2010; McCarthy et al. 2009; Zimmerman 2004). These studies have also shown that a reduction in boarding numbers and crowding can eliminate or reduce these problems. After all of these considerations, the fourth step in Rosswurm and Larrabee's (1999) model for change is to design the actual changes to practice that should be implemented. In this case, this requires few additional resources other than learning materials for hospital staff to acquaint themselves with new procedures and practices -- there is no equipment necessary, and supplies used by the emergency department should actually decrease pretty much across the board as patients are more quickly sent to other departments of the hospital after stabilization (AEM 2008). The design, then, is one that is purely procedural, and should consist of clear triage and stabilization practices that effectively assess patients and determine the appropriate continuation of their care, whether that be on an outpatient basis or an inpatient basis in a non-emergency department of the hospital.

Actually implementing the designed changes is the next step in the model developed by Rosswurm & Larrabee (1999), and is again a matter of procedural change brought about training and education regarding new policies and standards. A specific hospital with a demonstrable overcrowding issue brought about by emergency department patient boarding should be selected for a pilot study, so that the results of the implemented changes can be rendered as clear as possible (with more dramatic change equating to clearer results, generally speaking). It has already been established that increasing the capacity for emergency department boarding is not really an effective solution to the observed problems, meaning that an elimination of the problem at its root should be more effective (Zimmerman 2004).

An evaluation of the pilot study and decisions regarding adaptations and adoptions marks the end of the fifth step in the Russwurm and Larrabee (1999) model, and leads directly to the sixth and final phase: the integration and maintenance of the proposed changes. It is likely that each individual institution will develop slightly different procedures for the assessment of patients in their...

Ongoing monitoring of the situation and the maintenance of new policies will also increase the efficiency of the hospital as a whole and the emergency department specifically, creating indirect benefits for all stakeholders as well (McCarthy et al. 2009; Bair et al. 2010).
Evaluation

An evaluation of the implemented changes can be conducted from several different levels and perspectives. From an overall administrative stance, a simple look at a few key statistics -- average length of stay in the emergency department, admittance rates and durations for patients entering the hospital through the emergency department, ED mortality rates during and subsequent to treatment, and other statistics noted in previous research can be used to evaluate the success of the changes. A more immediate perspective can examine the workload experienced by ED staff and stressors/issues noted by patients, which have also been correlated with overcrowding and ED boarding practices (Bair et al. 2010; McCarthy et al. 2009; Zimmerman 2004).