ASSIGNMENT 2

Name: Jessica Amanda Hamilton

R2206D14663296

Health Quality Management (54697)

Tutor: Bilal Selman

Literature Review

Introduction

The Emergency Department (ED), similarly recognized as the Emergency Room (ER) or
Accident & Emergency (A&E) department, is considered a specialized medical facility within a
hospital or medical center that is intended to provide urgent and immediate medical care to
persons who are suffering from acute illness, injury, or any other medical emergency (Dale et al.,
1995). The primary goal of the Emergency branch of the hospital is to stabilize and or treat
patients in critical condition and provide timely and appropriate medical care, typically 24/7
around the clock daily. The Emergency Department is known to function as a fast-paced and
vigorous environment where patients who visit this department are sorted and prioritized based
on the intensity or seriousness of their present condition, and patients with more life-threatening
complaints receive priority for immediate medical attention. The Emergency Department is
designed to provide timely and appropriate medical care to stabilize patients, address their
crucial medical needs, and make decisions regarding further treatment, such as inpatient
admission to the hospital, transfer to specialty care, and receiving care from a specialist medical
practitioner who will continue the necessary treatment, or discharge with appropriate follow-up
care (Dale et al., 1995, Hwang, 2004).

The Emergency and Accident Department is operated by a competent team of emergency

medicine-trained healthcare professionals, including physicians, nurses, and other support
workers (from the laboratory and x-ray department). They have specialized equipment and
resources to evaluate, diagnose, and manage a wide array of medical conditions, inclusive of, not
restricted to trauma, severe illnesses, heart attacks, strokes, respiratory distress, severe infections,
and other critical conditions that affect patients that come into the ER.

Quality in the ER refers to the degree of care rendered to patients who are seeking urgent
medical assistance. Various indicators of quality in the Emergency Room (ER), include patient
outcomes, patient satisfaction, and adherence to established clinical guidelines (Broccoli et al.,
2018). In general, quality in the Emergency Department necessitates a comprehensive strategy
that examines multiple variables that contribute to the quality of the Emergency Room which
includes timeliness, safety, efficacy, patient-centeredness, coordination, efficiency, and
accessibility (Broccoli et al., 2018). By emphasizing these critical factors, the ER can deliver the
highest possible quality care to patients who require urgent or immediate medical assistance. The
main goal and purpose of this paper as the frontrunner of Quality Assurance and Enhancement at
the Victoria General Hospital are to identify quality control tools so that improvement of
efficiency and effectiveness of patient satisfaction can occur, while considering and addressing
issues and shortcomings of the ED (congestion, prolong waiting period, lengthy duration of visit,
extensive patient flow time and high left- without- being -seen rates), and investigate clinical
governance while finding ways to aid in the improvement of quality of services offered to
patients who visit the Emergency Department.

The Problem

Because of the significant amounts of patients that visit the Emergency Room on a regular basis,
it has earned the reputation of being known as a fast-paced department. Due to this fact, various
issues have emerged, some of which have been ongoing and long-standing for some time, since
efforts to successfully address and curb these issues have proven futile. There are other concerns
afflicting the ED, however, the focus will be on some of the most pressing issues. Some of the
many issues encountered when visiting the Emergency Department cover a wide range from
overcrowding to lengthy wait times at the hospital.

Objectives

 To propose appropriate feasible strategies to address the challenges affecting the

Emergency Department.
 Produce scientific evidence on how to apply improvement approaches to analyze and
understand these issues so the organization can combat these problems in the ED.
 Presentation of the importance of clinical governance implementation in the department.
Methods and Materials

An automated database search was utilized to locate relevant publications for this literature
assessment research. For both published and ready-to-publish publications, the search scanned
bibliographic databases such as PubMed, Science Direct, Wiley online library, and Google
Scholar. Additionally, the literature study included manually analyzing bibliographies to identify
publications with pertinent and applicable data that satisfy the goals of this paper. To refine the
search, the following keywords were used overcrowding, Emergency Department, increased
length of Stay, time spent waiting, boarding, ED patient flow, quality assessment, and quality
assurance.

Literature on Assessment of the Emergency Room Department

The emergency department (ED) is known all over the world as an essential part of healthcare in
general, it caters to patients with urgent and critical medical attention who suffer from serious
illnesses or injuries. However, the ED also faces several trials that impact the quality of care
offered and the efficiency of operations. This paper will be focused on assembling pieces of
evidence from academic papers that highlight and show efficient scopes and techniques that are
applicable in evaluating the challenges of the ED and how to solve them effectively.

