complexity of practice at the doctoral level and the rich heritage that is the conceptual foundation of nursing (AACN, 2006). The educational part of this project will assist healthcare providers to understand the patterning of human behavior in interaction with the environment in normal life events and critical life situations after being discharge from the ED. This will help improve science discipline by understanding the nature and significance of health and health care delivery phenomena. This essential also maintains that the extensive understanding of the nursing theory ensures that advanced nursing practice is built upon a solid foundation. Graduates can therefore integrate nursing practice with organizational or analytical sciences. These science-based concepts can therefore be used to improve the quality of healthcare.
Essential II is the organizational and systems leadership to improve quality and systems thinking meaning that doctoral level knowledge and skills in these areas are consistent with nursing and health care goals to eliminate health disparities and to promote patient safety and excellence in practice (AACN, 2006). This essential helps in transforming research into practice. The project is based on quality improvement by making changes to current discharge policies by providing the best practice to discharge a patient. This will improve patient outcomes after being out of the ED and prevent them from returning because they didn’t understand discharge/after care instructions.
Essential III states scholarship and research are the hallmarks of doctoral education (AACN, 2006). This essential mainly focuses on the complex issues that face modern health. It further focuses on the medical dilemmas that physicians face in patient care, as well as shaping the evidence-based initiatives in the agenda of healthcare. The project uses analytic methods to critically appraise existing policies and other evidence to determine and implement the best practice to discharge a patient from the ED.
Project Alignment with Practice Site Mission and Goals
The practice site for this project is a standalone emergency department in Polk County in the state of Florida. Its mission and some of its goals are closely aligned with the project objectives. With regard to this project, the main missions and goals of the practice site include providing high quality care to the patients and ensuring that they don’t make unscheduled return visits to the emergency department. Another goal is ensuring safe transitions of care, which is essential in promoting better patient experiences, reducing costs, and enhancing the quality of outcomes. Unscheduled return visits to the emergency department reflects inadequate follow-up procedures or discharge practices. The goal of the project site is to eliminate such poor indicators of poor-quality patient care and ensure that the facility enhances its provision of high quality patient care.
Key Stakeholders
The key stakeholders in this project are the physicians, nurses, home care providers, managers, and prehospital care personnel, as well as the insurance companies who pay for the patients’ medical care. The emergency department stakeholders primarily focus on the several indicators that that focus mainly on their capacity to provide quality care. For emergency departments to effectively respond to patient care needs, the stakeholders must step in to ensure that the current environment of health care delivery, enabling the ED to adjust to changing models of care delivery; hence creating a controlled process that enhances the achievement of the goals and efficiencies of the healthcare facility.
Benefit of Project to Practice Clinical Area
The major benefits of this project to clinical practice is that it ensures the improvement of the quality of patient care, discharge process and follow-up care, as well as significantly reducing the overall cost of patient care. According to a study published in JAMA by Dr. Sabbatini and colleagues, it was determined that patients who return to the emergency department for further treatment have longer lengths of stay and increased costs during the repeat hospital admissions compared to those who do not return to the emergency department (Lee et al., 2015). A greater understanding of the essentials of this project will therefore be beneficial to physicians, nurses and other healthcare practitioners and improve their clinical practice; hence enhancing the overall patient care and outcomes, preventing unscheduled return visits to the emergency room.
Cost/Benefit Analysis
Return admissions in the emergency department often fail to adequately capture the deficits in the healthcare quality delivered during the first visit to the emergency department. The current efforts to provide the patients with quality care in the value-driven healthcare system has significant policy implications. The frequent changes in healthcare financing therefore give rise to certain policies which often encourage unnecessary hospitalizations which then encourage return admissions to the emergency department and hence increasing costs of healthcare. Appropriate measures should therefore be chosen by the healthcare providers to identify the quality of ED care and ensure that hospitals and physicians are incentivized to benefit the patients while also preventing the unwanted or unintended consequences (Soh et al., 2019).
