Kimberly D. Johnson

The Effect of Emergency Department Crowding on Patient Outcomes: A Literature Review

The purpose of this review was to summarize the findings of published reports that investigated quality-related outcomes and emergency department (ED) crowding. Of 276 data-based articles, 23 reported associations between patient outcomes and crowding. These articles were grouped into 3 categories: delay in treatment, decreased satisfaction, and increased mortality. Although these studies suggest that crowding results in poor outcomes, it is possible that other factors such as nursing care contribute to these adverse outcomes. Nursing care has been shown to contribute to both positive and negative patient outcomes in other settings. Building an understanding of how ED crowding affects the practice of the emergency nurse is essential to examining how nursing care, surveillance, and communication impact outcomes of emergency patients. Investigation into nurse-sensitive quality indicators in the ED has potential to develop strategies that deliver high quality of care, regardless of crowded conditions.

Exploring the Frequency of Blood Pressure Documentation in Emergency Departments

Purpose One of the most commonly performed task in the emergency department (ED) is reported as the monitoring of vital signs, yet there are no published standards of care that provide guidelines for the frequency of obtaining vital signs in the ED. The purpose of this exploratory study was to determine the frequency of documentation of vital signs recorded during ED visits across Veterans Health Administration (VHA) facilities. Methods Deidentified patient level data from the VHA electronic health record (EHR) were abstracted for emergency department visits for 12 randomly selected days in calendar year 2011. The dataset included vital signs data, associated time stamps, facility, length of stay, triage category based on the Emergency Severity Index (ESI), and patient disposition for all patients. Descriptive statistics were used to describe the frequency of the specific vital sign measures, and parametric and nonparametric tests were used to examine study variables by ESI. Findings The sample consisted of over 43,232 unique patient visits to 94 VHA EDs with a median length of stay of 173.3 min (interquartile range [IQR], 96.1–286.9). The mean number of times that blood pressure (BP) was recorded per visit was 1.23 (SD 1.175). For the entire sample, median time between blood pressure measurements was 139.7 min (IQR, 81.6–230.1). There was a significant difference in median length of stay and median time between blood pressure by ESI category. Conclusions In this dataset, median time between documentation of BP in the ED was every 2.3 hr for all patients. While the median time was statistically significant between ESI categories, these times may not be clinically relevant. More important was the inconsistent documentation of vital signs of ED patients in the designated fields in the EHR. Most facilities (84.1%) documented BP for >75% of patient visits. However, eight facilities (9.1%) had BP documented in <50% of patient visits. Clinical Relevance It seems unlikely that vital signs are not monitored in the ED; nurses anecdotally report that vital signs are recorded on a paper chart and later scanned as an image into the EHR. However, lack of consistent process in documentation of vital signs may decrease the care teams ability to note early warning signs of physiological instability or deterioration.PURPOSE One of the most commonly performed task in the emergency department (ED) is reported as the monitoring of vital signs, yet there are no published standards of care that provide guidelines for the frequency of obtaining vital signs in the ED. The purpose of this exploratory study was to determine the frequency of documentation of vital signs recorded during ED visits across Veterans Health Administration (VHA) facilities. METHODS Deidentified patient level data from the VHA electronic health record (EHR) were abstracted for emergency department visits for 12 randomly selected days in calendar year 2011. The dataset included vital signs data, associated time stamps, facility, length of stay, triage category based on the Emergency Severity Index (ESI), and patient disposition for all patients. Descriptive statistics were used to describe the frequency of the specific vital sign measures, and parametric and nonparametric tests were used to examine study variables by ESI. FINDINGS The sample consisted of over 43,232 unique patient visits to 94 VHA EDs with a median length of stay of 173.3 min (interquartile range [IQR], 96.1-286.9). The mean number of times that blood pressure (BP) was recorded per visit was 1.23 (SD 1.175). For the entire sample, median time between blood pressure measurements was 139.7 min (IQR, 81.6-230.1). There was a significant difference in median length of stay and median time between blood pressure by ESI category. CONCLUSIONS In this dataset, median time between documentation of BP in the ED was every 2.3 hr for all patients. While the median time was statistically significant between ESI categories, these times may not be clinically relevant. More important was the inconsistent documentation of vital signs of ED patients in the designated fields in the EHR. Most facilities (84.1%) documented BP for >75% of patient visits. However, eight facilities (9.1%) had BP documented in <50% of patient visits. CLINICAL RELEVANCE It seems unlikely that vital signs are not monitored in the ED; nurses anecdotally report that vital signs are recorded on a paper chart and later scanned as an image into the EHR. However, lack of consistent process in documentation of vital signs may decrease the care teams ability to note early warning signs of physiological instability or deterioration.