Overcrowding

A major challenge in the emergency department is overcrowding. It has become a very serious
and growing issue that is common around the world today (Di Somma et al., 2014). Overfilling
in the ED describes a condition affecting the quantity of any patient seeking immediate care that
exceeds the department's capacity to provide timely and effective care (Hwang, 2004). Research
done by different studies revealed that overcrowding can lead to extended waiting periods for
patients, medical services delays, and potential harm to patient safety. This situation can arise
due to the product of a variety of internal and external factors, such as high patient volume,
limited or shortage of resources, inadequate staffing levels (ED nurses and physicians), and a
lack of available hospital beds. ED overcrowding is a significant challenge that decides on the
standard of care provided and the overall efficiency of the healthcare system (Rezaei et al.,
2017, Di Somma et al., 2014).

For years the reasons for overcrowding in the Emergency Department have been studied
extensively and researchers have accounted for various factors that account for this issue. Some
of the commonly listed contributing factors are cited in many papers as follows: Patients who
may not be able to access primary care, unnecessary trips to the ED, scheduling of surgeries, and
illness that occurs specifically during particular the seasons.

Patients who lack access to primary care, including the uninsured and those with low incomes,
often turn to emergency rooms for non-urgent medical issues. This can lead to overcrowding and
longer wait times for patients who have more urgent medical needs (Salway et al., 2017).
However, studies done on the uninsured have not strongly supported the argument that these
classes of individuals occupied the Ed more often when compared to covered patients, or that
they contribute to a significant cause of crowding (Salway et al., 2017). In research conducted
recently in Oregon, 23% of patients associated with Medicaid (public-based insurance) visited
the ED in one year, with 3% of patients accounting for 50% of ED visits (Wang et al., 2018 ;
Salway et al., 2017).

In recent years, there has been increasing focus on the boarding of admitted patients as the
primary cause of overcrowding in the emergency department (ED). When there are no suitable
inpatient beds available, patients are frequently kept in the ED, which is a significant contributor
to the problem of ED overcrowding. Numerous studies have demonstrated a clear and strong
association between ED admissions and overcrowding, with boarding being a major factor.
Essentially, the hospital's overload, not the ED's, is the primary source of ED overcrowding
(Salway et al., 2017).

Extended length of stay

Studies done before have shown crowding in the Emergency Department is connected to adverse
patient consequences. An increase in hospital length of stay (LOS) is one such impact. According
to (Driesen et al., 2018), the Emergency Department LOS is defined as the overall amount of
time from the initial recorded time after the arrival at the ED, inclusive of triage or registration,
to the time that the patient is released from the emergency department. Hospital bed shortage is a
frequently cited cause responsible for increased length of time. Other considerations include
doctor consultation delays and quick and easy accessibility to radiography and laboratory
facilities (Andersson et al., 2020).

Previous studies exploring the patient-related elements that lead to a longer stay in the
emergency department have identified certain patient groups that are at a higher risk of
exceeding a 4-hour ED-LOS. These patient groups include individuals aged 65 and above,
patients arriving during peak periods, patients undergoing surgical procedures, neurology or
internal medicine patients, patients in need of radiology or laboratory examinations, and patients
classified as Emergency Severity Index 2 or 3. (Driesen et al., 2018).

Prolonged wait time for sick patients.

The Centers for Disease Control (CDC) reports that over 10% of patients triaged as critical by
nurses in emergency departments waited for more than an hour before seeing a physician. It's
worth noting that many illnesses require time-sensitive treatment. According to a study by
Horwitz et al. (2010) on emergency department wait times, only 67% of critically ill patients in
the United States were seen within the recommended timeframes. (Horwitz et al., 2010).

Pines et al. conducted a study on the incidence of acute coronary syndrome (ACS) in crowded
versus non-crowded emergency departments. The study discovered a significant increase in
several serious adverse outcomes, including death, cardiac arrest, heart failure, late myocardial
infarction, arrhythmias, stroke, or hypotension, among patients who arrived during an eight-day
period of overcrowding. Specifically, the incidence of adverse effects was on average 6% for
overcrowded periods versus 3% for non-crowded periods. (Pines et al., 2009). When
interventions are carried out early, more beneficial outcomes are obtained. If a diagnosis
becomes known too late, it may result in a lifelong disability or fatality. Wait times can be
reduced by lowering access challenges (Salway et al., 2017).

Excessive patient flow time

Factors that are specific or internal to the emergency department itself are considered
“throughput factors”. These factors generally affect the patient from the moment of admission to
release, hospitalization, or transfer. The productivity of the emergency department may be
influenced by the efficiency of hospital workers. The need for adequate assistance and ensuring
that staff working capacity is balanced must be emphasized to ensure that the department's flow
is accurate, particularly in emergency situations (Sartini et al., 2022).

Any factor that interferes with the movement of patients through the emergency department can
cause overcrowding. When any resource such as healthcare providers, consultants, diagnostic
services, or bed availability has a demand that exceeds its capacity to accommodate patients, it
creates a bottleneck in the flow of the system. Therefore, the flow will remain optimal only when
the resources are adequate to match the demand at all stages of the patient's journey. (Sartini et
al., 2022).