Scope of the Project
This project covers not only the causes and implications of unscheduled return visits to the emergency room, but also its effects on the quality of health or patient outcomes. The US and the worldwide healthcare framework have been encountering a fast increment in the demand for ED. This has been resulting in the congestion of these rooms. Various studies have affirmed that between 2001 and 2008 ED returns were extensively high, and over half of the patients recorded multiple visits every year (Ericksen & Kocher, 2019). Out of these patients, over 1% had visited the ED in more than five times and added up to 18% of the considerable number of visits. The Centers for Disease Control evaluates that the US medicinal services framework records 145.6 million ED visits and return visits of at least 12.6 million every year (2017). In 2014, about 5.7% of the ED visits included patients that had been admitted before over the last three days on the grounds that the patients didn't comprehend the release directions (CDC, 2017).
Moreover, this project covers the clinical interventions that would be necessary for reducing the rate of unscheduled return visits to the emergency department, and their implementation. The implementation strategy will entail the training of healthcare physicians on the fitting ways for releasing patients. It will likewise incorporate learning the discharge agenda that will be given to patients at the hour of their release, and which they need to check the imprint boxes of what they understand. They at that point need to sign after understanding and afterward come back to the medical caretaker after the training session. The expected outcome and evaluation strategy will be controlled by the degree to which the patients understand the instructions. The effectiveness of this intervention will be showed in the improvement of service delivery in the ED. The technique is required to diminish the congestion at the ED and improve patient outcomes.
References
American Association of Colleges of Nursing (AACN). (2006). DNP essentials. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf
Centers for Disease Control and Prevention. (2017). Emergency department visits. Retrieved from https://www.cdc.gov/nchs/fastats/emergency-department.htm
Ericksen, G. M., & Kocher, K. (2019, April 12). Trends in Emergency Department Use by Rural and Urban Populations in the United States. Retrieved from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730472
Hayward, J., Hagtvedt, R., Ma, W., Vester, M., Gauri, A., & Holroyd, B. R. (2018). P068: Predictors of admission in unscheduled return visits to the emergency department. CJEM, 20(S1), S81-S81. doi:10.1017/cem.2018.266
Healthy People 2020. (2019). Environmental health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health
Lee, S. H., Kim, K., Kim, H., Jeong, J. H., Kang, C., Rhee, J. E., … Hwang, S. S. (2015). Effect of multifaceted interventions on reducing return visits within 72 h after non-traumatic emergency department visits. Emergency Medicine Australasia, 27(5), 431-439. doi:10.1111/1742-6723.12457
Rafnsson, V., & Gunnarsdottir, O. (2010). 177: Return Visits, Hospitalization and Mortality After Uncompleted Initial Visit to the Emergency Department: A Prospective Study. Annals of Emergency Medicine, 56(3), S59. doi:10.1016/j.annemergmed.2010.06.224
Rikard, R. V., Thompson, M. S., & Beauchamp, A. (2016). Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022195/
Rising, K. L., Padrez, K. A., O’Brien, M., Hollander, J. E., Carr, B. G., & Shea, J. A. (2015). Return Visits to the Emergency Department: The Patient Perspective. Annals of Emergency Medicine, 65(4), 377-386.e3. doi:10.1016/j.annemergmed.2014.07.015
Rushforth, H. (2015). Advanced Nursing Practice: The Theoretical Context and Evidence Base. Advanced Nursing Practice, 21-49. doi:10.1007/978-0-230-37812-4_2
Sayah, A., Rogers, L., Devarajan, K., Rocker, K. L., & Lobon, F. L. (2014). Minimizing ED Waiting Times and Improving Patient Flow and Experience of Care. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009311/
Schrader, C. D., Robinson, R. D., Blair, S., Shaikh, S., Ho, A. F., D’Etienne, J. P., … Wang, H. (2019). Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study. BMC Health Services Research, 19(1). doi:10.1186/s12913-019-4300-1
Soh, Lin, Pan, Ho, Mahadevan, Chua, & Kuan. (2019). Risk Factors for Emergency Department Unscheduled Return Visits. Medicina, 55(8), 457. doi:10.3390/medicina55080457
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