A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?

BackgroundShared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances.MethodsRealist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations).ResultsNine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one’s ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others’ illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients’ needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust.ConclusionsNine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

Associations Between Muscle-Related Cytokines and Selected Patient Outcomes in the ICU

Introduction: Systemic cytokines produced by contracting skeletal muscles may affect the onset and severity of intensive care unit (ICU)-acquired weakness after critical illness. Aims: The purpose of this research was to determine the serum levels of interleukin (IL)-8, IL-15, and tumor necrosis factor-α (TNF-α) among patients receiving mechanical ventilation for >48 hr and examine the relationships of these myokines to outcomes of patient delirium, muscle strength, activities of daily living (ADLs), duration of mechanical ventilation, and length of ICU stay. Methods: In this exploratory, repeated-measures interventional study, the 36 participants received 20 min of once-daily in-bed or out-of-bed activity using an established early progressive mobility protocol after physiologic stability had been demonstrated for >4 hr in the ICU. Blood samples were drawn on 3 consecutive days, beginning on the day of study enrollment, for serum cytokine quantification. Results: IL-8, IL-15, and TNF-α were highly variable and consistently elevated in participants compared to normal healthy adults. About 1/3 of participants were positive for significant muscle weakness at discharge from ICU. Repeated values of mean postactivity IL-8 serum values were significantly associated only with ADL following ICU discharge. There were no significant associations with repeated values of mean postactivity IL-15 or TNF-α serum values and outcomes. Conclusion: Results provide preliminary data for exploring the potential effects of elevated serum values IL-8 and IL-15 in muscle health and TNF-α for muscle damage, including effect sizes to calculate the sample sizes needed for future studies.

Dose of Early Therapeutic Mobility: Does Frequency or Intensity Matter?

Objective: Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. Design: Randomized interventional study with repeated measures and blinded assessment of outcomes. Setting: Four adult intensive care units (ICUs) in two academic medical centers. Subjects: Fifty-four patients with > 48 hr of mechanical ventilation (MV). Intervention: Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. Measurements: Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. Main Results: Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. Conclusion: Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

A Review of the Management of Loss of Pregnancy in the Emergency Department

Introduction: Women frequently seek ED care for complications in early pregnancy, including loss of pregnancy. This review evaluates the current literature and discusses the care of patients experiencing loss of pregnancy in the emergency department. Methods: A review of pertinent studies identified through multiple database searches was conducted to determine the existing body of knowledge for the care of ED patients diagnosed with loss of pregnancy. Each of the studies was examined for inclusion criteria and a subsequent analysis of the included studies identified themes related to the care of the women. Results: Thirty‐two original research articles and systematic reviews published between 1990 and 2016 were included in the review. Eleven articles addressed recommendations for clinical practice, 5 reported statistics related to pregnancy outcome and clinical presentation, 4 discussed the use of speculum examinations, 4 discussed interventions to decrease ED length of stay, and 3 investigated the use of ultrasound in the emergency department. Only 5 of the articles reviewed discussed emotional support and/or experiences of women with loss of pregnancy in the emergency department. Conclusion: Although there are multiple recommendations for the clinical management of loss of pregnancy in the emergency department, the psychological and emotional support of women was addressed infrequently. Additional studies investigating holistic care would be beneficial for ED providers in the management of early loss of pregnancy. Contribution to Emergency Nursing PracticeThis review identifies current best practice for management of loss of pregnancy in the emergency department, including incorporating targeted ultrasound, decreased use of speculum examinations, and operational changes to improve patient length of stay.Emergency care should incorporate clinical and psychological care for patients experiencing loss of pregnancy; however, few resources are available for psychological care.This review recognizes a need for additional research and education in the emotional care and psychological health of women experiencing loss of pregnancy in the emergency department.