Patients leave without being treated.

Boarding increases walkouts from patients, sometimes even from those who may require
hospitalization. The boarding practice occurs when patients are held up in the emergency
department after being admitted to the hospital, or because there are no available inpatient beds
(American College of Emergency Physicians, 2018). The initial phase of boarding, often known
as time zero, is the important point when the decision to admit or place the patient on observation
was taken. Boarding results in a variety of problems which include but are not limited to
ambulance denials, lengthy waiting times for patients in the emergency department can cause
increased distress and discomfort for those waiting. Patients may be forced to lie on gurneys in
hallways for hours, or even days, which can negatively impact their care and comfort.
Additionally, the prolonged presence of these patients can also affect the ability of emergency
department staff to care for other patients in a timely and efficient manner. An overwhelmed ED
complicates and jeopardizes its ability to appropriately respond to patients' emergencies.
Reduced time spent in the ED by patients who obtained an “admit" or "observation" decision
from the doctor can considerably enhance patients' access to treatment while improving the
quality of care (Rezaei et al., 2017).
Figure 1: Illustration of the Impact of Boarding on Hospitalized Patients on ED Functions.

Hospitals typically operate efficiently when the census is at 85% (Green). However, when the
census exceeds this level, and admissions from the emergency department accumulate due to
longboarding (yellow), the hospital can become overwhelmed. Most hospitals can manage
inefficiencies when the census is less than 90% (Red). But, when the emergency department
becomes swamped and backed up, it can overcrowd the waiting room and delay service for
patients, increasing the risk of patient harm.

The Six Sigma DMAIC methodology is utilized as a means of measuring and improving
quality.

The DMAIC methodology, which stands for Define-Measure-Analyze-Improve-Control, is the

primary process used in Lean Six Sigma (LSS) initiatives. It allows medical experts to use the
DMAIC concept when an existing process does not match the client's needs. This methodology
involves transforming a practical issue into statistical data, and it is used to improve specific
areas of organizational processes. The DMAIC phases are based on factual data rather than
guesswork or opinion.
Phase: “Define”

The "Define" stage is crucial in the DMAIC process as the project's success heavily relies on its
proper execution. This phase involves identifying the problem to be solved, which is the first step
in addressing congestion in the emergency department (ED). Accurately describing and
quantifying the issue is critical, and data collection on patient wait times, bed occupancy rates,
and staffing levels may be necessary. In addition, defining specific goals and objectives, such as
decreasing wait times or increasing bed availability, is a crucial aspect of the Define step..
Furthermore, it is critical to include key stakeholders in the Define stage, such as ED personnel,
patients, and hospital managers, to ensure that everyone's wants and concerns are addressed. his
can aid in identifying potential improvement hurdles and ensuring that presented solutions are
practical and effective (Rezaei et al., 2017).
Figure 2: Portraying SIPOS (Suppliers – Inputs – Process – Outputs – Customers)

In Figure 2, SIPOC assessments are conducted at this level to define and understand the process.
Mapping out the process using SIPOC can reveal areas for potential improvement and clearly
define the roles and responsibilities of each participant. It can also be used to ensure that the
process is patient-centered and that their needs are met. Additionally, it ensures that the inputs
and suppliers align with the department's requirements. (Ortiz-Barrios & Alfaro-Saiz, 2020).

Phase: Measure

Understanding the existing method, measuring its metrics, and applying adjustments to improve
its performance are all part of the measurement phase. A protocol was formed through the
production of a process flow chart, which aided in the clarification and agreement on the
project's scope. Level 1 patients are treated quickly and may have several stages in the process
flowchart performed concurrently according to the severity of their disease. Patients in category
2 and 3 are required to provide their personal information and primary concerns during
registration before undergoing medical assessments. After medical review, patients can be
reclassified and may require imaging and laboratory tests as well as medical consultation,
whereas those in Level 1 can proceed directly to the doctor.

The Emergency Department process is finalized based on the doctor's assessment or

recommendation, which may include admitting the patient to the wards, referring them to the
surgical team for emergency surgery, issuing a prescription for medication, providing discharge
instructions with post-treatment or post-evaluation advice, or discharging them with post-
treatment or post-evaluation instructions. (Mitchell et al., 2020).
Figure 3: Patient Flow Procedure, which Connects the Triage Category to Important Steps
in the ED Patient Experience.

Phase:Analyse
During the analysis phase, the Quality Assurance department identifies potential sources of
variation that may have led to the identified issues, with the ultimate goal of determining the root
causes of the problem in order to implement an effective solution in the next phase. To categorize
the primary causes and sub-causes of the issues, a Fishbone diagram, also known as a cause-and-
effect diagram, is utilized. Fishbone diagrams are effective tools for identifying potential causes
of a problem (Mitchell et al., 2020).
Figure 4: The Concept of Cause-and-Effect Issues that lead to a longer period of service are
depicted in a diagram.

