Benchmark -Evidence-Based Practice Project: Literature Review

Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example

Overcrowding in the Emergency Department and delays is a systemic issue that adversely impacts boarding, increases Left Without Being Seen (LWBS) rates, creates barriers to timely access of care, and subsequently impacts the quality of care and patient outcomes. Besides, these challenges are associated with medical errors, poor satisfaction levels among patients and staff, adverse public health outcomes, mortality, and low healthcare revenues (Morley et al., 2018). Overcrowding results in many patients who are either waiting to be seen, waiting to undergo assessment, waiting for treatment, or waiting for release. Factors such as a prolonged hospital stay, delayed consultancy, laboratory testing/imaging, staff shortage, and inadequate inpatient bed capacity lead to overcrowding.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Despite these system-wide inefficiencies, the current systems focus on bedding in the medical-surgical units. Therefore, there is a need for medical providers to devise measures to improve patient movement through the ED in a specified amount of time to minimize the patient backlog that results in overcrowding. Adopting a bed ahead policy in medical-surgical units will reduce overcrowding, leading to less wait time, appropriate admission rates, and positive health outcomes.  The purpose of this paper is to review evidence-based literature to support the need needs for intervention for overcrowding in EDs and its importance in patient and staff satisfaction.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

PICOT Statement

‘For ED patients aged 18 years or more and admitted to the medical-surgical unit of a healthcare organization offering acute care (Population-P), does the implementation of bed ahead concept-based system (Intervention-I) compared to the current system of bed assigning (Comparison-C) lead to decreased delays at the time of admission and subsequent LOS (Outcome-O) within four months of the project’s implementation? (Time-T)'(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Search methods

In this study, keywords and phrases, including bed-head concept system, overcrowding in Emergency Departments, admission delays, and length of stay, were used during the search. The keywords and phrases were combined into possible Medical Subject Heading (MeSH) such as “impact of bed-head concept system on admission delays” or “impact of bed-head concepts on length of stay in acute care settings.” Search medical engines such as PubMed, Cochrane Library, Google Scholar, Science Direct, and Ebscohost to search medical Libraries and databases such as MEDLINE, Medline plus, PsycINFO, EMBASE, and Cochrane Database of Systematic reviews for evidence-based pieces of literature published in the last five years. These databases provide a comprehensive collection of updated and evidence-based publications on health information. Moreover, reputable websites such as the Centers for Disease Prevention and Control, the National Institute of Health, and the Department of Health and Human Services were searched for EB literature.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Synthesis of the Literature

From the literature search, eight articles were identified for this project. DiGiacomo et al. (2020) sought to determine the effect of bed ahead policy on hospital stays and patient outcomes.  The study was conducted among Level 1 trauma care patients.  The study adopted a retrospective review methodology among trauma patients in an ICU. The study evaluated the policy impact on patient complications, ICU/hospital length of stay (LOS), and mortality. The researchers noted statistically significant improvements in LOS, decreased competition, and mortality rates. For this project, adopting the ICU bed pre-assigning approach would reduce the LOS in the medical-surgical unit.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Jung et al. (2021) determined the impact of overcrowding in EDs on admission rates. The study involved 73,776 hospital ED patients. The study adopted a retrospective cohort methodology. The authors obtained data from the hospital’s EMR system and used SAS version 9.3 for statistical analysis.  The authors found out that overcrowding in the ED leads to significant problems like unnecessary medical resources allocation and admissions. This article recommends collaboration among ED staff, which would be crucial in implementing the bed ahead concept in medical-surgical units.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Lee et al. (2017) implement a strategy to enhance high-turnover utility bed intervention in EDs. The study involves 70515 adult ED patients during the pre-intervention and 69706 in post-intervention. The authors adopted a before-and-after observational cohort methodology. The study’s intervention involved the implementation of a high-turnover bed intervention for EDs. The study findings include increased admission opportunities, decreased ambulance diversion hours, and shortened stay in the ED. Incorporating some aspects of high-turnover utility bed intervention would help the proposed project reduce LOS in the medical-surgical unit.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Lee et al. (2020) sought to predict ED patient decisions to support admission resource allocation. The study involved 172809 level I trauma patients whose data are in the hospital database. The authors adopted a quantitative methodology utilizing three levels of categorization of schemes for modeling disposition decisions. The intervention involved modeling the process of ED disposition decision as a hierarchical multiclass while dealing with the progressive accrual of clinical information throughout the ED caregiving process. Incorporating some aspects of the disposition decision classification model will improve the bed ahead concept in the proposed project.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Mathews et al. (2017) established a conceptual framework to improve patient flow and bed use in critical care. The study involved 2710 adult patients in medical ICU and step-down units. The authors adopted a quantitative simulation modeling method. The intervention involved creating a model of existing patient flow before investigating alternative bed allocation and triage strategies. The model reduced ICU wait time through appropriate bed allocation to patients. Integrating this new simulation model’s concept would positively impact patient outcomes in the medico-surgical unit and reduce the LOS within this unit.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Peltan et al. (2019) sought to relate overcrowding in the EDs to delayed antibiotics for sepsis. The study was conducted in two community hospitals with 3572 patients. The authors adopted a retrospective quantitative cohort methodology.  The Markov multistate models were used to investigate the link between ED crowding and antibiotic care. The findings linked delayed sepsis antibiotic use to ED overcrowding.  The findings can be adopted to implement strategies to reduce delays in the medical-surgical unit and the associated LOS.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Resouli et al. (2019) evaluated the challenges, consequences, and recommendations for mitigating emergencies in EDs. The authors assessed different studies conducted in different settings whose content addressed crowding in emergencies of hospitals. The authors adopted a qualitative systematic review methodology to retrieve and evaluate 106 articles from PubMed and EMBASE databases. This study identifies the challenges, effects, and lessons drawn from ED crowding to formulate measures and strategies that can resolve the adverse effects of crowding in the medical-surgical units.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Yarmohammadian et al. (2017) reviewed strategies to mitigate challenges associated with EDs.  The authors adopted a systematic review methodology following a computer search on PubMed, Direct, Wiley Online Library, and Google Scholar. Thirty articles were identified for the study.  The study identified interventions such as fast-tracking and streaming patients’ health journeys, adopting appropriate triage systems, collaboration among team triage teams, and modeling patient journeys as solutions to ED challenges at the EDs. From this study, identifying the challenges in the medical-surgical unit would help choose the most appropriate strategy to solve them in advance.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Comparison of Articles

