Running Head: IMPROVING BAD

OUTCOMES 1

Improving Bad Outcomes in the Emergency Room

Mitchel Taylor

Brigham Young University – Idaho

Nurse 422

Brother Sanders
IMPROVING BAD OUTCOMES 2

Improving Bad Outcomes in the Emergency Room

Background

The emergency room of hospitals is a place of hope and last resort for the physically and

mentally injured to which they turn to for help. However, much of the time, patients are not

always helped efficiently or at all which results in bad outcomes for patients. Bad patient

outcomes in the emergency department of a hospital are caused by multiple issues. Some of

those issues being that the hospital is understaffed, the hospital does not have sufficient

resources, or the right resources required, the wait times to finally be admitted or seen by a

physician are too long, or the ER is overcrowded.

Understaffed emergency departments are a common problem leading to bad outcomes in

many hospitals. It can lead to longer wait times, exhausted staff personnel, medication errors and

inadequate patient care. In 2012, 51% of emergency room nurses reported that their workload

caused them to miss a change in their patients’ conditions (Burstrom, Starrin, Engstrom, &

Thulesius, 2013). Changes in a patient’s condition, especially in the ER, can result in serious

patient injury and even death. In a study conducted by the Emergency Nurses Association,

approximately 86% of emergency nurses have experienced moderate to high levels of

compassion fatigue and anywhere from 55-85% of nurses in any department will develop

compassion fatigue of some level or another in their career (Hooper, Craig, Janvrin, Wetsel, &

Reimels, 2010). Burnt out ER department staff can lead to serious patient complications and bad

outcomes.

Wait times to be seen by a doctor are among the top reasons for a bad outcome in the ER

setting. In May 2014, the Centers for Disease Control and Prevention reported that the average
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wait time for the Emergency room was 30 minutes, but when things get busy, that time can

easily increase to about 2 hours plus the time for a physician to actually see you (Centers for

Disease Control and Prevention, 2010) Depending on the situation, 2 hours or even 30 minutes is

more than enough time for situations to exacerbate and conditions to worsen, even to the point of

death.

Overcrowded hospitals have become an all too common epidemic. Hospitals are

saturated, increasing both the understaffed issue and the wait times issue mentioned above. One

of the problems perpetuating this is that the ER is not being utilized by many people for its true

purpose. Many people abuse the emergency department by going there, sometimes on a

consistent basis, for things that aren't true emergencies (Dickson, Anguelov, Vetterick, Eller, &

Singh, 2009). Non-emergent situations can take up the same amount of time, man power and

resources as actual emergencies in most situations.

Improvements in the ER

Many hospitals are rethinking how the emergency room runs and a large number of

studies are being conducted with an end to discover how to manage them more effectively and

decrease the number of bad outcomes in the ER department. Following are some examples of

what some hospitals are doing to try and improve ER outcomes. Many of them are inspired by

research as well as being experimental in an attempt to ultimately improve patient outcomes in

the ER.

A Florida Hospital in Tampa implemented a new flexible patient flow strategy called

“immediate bedding and team triage” to ensure that patients are seen almost immediately by

doctors. The system focuses on bedding patients immediately as soon as they arrive bypassing
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immediate triage when they enter which is a standard practice in ERs across the nation. When

there are no beds available they switch to a team triage system in which patients are put into a

triage room right away when entering the hospital. Immediately upon entering, the hospital

preforms a blood draw, then immediately after both a physician and a nurse assigned to the triage

room preform a 90 second evaluation. This new system has helped this particular hospital climb

from the 6th percentile in patient satisfaction to the 85th percentile. (Esbenshade, O’Bryon, &

Tirheimer, 2015) This system has helped the hospital almost completely eliminate the number of

patients that leave without being seen.

A number of hospitals in California have implemented a different approach to combatting

bad patient outcomes as a result of overcrowding. Based on the identification that not all patients

admitted to the ER are actually in a life-threatening situation, and that many of them are much

less severe, such as fevers, sprains and other non-emergencies. These hospitals have restructured

their ERs to have two separate ER sections. One department for true emergencies which has the

resources and equipment needed for one and the other for less severe problems. Physically

separated, but right next to each other, the two sections work separately continually taking in

patients who qualify for their department. A triage nurse who briefly evaluates incoming patients

determines what section they are to be sent to. The rate at which non-emergent patients are seen

and discharged is much faster and the number of patients who leave without being seen or

without completing treatment has decreased by 89%. (Roh, 2016). The idea of this system is to

increase the rate in which non-emergent patients are seen and can move through a faster system

designed for them. And at the same, non-emergent patients are not occupying rooms and

resources needed for more severe cases. The results of this strategy has greatly increased patient

outcomes and satisfaction.

