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Increased Emergency Department Boarding Times

Marija Djokovic
Prolonged boarding times (increased wait times for admitted patients) in the emergency
department result in an increase in morbidity and mortality in critically ill adult patients
to the ICU. Overcrowding in the emergency department (ED), medication errors, and a
delay in
transfer to the ICU are the leading reasons for an increase in morbidity and mortality.
project focuses on a comprehensive assessment of a Las Vegas emergency
department. The
assessment will determine if the issues cited in the literature of: 1) overcrowding, 2)
errors, and 3) delay in transfer are a current problem in the Las Vegas emergency
department and
based on the assessment data and evidence-based plan will be developed.

Common infection control practices in the emergency department:
A literature review
Eileen J. Carter et al
Background: Health care-associated infections (HAIs) are a major health concern,
despite being largely
avoidable. The emergency department (ED) is an essential component of the health
care system and
subject to workflow challenges, which may hinder ED personnel adherence to guideline-
based infection
prevention practices.
Methods: The purpose of this review was to examine published literature regarding
adherence rates
among ED personnel to selected infection control practices, including hand hygiene
(HH) and aseptic
technique during the placement of central venous catheters and urinary catheters. We
also reviewed
studies reporting rates of ED equipment contamination. PubMed was searched for
studies that included
adherence rates among ED personnel to HH during routine patient care, aseptic
technique during the
placement of central venous catheters and urinary catheters, and rates of equipment
Results: In total, 853 studies was screened, and 589 abstracts were reviewed. The full
texts of 36 papers
were examined, and 23 articles were identified as meeting inclusion criteria. Eight
studies used various
scales to measure HH compliance, which ranged from 7.7% to 89.7%. Seven articles
examined central
venous catheters inserted in the ED or by emergency medicine residents. Detail of
aseptic technique
practices during urinary catheterization was lacking. Four papers described equipment
contamination in
the ED.
Conclusion: Standardized methods and definitions of compliance monitoring are needed
to compare
results across settings.

As stated in this study, to be able to lessen the population of patients in the emergency
room, an advance nursing intervention should be given at the time the patient got to the
triage. It can also help alleviate the complaint of the patients and vacate the beds that
patients with a critical case will need.

Mary A. Stauber et al
Introduction: Over the past 15 years, emergency departments
have become overcrowded, with prolonged wait times and an
extended length of stay (LOS). These factors cause delay in
treatment, which reduces quality of care and increases the
potential for adverse events. One suggestion to decrease LOS in
the emergency department is to implement advanced nursing
interventions (ANIs) at triage. The study purpose was to
determine whether there was a difference in ED LOS between
patients presenting with a chief complaint of abdominal pain
who received ANIs at triage and patients who did not receive
ANIs at triage.
Methods: A retrospective chart review was performed to
determine the ED LOS (mean time in department and mean time
in room [TIR]). The convenience sample included ED patients who
presented to a large Midwestern academic medical centers
emergency department with a chief complaint of abdominal pain
and Emergency Severity Index level 3. Independent-samples t
tests were used to determine whether there was any statistical
difference in LOS between the two groups. Cohens d statistic
was used to determine effect size.
Results: Implementation of ANIs at triage for patients with lowacuity
abdominal pain resulted in an increased time in department
and a decreased TIR with a medium effect size.
Conclusion: A reduction in TIR optimizes bed availability in the
emergency department. Low-acuity patients spend less time
occupying an ED bed, which preserves limited bed space for the
sickest patients. Results of diagnostic tests are often available by
the time the patient is placed in a room, facilitatin
Healthcare workers and health care-associated
infections: knowledge, attitudes, and behavior in
emergency departments in Italy
Cristiana Parmeggiani et al
Background: This survey assessed knowledge, attitudes, and compliance regarding
standard precautions about
health care-associated infections (HAIs) and the associated determinants among
healthcare workers (HCWs) in
emergency departments in Italy.
Methods: An anonymous questionnaire, self-administered by all HCWs in eight
randomly selected non-academic
acute general public hospitals, comprised questions on demographic and occupational
characteristics; knowledge
about the risks of acquiring and/or transmitting HAIs from/to a patient and standard
precautions; attitudes toward
guidelines and risk perceived of acquiring a HAI; practice of standard precautions; and
sources of information.
Results: HCWs who know the risk of acquiring Hepatitis C (HCV) and Human
Immunodeficiency Virus (HIV) from a
patient were in practice from less years, worked fewer hours per week, knew that a
HCW can transmit HCV and
HIV to a patient, knew that HCV and HIV infections can be serious, and have received
information from educational
courses and scientific journals. Those who know that gloves, mask, protective eyewear,
and hands hygiene after
removing gloves are control measures were nurses, provided care to fewer patients,
knew that HCWs hands are
vehicle for transmission of nosocomial pathogens, did not know that a HCW can
transmit HCV and HIV to a
patient, and have received information from educational courses and scientific journals.
Being a nurse, knowing
that HCWs hands are vehicle for transmission of nosocomial pathogens, obtaining
information from educational
courses and scientific journals, and needing information were associated with a higher
perceived risk of acquiring a
HAI. HCWs who often or always used gloves and performed hands hygiene measures
after removing gloves were
nurses, provided care to fewer patients, and knew that hands hygiene after removing
gloves was a control
Conclusions: HCWs have high knowledge, positive attitudes, but low compliance
concerning standard precautions.
Nurses had higher knowledge, perceived risk, and appropriate HAIs control measures
than physicians and HCWs
answered correctly and used appropriately control measures if have received
information from educational courses
and scientific journals.

The Effect of Emergency Department
Crowding on Patient Outcomes
Kimberly D. Johnson et al
The purpose of this review was to summarize the findings of published reports that
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 nursesensitive
quality indicators in the ED has potential to develop strategies that deliver high quality of
care, regardless of crowded conditions.

Emergency Department Triage Scales and Their
Components: A Systematic Review of the
Scientific Evidence
Nasim Farrohknia et al
Emergency department (ED) triage is used to identify patients level of urgency and
treat them based on their
triage level. The global advancement of triage scales in the past two decades has
generated considerable research
on the validity and reliability of these scales. This systematic review aims to investigate
the scientific evidence for
published ED triage scales. The following questions are addressed:
1. Does assessment of individual vital signs or chief complaints affect mortality during
the hospital stay or within
30 days after arrival at the ED?
2. What is the level of agreement between clinicians triage decisions compared to each
other or to a gold
standard for each scale (reliability)?
3. How valid is each triage scale in predicting hospitalization and hospital mortality?
A systematic search of the international literature published from 1966 through March
31, 2009 explored the British
Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and
PubMed. Inclusion was limited to
controlled studies of adult patients (15 years) visiting EDs for somatic reasons.
Outcome variables were death in
ED or hospital and need for hospitalization (validity). Methodological quality and clinical
relevance of each study
were rated as high, medium, or low. The results from the studies that met the inclusion
criteria and quality
standards were synthesized applying the internationally developed GRADE system.
Each conclusion was then
assessed as having strong, moderately strong, limited, or insufficient scientific evidence.
If studies were not
available, this was also noted.
We found ED triage scales to be supported, at best, by limited and often insufficient
The ability of the individual vital signs included in the different scales to predict outcome
is seldom, if at all,
studied in the ED setting. The scientific evidence to assess interrater agreement
(reliability) was limited for one
triage scale and insufficient or lacking for all other scales. Two of the scales yielded
limited scientific evidence, and
one scale yielded insufficient evidence, on which to assess the risk of early death or
hospitalization in patients
assigned to the two lowest triage levels on a 5-level scale (validity).