Using Simulation to Assess the Impact of Triage Interruptions

Introduction Interruptions are common in the emergency department and contribute to catastrophic errors. Care priorities and acuity levels are assigned during triage, meaning that mistakes and omissions during the triage process could have detrimental effects on patients. The purpose of this project was to assess the feasibility of investigating the impact of interruptions on triage and the decision‐making process in a simulated setting. Methods A 2‐phase, sequential exploratory mixed method design was used. Nine nurses from 3 emergency departments in a Midwest area participated. A short demographic questionnaire was used to collect information about the nurses’ education and experience. The Emergency Severity Index (ESI) was used for triage categorization. Each participant completed 2 scenarios (one interrupted and one uninterrupted). After completion of the scenarios, video‐simulated recall interviews were used to assess the simulation experience and the impact that interruptions had on the triage decision‐making process. Results Triage time had a mean of 10 minutes and ranged between 4.34 minutes and 13.45 minutes. However, triage was significantly longer during the interrupted scenarios. Seventy‐seven percent of the acuity assessments (ESI) were correct. Of the 18 scenarios, 3 uninterrupted scenarios had incorrect ESI scores, and one interrupted scenario had a missing acuity score. Discussion This study provides the basis for future work that looks at how nurses successfully manage interruptions and tests interventions to assist triage nurses in managing or reducing interruptions during this important patient assessment process.

Barriers to Research Recruitment of Women Experiencing a Pregnancy Loss in the Emergency Department

Women often come to the emergency department (ED) with signs and symptoms suggesting an early pregnancy loss; yet, little is known about their experience and how it relates to future outcomes. To improve patient outcomes and experiences of women seeking care for a pregnancy loss, research is required. However, recruitment of participants experiencing an event such as a pregnancy loss is challenging. The purpose of this article is to discuss the application of an electronic medical record (EMR)-based participant screening tool recruiting women seeking care for a pregnancy loss in the ED. This study implemented an EMR-based prompt to assist participant screening completed by ED nurses: (a) The prompts were based on criteria built into triggers that activated a recruitment screening form to print upon discharge; (b) nurses completed the form with patients, asking for willingness to be contacted at home; and (c) participants were subsequently contacted and enrolled in the study. Our research screening program was implemented continuously in 2 EDs: a large, urban, academic medical center and a community academic hospital. Data were analyzed through descriptive statistics of reports built within the EMR. These reports signaled when the screening tool flagged participants and subsequently tied the corresponding information to the completed forms. The recruitment tool fired 1,169 times, with 61% (n = 714) screened. Fifty percent (n = 37) of women experiencing an early pregnancy loss were willing to be contacted at home for research recruitment. Of those approached after discharge (n = 24), 33% (n = 8) enrolled in the study. Of note, at one site, 14% (81/577) of potential participants with early pregnancy loss symptoms left before seeing a provider, with 26% (150/577) of these encounters were repeat visits. Staff education, nurse reluctance to approach potential participants, and patients who left without being seen led to barriers in participant screening.

The Triage Interruptions Assessment Tool: An Instrument Development.

Interruptions contribute to catastrophic errors in health care. Interruptions are breaks in the performance of a human activity initiated by a source internal or external to the recipient. Errors during the initial triage assessment can lead to errors in estimating the acuity of a patient and resources required for appropriate care. To advance the science, a valid and reliable instrument to measure this phenomenon is required. The purpose of this mixed-methods/exploratory sequential study was to develop an instrument sensitive to the uniqueness of the triage assessment that would categorize and measure the number and causes of triage interruptions. The study included 3 phases. Phase 1: Qualitative focus groups were used to qualitatively explore interruptions in triage. In Phase 2: Content Validity Assessment, an online survey was used and a content validity index was calculated for each item to determine which items should be modified or removed. A descriptive correlational design was used to assess interrater reliability in Phase 3. Many of the items identified during the focus group sessions were already on the study instrument; some new items were added. Content validity for the entire instrument was 0.82 and increased to 0.91 once irrelevant items were removed. Interrater reliability for the entire instrument demonstrated substantial agreement at 0.773. The study instrument was shown to have strong psychometrics and can be used in practice to better understand what interruptions are occurring in triage and how they affect the triage process.