Mark McClelland

The Past, Present, and Future of Urgent Matters: Lessons Learned from a Decade of Emergency Department Flow Improvement

Over the past decade, emergency departments (ED) have encountered major challenges due to increased crowding and a greater public focus on quality measurement and quality improvement. Responding to these challenges, many EDs have worked to improve their processes and develop new and innovative models of care delivery. Urgent Matters has contributed to ED quality and patient flow improvement by working with hospitals throughout the United States. Recognizing that EDs across the country are struggling with many of the same issues, Urgent Matters-a program funded by the Robert Wood Johnson Foundation (RWJF)-has sought to identify, develop, and disseminate innovative approaches, interventions, and models to improve ED flow and quality. Using a variety of techniques, such as learning networks (collaboratives), national conferences, e-newsletters, webinars, best practices toolkits, and social media, Urgent Matters has served as a thought leader and innovator in ED quality improvement initiatives. The Urgent Matters Seven Success Factors were drawn from the early work done by program participants and propose practical guidelines for implementing and sustaining ED improvement activities. This article chronicles the history, activities, lessons learned, and future of the Urgent Matters program.

Elaborating on theory with middle managers' experience implementing healthcare innovations in practice.

BackgroundThe theory of middle managers’ role in implementing healthcare innovations hypothesized that middle managers influence implementation effectiveness by fulfilling the following four roles: diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. The theory also suggested several activities in which middle managers might engage to fulfill the four roles. The extent to which the theory aligns with middle managers’ experience in practice is unclear. We surveyed middle managers (n = 63) who attended a nursing innovation summit to (1) assess alignment between the theory and middle managers’ experience in practice and (2) elaborate on the theory with examples from middle managers’ experience overseeing innovation implementation in practice.FindingsMiddle managers rated all of the theory’s hypothesized four roles as “extremely important” but ranked diffusing and synthesizing information as the most important and selling innovation implementation as the least important. They reported engaging in several activities that were consistent with the theory’s hypothesized roles and activities such as diffusing information via meetings and training. They also reported engaging in activities not described in the theory such as appraising employee performance.ConclusionsMiddle managers’ experience aligned well with the theory and expanded definitions of the roles and activities that it hypothesized. Future studies should assess the relationship between hypothesized roles and the effectiveness with which innovations are implemented in practice. If evidence supports the theory, the theory should be leveraged to promote the fulfillment of hypothesized roles among middle managers, doing so may promote innovation implementation.

The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.

Increasing Throughput: Results from a 42-Hospital Collaborative to Improve Emergency Department Flow

BACKGROUND An 18-month collaborative in 42 hospitals across 16 communities in the United States to improve emergency department (ED) flow was conducted from October 2010 through March 2012. METHODS Hospitals were invited to participate through the Aligning Forces for Quality (AF4Q) program. Each participating hospital identified one or more interventions to improve ED flow and submitted data on four measures of ED flow: discharged length of stay (LOS), admitted LOS, boarding time, and left without being seen (LWBS) rates. Participating hospitals also provided quarterly progress reports on challenges encountered and lessons learned. Univariate linear regression was used to assess the effectiveness of interventions at the hospital level, where an improvement was defined as a negative slope in one or more of the throughput indicators. Challenges and lessons learned were tabulated and described. RESULTS A total of 172 interventions were implemented across the 42 hospitals. Two thirds (n = 28) demonstrated improvement on at least one measure of ED flow. Among hospitals demonstrating improvement, the average reduction in discharged LOS was 26 minutes (95% confidence interval [CI] 11 to 41); admitted LOS, 36.5 minutes (95% CI 20 to 53), boarding time, 20.9 minutes (95% CI 12 to 30), and LWBS seen rates decreased by 1.4 absolute percentage points (95% CI 0.2 to 2.7). Teams were frequently challenged by issues related to leadership, staff buy-in, and resource constraints. CONCLUSION The majority of hospitals in this collaborative improved on one or more ED flow measures. Many challenges were shared across hospitals, demonstrating that successful approaches to ED flow improvement require certain fundamental elements, including engaged leadership and staff, and sufficient resources.

Hospital Culture of Transitions in Care: Survey Development.

