Quality improvement as defined by the Department of Health and Human (2011) services
is a systematic action that leads to measurable improvement in health care services. The Institute
of Medicine (IOM) defines quality in health care as a direct correlation between the level of
improved health services and the desired health outcome. A quality improvement opportunity at
my hospital can be a flow problem, moving patient through in the emergency department is a big
problem. This paper will focus on the patient flow issue, why a quality improvement is needed
and what is the expected outcome, the steps necessary to implement the quality improvement
initiative. Evaluate to see if there was improvement.
Patient Flow in the Emergency Department
The emergency department is a high stress and high demand area to begin with, imagine
being over capacity or unable to move patient to their inpatient bed. During the days there are
discharges and those empty beds are assigned to the new admits in the ED. The problem is the
assignments are not done until 6pm in the evening, right before change of shift the outgoing
nurse refuse to take report at that time and if and when report are given we cannot find an
available patient care technician (PCT) or transporter to bring the patient to the floors.
Why quality improvement is needed
When you have all these admitted patient in the emergency department, unless they are a
critical care (ICU) patient they do not received the care that they deserved in an ER, so being
admitted and awaiting transport for over 2 hours is a delay in patient care and can put the patient
at risk for developing skin breakdown and ulcers those ER stretchers are not the most
comfortable, and for someone who is at risk for ulcers and skin breakdown, they should not be in
there longer than necessary. When the nurses on the admitted floor refuse to take report from the
outgoing ER nurses for over one and half hours is not only a delay patient care, but also can be a
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miscommunication in continuity of care. The ER nurse that had the patient for over 6 hours
should be given report the admitted nurses, not the ER nurse who just came on shift and was not
involved at all in the patient care.
Expected outcome
Making a smooth transition from the ER to the admitted inpatient bed is the expectation
of the patient and the hope of the ER nurses, this writer have seen so many patient admitted not
with a life threatening problem, but none the less needed to be admitted for observation left
Against Medical Advice (AMA) just because it take so long for them to get transferred to their
inpatient beds or to get a bed in itself, sometimes they are holding in the ER for a while before
getting a bed assignment.
Steps necessary
One would expect to get extra PCT, or have a PCT coming on shift at the hours of 3 pm
to help transport patient upstairs to their inpatient beds, and educate nurses on the floors that they
should take report on their admitted patient from the ER even if it is 630 pm, or have the
oncoming nurse take report on those incoming ER patients first, not only because the ER nurse
wants to go home but it help in the continuity of care and help relieved the flow in the ER, so the
patient that are waiting to be seeing can be brought back to a bed. Have a triage team consist of a
Family Nurse Practitioner or Doctor and a nurse in triage to start seeing patient as they arrived to
help decrease our waiting time and increase patient satisfaction.
Previous research
Multiple research and studies reflect that quality of care is impacted during crowding,
which results in treatment delays and decreased patient satisfaction. For most having a primary
care provider is impossible due to the lack of health care coverage and the cost. Researchers
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suggest placing a Family Nurse Practitioner (FNP) or doctor in triage to help alleviate the flow
and the overcrowding in the ED. Rowe et al. evaluated the impact of having a doctor, of any
grade, assisting the triage process. They demonstrated that a physician in triage is an effective
intervention to alleviate the effects of ED crowding. Triage performed specifically by a senior
doctor has been proposed as a way of accelerating patient flow through the ED, reducing
admissions and improving the time to key decision making. This is done by initiating prompt
patient assessment, appropriate diagnostic testing and initiating treatment earlier in the patient’s
journey. This includes the identification of definite admissions and expediting sw