Patricia Kunz Howard

Modeling and analysis of the emergency department at University of Kentucky Chandler Hospital using simulations.

INTRODUCTION In this article, we present a simulation study conducted in the emergency department at the University of Kentucky Chandler Hospital. METHODS Based on analysis of process and flow data, a simulation model of patient throughput in the emergency department has been developed. RESULTS What-if analyses have been proposed to identify bottlenecks and investigate the optimal numbers of human and equipment resources (eg, nurses, physicians, and radiology technology). The simulation results suggest that 3 additional nurses are needed to ensure desired clinical outcomes. Diagnostic testing, the computed tomography scan in particular, is found to be a bottleneck. As a result, acquisition of an additional computed tomography scanner is recommended. Hospital management has accepted the recommendations, and implementation is in progress. DISCUSSION Such a model provides a quantitative tool for continuous improvement and process control in the emergency department and also is applicable to other departments in the hospital.

Workplace Violence in Healthcare Settings: Risk Factors and Protective Strategies

&NA; This article describes the risk factors and protective strategies associated with workplace violence perpetrated by patients and visitors against healthcare workers. Perpetrator risk factors for patients and visitors in healthcare settings include mental health disorders, drug or alcohol use, inability to deal with situational crises, possession of weapons, and being a victim of violence. Worker risk factors are gender, age, years of experience, hours worked, marital status, and previous workplace violence training. Setting and environmental risk factors for experiencing workplace violence include time of day and presence of security cameras. Protective strategies for combating the negative consequences of workplace violence include carrying a telephone, practicing self‐defense, instructing perpetrators to stop being violent, self‐ and social support, and limiting interactions with potential or known perpetrators of violence. Workplace violence is a serious and growing problem that affects all healthcare professionals. Strategies are needed to prevent workplace violence and manage the negative consequences experienced by healthcare workers following violent events.

Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department

From the EMSC Panel (Writing Committee) on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department: Sharon E. Mace, MD, Chair, American College of Emergency Physicians (ACEP) Lance A. Brown, MD, MPH (ACEP) Lisa Francis, BSN, RN (Society of Pediatric Nurses) Steven A. Godwin, MD (ACEP) Sigrid A. Hahn, MD (ACEP) Patricia Kunz Howard, PhD, RN, CEN (Emergency Nurses Association) Robert M. Kennedy, MD (American Academy of Pediatrics) David P. Mooney, MD (American Pediatric Surgical Association) Alfred D. Sacchetti, MD (ACEP) Robert L. Wears, MD, MS, Methodologist (ACEP) Randall M. Clark, MD (American Society of Anesthesiologists)

Modeling and Analysis of Care Delivery Services Within Patient Rooms: A System-Theoretic Approach

Care services within the patient rooms are the most critical and time consuming processes in patient care deliveries in emergency department, clinics, and other healthcare facilities. In this paper, we introduce a Markov chain model to study such processes. A closed, parallel, and reentrant network with limited resources is used to model the process. Formulas to evaluate the patient length of stay and staff utilizations are developed. System-theoretic properties are discussed. The extension to non-Markovian scenarios is also investigated. Such a model provides a quantitative tool for healthcare professionals to study and improve patient flow in care deliveries.

A system model of work flow in the patient room of hospital emergency department.

Modeling and analysis of patient flow in hospital emergency department (ED) is of significant importance. In a hospital ED, the patients spend most of their time in the patient room and most of the care delivery services are carried out during this time period. In this paper, we propose a system model to study patient (or work) flow in the patient room of an ED when the resources are partially available. A closed and re-entrant process model is developed to characterize the care service activities in the patient room with limited resources of doctors, nurses, and diagnosis tests. Analytical calculation of patient’s length of stay in the patient room is derived, and monotonic properties with respect to care service parameters are investigated.

Modeling and analysis of hospital emergency department: An analytical framework and problem formulation

In this paper, we propose an analytical framework for modeling and analysis of hospital emergency departments (ED). Using such a framework, we intend to develop methods that can be used to improve ED performance through redistributing limited resources and through identifying and mitigating bottlenecks. Specifically, the following problems will be addressed: (1) analytical modeling and investigation of patient flow and quality of care (e.g., patient outcome or length of stay) in emergency departments, (2) identifying the factors that impede ED performance in the strongest manner and obtaining optimal distribution of limited resources for the best quality of care, and (3) determine optimal workforce configuration and resource allocation to achieve desired performance. A system-theoretic method is proposed to model ED as a complex network with split, parallel, closed, and re-entrant structures, for performance analysis, bottleneck mitigation and resource allocation.

Compliance With Hand Hygiene Guidelines

The Research to Practice column attempts to serve 2 purposes: (1) fine-tune the research critique skills of advanced practice nurses and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research paper is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. In this column, T. Eckmans, J. Bessert, M. Behnke, P. Gastmeir, and R. Henning (2006) investigate the effect of having a trained observer assess for compliance with antiseptic hand rub use in intensive care units. The implications of these findings for advanced practice nurses are discussed.

Diagnosing and treating mild traumatic brain injury in children.

Review of recent evidence with translation to practice for the advanced practice nurse role is presented using a case study format for “Mild Traumatic Brain Injury in Children.” This “short review” describes the state of the science regarding diagnosis and treatment of mild traumatic brain injury in children, demonstrating multiple challenges to synthesizing existing research into practice guidelines. Implications of this lack of clear research evidence on advanced practice nursing are discussed along with suggestions for using alternative sources of evidence.

Comprehension of discharge instructions.

The Research to Practice column attempts to serve two purposes: (1) fine-tune the research critique skills of advanced practice nurses and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research paper is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. This particular column reviews the article: Engel, K., Heisler, M., Smith, D., Robinson, C., Forman, J., & Ubel, P. (in press). Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Annals of Emergency Medicine.

Is Subdissociative Ketamine As Safe and Effective As Morphine for Pain Management in the Emergency Department

&NA; Review of recent evidence with translation to practice for the advanced practice nurse (APN) role is presented using a case study module for “Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial.” This prospective, randomized controlled inquiry enrolled 90 patients into 2 groups (ketamine vs. morphine) for patients seeking care in an emergency department with acute pain. Data regarding pain scores were collected at baseline, 15, 30, 60, 90, and 120 min. Study subjects reporting persistent pain could receive rescue analgesia with fentanyl. Initial pain scores for the subjects in each of the groups were comparable (ketamine: 8.6; morphine: 8.5). Pain management for the 2 groups revealed similar average doses (ketamine: 21.8 mg; morphine: 7.7 mg). Although subjects in both groups reported reduction in pain scores at 15 and 30 min, no clinical significance was found. Subjects experienced greater pain relief (pain score = 0) in the ketamine group at 15 min (percentage difference 31%; 95% confidence interval [13, 49]), yet this was not sustained at the 30-min interval. There were no serious or life-threatening adverse effects in either group. This study highlights the important role of the APN in providing quality care, communication about pain management, and related follow-up care.