Understanding hospital culture is important to effectively manage patient flow. The purpose of this study was to develop a survey instrument that can assess a hospitals culture related to in-hospital transitions in care. Key transition themes were identified using a multidisciplinary team of experts from 3 health care systems. Candidate items were rigorously evaluated using a modified Delphi technique. Findings indicate 8 themes associated with hospital culture-mediating transitions. Forty-four items reflect the themes.

The relationship between Metabolic Syndrome and adherence to cardiac rehabilitation.

• Patients with Metabolic Syndrome are at double the risk of heart disease compared to those without.

Functional Capacity but Not Early Uptake of Cardiac Rehabilitation Predicts Readmission in Patients with Metabolic Syndrome

Background: Phase II cardiac rehabilitation reduces hospital readmissions and cardiovascular disease risk factors and improves functional capacity. Cardiovascular disease risk factors double with patients with metabolic syndrome, a population less likely to adhere to cardiac rehabilitation. Purpose: The aim of this study was to determine relationships between cardiac rehabilitation uptake timing, demographic variables and functional capacity, and readmission in patients with metabolic syndrome. Methods: This retrospective, medical records study involved 353 patients with metabolic syndrome who subsequently received cardiac rehabilitation. Logistic regression was used to examine relationships between time from discharge to cardiac rehabilitation uptake and readmission. Unordered categorical factors were compared between readmission groups using Pearson &khgr;2 tests. Multivariable logistic regression was used to identify predictors of readmission. Results: Patients readmitted within 30 and 90 days of hospitalization were more often women (P ⩽ .018) and nonwhite (P ⩽ .002) and had lower functional capacity (P < .001). In multivariable analysis, white race (odds ratio [OR], 0.50 [95% confidence interval (CI), 0.25–0.99]; P = .045) and higher functional capacity (OR, 0.80 [95% CI, 0.68–0.93]; P = .005) were protective against hospital readmission within the first 90 days. Race, sex, and functional capacity remained significant predictors of readmission at 1 year. In multivariable analysis, only race (OR, 0.41 [95% CI, 0.22–0.79]; P = .007) and functional capacity (OR, 0.83 [95% CI, 0.73–0.95]; P = .007) were significant. Early cardiac rehabilitation was not associated with readmission at any time point (P > .05). Conclusions: Sex, race, and functional capacity were important predictors of readmission for metabolic syndrome, even when cardiac rehabilitation intake was delayed. Results raise questions about the unique traits of patients with metabolic syndrome and need for novel approaches to improve cardiac rehabilitation utilization and functional capacity in metabolic syndrome.

Strategies to influence RN specialty certification.

nursingmanagement.com S pecialty certification provides recognition for key professional attributes that affect patient outcomes, nurse satisfaction, and collaboration with other providers.1,2 The certification process enhances professional development and growth.3 There’s a growing trend in hospitals to pursue recognition through the American Nurses Credentialing Center’s Magnet Recognition® or Pathway to Excellence® programs. These programs make nurse certification a high priority, as demonstrated by their foci on plans for certifica tion and attainment of continuous improvement of nurse certification rates.4,5 Despite increasing acceptance of the importance of specialty certification, very little is known about what motivates—or discourages—noncertified nurses who are likely to certify in the near future. Because the certification process can involve considerable expense for nursing departments, a better understanding of nurses actively moving toward certification may enable nurse executives to be more effective in increasing their facilities’ proportions of certified nurses. By Deborah Solomon, MSN, RN, ACNS-BC; Meredith Lahl, MSN, PCNS-BC, PNP-BC, CPON; Marian Soat, MSN, RN, CCNS, CCRN; James Bena, MS; and Mark McClelland, DNP, RN, CPHQ Strategies to influence RN specialty certification

Enhancing care of older adults in the emergency department: Old problems and new solutions

The dramatic increase in the number of older adults in our society is creating greater demand for age-appropriate health care services. Because older adults use proportionally more emergency services than any other age group, it is important to address problems and find solutions to emergency care for this vulnerable population. Older adults often need specialized care to meet complex physical and psychological needs in an emergency department (ED). A new focus on establishing geriatric EDs holds promise for reducing barriers to ED access and decreasing suboptimal outcomes. Recently published geriatric ED guidelines provide health care professionals with recommendations to systematically improve emergency care for older adults.