This article provides a sample solution to Chapter Two of the DPI Project on LWBS.
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Solution
Chapter Two of the DPI Project on LWBS
Chapter Two
In the US, just like in many other countries of the world, overcrowding is one of the leading factors linked to increased patient morbidity as well as mortality. The extended patient wait leads to lower levels of patient satisfaction. Additionally, healthcare organizations also face financial penalties for not having achieved health quality performance measures. After conducting a PICOT framework guided literature search and subsequent review, the nurse researcher was able to recognize many interventions seeking to decrease overcrowding within the ED but few if any sought to investigate the impact of having a clinical interprofessional team in triage (CITiT) to reduce the PWT and therefore decrease the door to physician wait time (Shen & Lee, 2018). The systematic review of the retrieved articles whose contents addressed strategies of reducing PWT and overcrowding and improvement of patient outcomes, Chapter 2, was divided into six sections whereby the first part is the introduction, followed by a theoretical framework discussion in section two. Section 3 outlines the themes and subthemes of the literature review while the project’s significance, methodology, and design form the fourth, fifth, and sixth sections, respectively. Besides the PICOT framework guide, other parameters for the study to be included had to be published in English between 2015 and 2020 and contents exploring measures that can reduce the patient wait times in the ED or the effects of team triage within the ED. Articles whose focus was those patients whole without being treated or left against medical advice were excluded just like those published in foreign languages or before 2015.
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Theoretical Framework
After assessing the quality improvement needs at Best Quality Healthcare Hospital (BQHH), the researcher chose Kurt Lewin’s three-step change model as the guide to this evidence-based practice QIP. Lewin’s theory comprises three steps unfreeze, change and refreeze. The model demands the existing learning to be tossed away and be substituted by the existing human systems. Under the Change theory of Lewin, there are driving forces that propel the change in potential change direction, while restraining forces push the proposed and desired change in the opposite direction. There are also equilibrium forces which are lowered or raised by the two opposing forces of driving and restraining. As such, Lewin’s change theory will help to answer the research questions like how to reduce the average wait time of 2hours and28 minutes in the ED identified while the rate of 3 % for patients who LWBS was way too high. Having a clinical interprofessional team in triage would help the clinicians to make appropriate decisions that not only reduce the PWT (Pielsticker et al., 2015). The primary independent variable was the door room, while the dependent variables included meeting the LWBS goal of 2% and average door to provider times in minutes before and after the CITiT intervention, the rate of LWBS as a percentage of those who were triaged.
Literature Review
After a systematic review of literature ad synthesis, three main themes emerged namely, maintaining a constant flow of patients, lack of enough space in the ED and having the ED staff doing things right
Theme 1: Maintaining a constant patient flow
. The need to realize most of the set targets by the BQHH Emergency Department, the research identified maintaining a constant flow of patients asking to the flow of a stream as patients go through the ED. The subthemes in the patient included
- Patient flow; the researcher identified that sending the appropriate patients kept the patient flow constant while sending the wrong ones resulted in a buildup of the patients ending in an overcrowded ED. The ED triage should channel the appropriate care zones.
- The process flow-At BQHH Emergency Department patients flow in and out of three private rooms with nine chairs in a process comprising of the unit clerk and nurses.
- Physicians flow-also determine the process flow since some patients do not require seeing a nurse.
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Theme 2: Lack of Space in the ED
The first theme was the lack of space within the ED. Most of the articles chosen for inclusion identified inadequate space as a contributing factor to overcrowding and increases of LWBS. The subthemes
- Poor service delivery since enough workforce cannot be accommodated.
- Compromised health standards and safety issues– dues the congestion in the room safety issues arise.
- Contributed to issues with infection control with congestion maintaining safe social distance and control some hospital-acquired infections is difficult.
Theme 3: Getting It Right
While, the ED at BQHH is set to implement team triage in July 2020, having an interprofessional team in triage began back in December 2019 seven months before after a nurse attended a seminar on ways to address ED overcrowding. The emerging subthemes are
- Adequate preparation work and being innovative.
- Having a dedicated leadership where everyone is encouraged to the solution from within.
- Having a multidisciplinary team that has a positive outlook and everyone envisions success.
Significance of the Project:
The significance of this QIP upon successful implementation is to decrease the door to physician-patient wait time, thus accelerating the delivery of care during times that experience heavy patient volume. Recording improved ED benchmark times after placing a clinical interprofessional team in triage is bound to reduce the number and rate of patients who LWBS, which in turn leads to improved patient outcomes.
Project Methodology
The researcher adopted the quasi-experimental design approach over the true or experimental design as the former has the advantage of greater external validity, use of different variable approaches, and the fact that the participles used are more accessible (Campbell, 2015). These benefits would help overcome the lack of realism in experimental design or the latter’s capacity to demonstrate causality without explaining causal effects (Grabbe, 2015).
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Project Design
After a review of the BQHH existing triage system, recommendations for educating the nurses on CITiT, particularly on the use of novel assessment and documentation framework, the project design was based on Lewin’s unfreeze where the staff with I the ED recognized that a change was needed. They were ready to attempt the new practices. In the change stage, the change would be implemented while refreeze would happen once the introduced change becomes part of the facility’s practice in the ED triage system.
References
Campbell, D. T., & Stanley, J. C. (2015). Experimental and quasi-experimental designs for research. Ravenio Books.
Grabbe, J. W. (2015). Implications of experimental versus quasi-experimental designs. In The Palgrave handbook of research design in business and management (pp. 141-152). Palgrave Macmillan, New York.
Pielsticker, S., Whelan, L., Arthur, A. O., & Thomas, S. (2015). Identifying patient door-to-room goals to minimize left-without-being-seen rates. Western Journal of Emergency Medicine, 16(5), 611.
Shen, Y., & Lee, L. H. (2018). Improving the wait time to consult at the emergency department. BMJ open quality, 7(1).
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