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Stanford hospital in California has implemented a similar system to improve their ER.

Stanford hospital conducted a study in their hospital and determined that 40% of the patients

who arrived at the ER needed to be hospitalized, but they also realized that 30% of the patients in

no way needed hospitalization whose issues were very minor. This meant that they were the

patients who spent long amounts of time in the waiting room waiting to see a doctor as other

more emergent cases took priority (Wykes, 2013). The shorter a patient stays in the waiting

room, the more efficient the emergency department and medical care is (Wykes, 2013). To help

improve the Stanford ER, they created what is called Fast Track. Fast Track is a dedicated team

composed of doctors, nurses and ED technicians whose main job is to treat the least severe and

sick patients efficiently and get them back out living their lives. After implementing this system

the median length of stay for their Fast Track patients was 60 minutes including waiting time,

treatment and discharge turning the longest waiting population into the shortest. This system has

benefited every aspect of the ER by making the ER staff less stressed, more able to handle higher

patient counts, improving patient satisfaction and improving staff efficiency with more critical

cases. All of these improvements contribute to a smaller number of bad outcomes for patients.

One of the most important qualities of an effective ER is the ability to work efficiently

with the amount of time given to the staff to manage situations. In many scenarios it can be a

make or break point for an ER. A hospital in Ontario, Canada, funded a study to improve their

ER in which they implemented substantial research and training of their ER staff. One of the key

factors they focused on that greatly improved their ER department efficiency was

communication between staff members which improved efficiency and the use of limited time.

In their study they found that a large amount of time was wasted as a result of

miscommunication and overlapping duties that lead to repeated assessments, questions and
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reviews for a single patient (Rotteau et al., 2015). The miscommunication and time wasted in the

ER contributed to the number of bad outcomes for patients in the ER. In order to improve this

problem, the hospital developed specific training to improve communication between ER staff

and training that helped them identify exactly what each staff members duties were so that there

was no overlapping duties between staff members.

Bad outcomes in the ER is a growing problem because of a variety of challenges that the

average ER has to deal with. But, there are improvements and strategies that can be implemented

to increase an ER’s efficiency and have shown to work in a number of hospitals. Improving the

efficiency of an ER and how it operates can greatly improve the number of bad outcomes in an

ER.
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References

Burstrom, L., Starrin, B., Engstrom, M., & Thulsesius, H. (2013). Waiting management at the

emergency department: A grounded theory study. BMC Health Services Research, 13(1), 1-10.

doi:10.1186/1472-6963-13-95

Centers for Disease Control and Prevention. (2011). The CDC guide to strategies to increase physical

activity in the community. Retrieved from:

http://www.cdc.gov/obesity/downloads/PA_2011_WEB.pdf

Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, A., & Singh, s. (2009). Use of lean in the emergency

department: A case series of 4 hospitals. Annals Of Emergency Medicine, 54(4), 504-510.

doi:10.1016/j.annemergmed.2009.03.024

Esbenshade, A., O’Bryon, S., & Tirheimer, W. (2015) 7 Tips for improving emergency department

patient flow. Leadership. Retrieved from: http://www.hfma.org/leadership/immediatebedding/

Hooper, C., Craig, J., Janvrin, D.R., Wetsel, M.A., & Reimels, E. (2010). Compassion satisfaction,

burnout, and compassion fatigue among emergency nurses compared with nurses in other

selected inpatient specialties. Journal of Emergency Nursing, 36(5), 420-427.

https://doi.org/10.1016/j.jen.2009.11.027

Roh, H., & Park, K. H. (2016). Brief reports: A scoping review: Communication between emergency

physicians and patients in the emergency department. Journal Of Emergency Medicine, 50(7),

34-743. doi:10.1016/j.jemermed.2015.11.002

Rotteau, L., Webster, F., Salked, E., Hellings, C., Guttman, A., Vermeulen, M. J., & … Schull, M.J.

(2015). Ontario’s emergency department process improvement program: The experience of

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implementation. Academic Emergency Medicine: Official Journal Of The Society For Academic

Emergency Medicine, 22(6), 720-729. doi:10.1111/acem.12688

Wykes, S. (2013). New emergency department programs shorten wait times. Stanford Medicine.

Retrieved from: https://med.stanford.edu/news/all-news/2013/02/new-emergency-department-

programs-shorten-wait-times.html