Phase: Improved

The improvement phase involves developing the necessary improvements that will fix the issue.
Here you may plan and manage experimental testing. The ultimate goal is to determine whether a
solution can address your problem.

The following are plans to employed for improvements:

 Enhance the patient triage process: To minimize wait times, it is crucial to develop an
efficient screening process where patients are prioritized based on their level of urgency.
This can be accomplished by reducing the number of triage forms, using technology to
speed up the process, or hiring more staff members during peak hours.
  Minimize unneeded tests and procedures: Excessive tests and procedures can raise wait
times and expenditures. Healthcare practitioners can improve efficiency and reduce wait
times by following evidence-based principles and standards that reduce the amount of
unnecessary tests and procedures.
 Enhance employee education and assistance: Improve employee education and support:
Consistent training and support for employees can help them enhance their skills and
knowledge, leading to more efficient and effective care delivery. This can involve
providing ongoing training on Lean Six Sigma principles, ensuring adequate staffing
levels, and promoting teamwork and communication within the team.

By utilizing these techniques, healthcare staff can enhance the quality and effectiveness of care
provision in the emergency department, leading to reduced wait times and increased patient
contentment (Oredsson et al., 2011).

Phase: Control

During the control phase, it is essential to sustain the monitoring and documentation of data
regarding patient wait times, overcrowding, patient contentment, and other significant
performance indicators. To track the process and detect any variations or deviations, statistical
process control (SPC) methods can be implemented. The accumulated data can then be analyzed
to identify patterns, trends, or noteworthy deviations, and corrective measures can be taken
promptly, if needed. In addition, incorporating visual management tools like dashboards to
oversee advancements and pinpoint areas for enhancement is a vital aspect of the control phase.
Exhibiting data in a visual format in real-time helps healthcare personnel in recognizing
problems promptly and resolving them. For instance, if wait times are rising during particular
hours of the day, this pattern can be noted and recognized as peak hours. Subsequently, this data
can be utilized to schedule extra staff during those hours.
Figure 5: Illustration of the Ideal Patient Journey

Clinical Governance Enhancement Strategies

Clinical governance is a framework that ensures the provision of high-quality, safe, and effective
patient care. In the emergency department (ED), clinical governance can be enhanced by
implementing various strategies. Some of these strategies include:

 Continuous Professional Development (CPD): ED staff should receive regular training

and development opportunities to update their clinical knowledge and skills. This will
help ensure they are up-to-date with the latest clinical guidelines and best practices.
 Clinical Audit: Conduct regular clinical audits to identify areas of improvement in patient
care. This can involve reviewing patient notes, examining treatment protocols, and
gathering feedback from patients.
  Incident Reporting: Encourage ED staff to report any incidents or near-misses. This will
enable the identification of potential hazards, allowing for corrective action to be taken
before any harm is caused.
 Clinical Guidelines: Implement evidence-based clinical guidelines and protocols to
provide a consistent approach to patient care. This can improve patient outcomes and
reduce the risk of clinical errors.
 Multidisciplinary Teamworking: Encourage collaboration and communication between
ED staff, including nurses, doctors, and other healthcare professionals, to enhance the
delivery of care.
 Patient Safety Culture: Develop a patient safety culture in the ED by encouraging staff to
take ownership of patient safety and promoting an environment where reporting incidents
and near-misses is encouraged.
 Quality Improvement: Establish a system for monitoring and improving the quality of
care provided in the ED. This can include regular data analysis, feedback, and
benchmarking against other EDs.

By implementing these strategies, clinical governance can be enhanced in the ED, leading to
improved patient outcomes and a safer, more effective healthcare service.

Conclusion

The consequences of overcrowding and long wait times at emergency departments can be severe
and life-threatening. Patients who require urgent medical attention may not receive timely care,
which can lead to worsened health outcomes, increased healthcare costs, and a strain on
healthcare systems. It is imperative that healthcare policymakers, providers, and stakeholders
work together to address this issue and find solutions that prioritize patient safety and efficient
delivery of care.

There are several potential strategies that could be implemented to reduce overcrowding and
long wait times at emergency departments, such as increasing funding for emergency services,
improving primary care access, and implementing better triage systems. These efforts will
require collaboration and cooperation from healthcare providers, administrators, and
policymakers at all levels. Ultimately, reducing overcrowding and long wait times at emergency
departments is essential for ensuring that patients receive timely, high-quality care when they
need it most. By prioritizing patient safety and effective delivery of care, we can improve health
outcomes and reduce the burden on healthcare systems.
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