The studies were either carried out within ED hospital settings (DiGiacomo et al., 2020; Jung et al., 2021; Lee et al., 2017; Peltan et al., 2019), used data from EDs databases (Lee et al., 2020), or literature review on studies conducted in EDs settings (Resouli et al., 2019; Yarmohammadian et al., 2017). The common themes across the articles are associated with the impact of overcrowding at the EDs, such as increased LOS, mortality, admission rates, inappropriate allocation of medical resources (DiGiacomo et al., 2020; Jung et al., 2021; Lee et al., 2017, Mathews et al., 2017).(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

The studies adopted various methodologies, including retrospective cohort methods (Jung et al., 2021, Lee et al., 2017; Peltan et al., 2019), modeling of patients data (Lee et al., 2020; Mathews et al., 2017), and systematic reviews of existing literature (Resouli et al., 2019; Yarmohammadian et al., 2017).  The interventions for ED overcrowding from these studies include bed-ahead policy (DiGiacomo et al., 2020), collaboration among working staff to implement appropriate admission policy (Jung et al., 2021), high turnover utility bed intervention (Lee et al., 2017), and modeling of ED disposition decision process (Lee et al., 2020). Yarmohammadian et al. (2017) outline several interventions for ED overcrowding, including streaming of patient journeys, fast-tracking patients, developing triage systems, point of care testing/imaging, and use of patient journey models.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Suggestions for Future Research

Overcrowding is identified across the sources as a chronic problem affecting the operations of EDs across many hospitals. Factors such as limited bed capacity, staff shortage, poor triage and admission systems, and inadequate collaboration among ED staff exacerbates ED overcrowding (DiGiacomo et al., 2020; Jung et al., 2021; Lee et al., 2017; Lee et al., 2020; Peltan et al., 2019; Resouli et al., 2019; Resouli et al., 2019; Yarmohammadian et al., 2017). Other factors such as poor clinical decisions and lack of point of care testing/images also contribute to ED overcrowding. The typical outcomes and impacts include increased dwell time, unnecessary resource allocation, needless admission, increased ambulance diversion, delayed sepsis antibiotic use, adverse health outcomes, and financial losses.  The identified interventions can be adopted and incorporated in the project to facilitate seamless implementation of the proposed bed ahead policy for medical-surgical units. However, further research is necessary to create an effective admission system based on needs, as this would limit adverse outcomes on patients(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Conclusion

Overcrowding is identified across the sources as a chronic problem affecting the operations of EDs across many hospitals. Overcrowding increases dwell time, unnecessary resource allocation, needless admission, increased ambulance diversion, LOS, delayed sepsis antibiotic use, adverse health outcomes, financial losses, and mortality. Factors such as limited bed capacity, staff shortage, poor triage and admission systems, and inadequate collaboration among ED staff exacerbate ED overcrowding. Other factors such as insufficient clinical decisions and lack of point of care testing/images also contribute to ED overcrowding.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

The interventions for ED overcrowding include bed-ahead policy, collaboration among working staff to implement appropriate admission policy, high turnover utility bed intervention, and modeling of ED disposition decision process. Other relevant ED overcrowding interventions include streaming patient journeys, fast-tracking patients, developing triage systems, point of care testing/imaging, and using patient journey models. Together, the interventions can be incorporated into the bed ahead policy to enhance implementation through elaborate and seamless collaboration and cooperation among ED staff and evidence-based processes across every level of the ED. (Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

References

DiGiacomo, J. C., Angus, L. G., Wallace, R., Cardozo-Stolberg, S., Gerber, N., Munnangi, S., … & Skarka, K. (2020). The Impact of an ICU “Bed Ahead” Policy on ED Length of Stay and Patient Outcomes. Annals of Surgery, 271(2), 303-310. (Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)https://doi.org/10.1097/sla.0000000000002832

Jung, H. M., Kim, M. J., Kim, J. H., Park, Y. S., Chung, H. S., Chung, S. P., & Lee, J. H. (2021). The effect of overcrowding in emergency departments on the admission rate according to the emergency triage level. PloS One, 16(2), e0247042. (Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)https://doi.org/10.1371/journal.pone.0247042

Lee, I. H., Chen, C. T., Lee, Y. T., Hsu, Y. S., Lu, C. L., Huang, H. H., … & Yang, U. C. (2017). A new strategy for emergency department crowding: high-turnover utility bed intervention. Journal of the Chinese Medical Association, 80(5), 297-302. (Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)https://doi.org/10.1016/j.jcma.2016.11.002

Lee, S. Y., Chinnam, R. B., Dalkiran, E., Krupp, S., & Nauss, M. (2020). Prediction of emergency department patient disposition decision for proactive resource allocation for admission. Health Care Management Science, 23(3), 339-359. https://doi.org/10.1007/s10729-019-09496-y

Mathews, K. S., & Long, E. F. (2017). A conceptual framework for improving critical care patient flow and bed use. Annals of the American Thoracic Society, 12(6), 886-894(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example). https://doi.org/10.1513/annalsats.201409-419oc

Peltan, I. D., Bledsoe, J. R., Oniki, T. A., Sorensen, J., Jephson, A. R., Allen, T. L., … & Brown, S. M. (2019). Emergency department crowding is associated with delayed antibiotics for sepsis. Annals of Emergency Medicine, 73(4), 345-355. (Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)https://doi.org/10.1016/j.annemergmed.2018.10.007

Rasouli, H. R., Esfahani, A. A., & Farajzadeh, M. A. (2019). Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study. BMC Emergency Medicine, 19(1), 1-10. https://doi.org/10.1186/s12873-019-0275-9

Yarmohammadian, M. H., Rezaei, F., Haghshenas, A., & Tavakoli, N. (2017). Overcrowding in emergency departments: A review of strategies to decrease future challenges. Journal of research in medical sciences: The Official Journal of Isfahan University of Medical Sciences, 22, 23. https://doi.org/10.4103/1735-1995.200277

Appendix

Criteria Description

The studies selected for this review were those conducted in EDs with subjects that require emergency medical attention. Reputable databases were searched, including MEDLINE, Medline plus, PsycINFO, EMBASE, and Cochrane Database of Systematic Reviews. Equally, articled evaluating the impact of EDs overcrowding and contributing factors met the criteria for selection. The articles that were published in English within the last five years were selected for inclusion. These criteria are crucial in identifying relatable, evidence-based, and updated literature to support the project intervention.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

APA Writing Checklist

Use this document as a checklist for each paper you will write throughout your GCU graduate program. Follow specific instructions indicated in the assignment and use this checklist to help ensure correct grammar and APA formatting. Refer to the APA resources available in the GCU Library and Student Success Center.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

☒ APA paper template (located in the Student Success Center/Writing Center) is utilized for the correct format of the paper. APA style is applied, and format is correct throughout.

☒  The title page is present. APA format is applied correctly. There are no errors.

☒ The introduction is present. APA format is applied correctly. There are no errors.

☒ Topic is well defined.

☒ Strong thesis statement is included in the introduction of the paper.

☒ The thesis statement is consistently threaded throughout the paper and included in the conclusion.

☒ Paragraph development: Each paragraph has an introductory statement, two or three sentences as the body of the paragraph, and a transition sentence to facilitate the flow of information. The sections of the main body are organized to reflect the main points of the author. APA format is applied correctly. There are no errors.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

☒ All sources are cited. APA style and format are correctly applied and are free from error.

☒ Sources are completely and correctly documented on a References page, as appropriate to assignment and APA style, and format is free of error.

Scholarly Resources: Scholarly resources are written with a focus on a specific subject discipline and usually written by an expert in the same subject field. Scholarly resources are written for an academic audience.

Examples of Scholarly Resources include: Academic journals, books written by experts in a field, and formally published encyclopedias and dictionaries.

Peer-Reviewed Journals: Peer-reviewed journals are evaluated prior to publication by experts in the journal’s subject discipline. This process ensures that the articles published within the journal are academically rigorous and meet the required expectations of an article in that subject discipline.

Empirical Journal Article: This type of scholarly resource is a subset of scholarly articles that reports the original finding of an observational or experimental research study. Common aspects found within an empirical article include: literature review, methodology, results, and discussion.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)

Adapted from “Evaluating Resources: Defining Scholarly Resources,” located in Research Guides in the GCU Library.

☒ The writer is clearly in command of standard, written, academic English. Utilize writing resources such as Grammarly, LopesWrite report, and ThinkingStorm to check your writing.(Overcrowding in the Emergency Department and Delays Comprehensive Nursing Essay Example)