Nurse practitioner staffing and emergency department crowding reduction

Hiring a Nurse Practitioner reduces wait times (overcrowding) in the Emergency Department

estimation of the ED (Emergency department) compromise with care afforded to patients because of overcrowding from the perspective of the provider of services.

/I researched literature and bonafide / authenticated texts that chose to: Study causation, impacts and resolution tactics aimed at ED crowding; Collected and analyzed data using established methods; specifically target the ED scenario and the day-to-day crowding at the ED in care centers and hospitals. There is in each case a lot of reporting done on the circumstances ( like shortages of beds and staff) and that have led to the crowding that can be seen to increase with each passing day at ED centers, the overall impact that has had on the quality of care given to the patients as a result, and the solutions that have either been worked out or are being discussed ( like additional staffing, increase in furniture for boarding, administrative measures and increase in primary care facilities) to alleviate the problem that is taking a grim shape very fast.

Conclusions: The most easily perceived notion associated with crowding is that of inadequate service and care provided to the patients. There is no unanimity amongst doctors, physicians, nurses and the patients themselves over the exact cause of compromised care, in what way care was compromised and what was the identity of the real sufferer.

Introduction

Crowding pervades almost all the ED's (emergency Departments) across the nation as of date. The causation is multidimensional. The main factors that cause crowding include, but are not limited to: rapidly diminishing capacity of the hospitals clubbed with the fact that there are a number of hospitals that are themselves closing down or, are at least closing down their ED's; The patients that report to ED's are increasing; a perceptible shortage of trained nurses and skilled staff; health care services in general and administrative procedures that need to be followed by the service providers has become very involved and cumbersome and a very practical logistical problem of the inability of the hospitals to smoothly transfer the ED patients to the 'in-patients' section leading to stagnation of movement of patients and adding to the crowding.

This crowding of epidemical scales has adversely affected health care services to the patients in ED. It has also led to unacceptable delays in providing care to the patients. The waiting-period for the patients has increased considerably enough to cause concern. Staffing problems and boarding inadequacy are the two glaring causes that have to be assessed and addressed as a result of which crowding manifests. Many solutions to the problem have been suggested to alleviate the situation of the patients. Urgent care that needs to be given at times of emergencies superseding normal situations is found wanting in its resources most of the times.

On the face of it, it is a simple case of demand -supply gap. Incessantly increasing patients that want to or need to access ED and a shortage of adequately trained staff for the purposes couple with other logistical factors like boarding inadequacies and space constraints as also inability of the service providers to ease out the treated patients to less critical or 'general' departments are at the root of this malady that affects the nation. There are processes and steps that can be taken to improve the situation, though. Curtailment of stay duration of patients admitted to ED, once the progress is assured is one of the steps that need to be taken. Steps have to be taken for: screening those in absolute need of the ED treatment and immediate release of those who have been treated and need not be boarded in the ED. There are many more roles that are expected of the ED in addition to its being the care provider of those suffering trauma or in need of urgent attention in complex cases. A plausible way out suggested is to train and employ Nurse Practitioners who would be equipped to decide the merits of a case and help screening process, taking the weight of the resident physician who are already burdened with lot more.

Rationale and significance for advanced practice nursing (nurse practitioners)

The origin of Nurse Practitioners in the U.S. can be traced back to the delicate and careful handling required for the infants and toddlers- broadly termed as pediatrics (Silver and Ford, 1967). The scope evolved to provide specialist care in the fields that include family care, old-age caring and of late to extraordinary care to patients of acute illnesses. NP's now provide medical care to: infants and babies, incapacitated patients, those who are seriously afflicted and those that need long-term care. The nursing and basic medical services are provided by the NP's to individuals, families and at times to groups as well ((American Academy of Nurse Practitioner (AANP, 2003).the services provided by the NP's have a much larger vista than providing the said services of nursing and medical attention in that they also provide for educating the society to take preventive measures as well as promoting healthy living lifestyles and general wellness habits and practices (AANP, 2002). ACNP (Acute Care Nursing Practitioners) basically developed and took shape to care for those acutely afflicted and in need of crucial medical attention, which had been inadvertently ignored. These activities accorded a specialist status to the ACNP fraternity. They are hence trained to obtain skills that supersede the NP's of everyday care. The special endowments that the ACNP's possess have seen their increased use and need of their services in the ED. In the following discussion, the emergence of the importance of the ACNP's in the ED domain is traced and its growth is studied (Cole and Kleinpell, 2006).

The medical insight and skills possessed by the ACNP's enable them to anticipate and suggest proper nursing and medical services needed for the patients competently. The nursing and medical acumen possessed by the advanced nurses is based on solid logic and practical experiences and hence useful to all categories and stages of patients; primary, secondary as well as tertiary. These nurses are well equipped to train people and communities, peers and leaders, mentor communities, take up leadership roles and also venture to participate in administration as well as provide scholarly inputs. ACNP's can not only act as aides to doctors and physicians and carry forward the medical services given by the doctors, they can also act independently as primary health care providers on their own.

The skills possessed by the ANP's enable them to provide health care services in all cases at least as a primary service and their scope is not bound by community, society age or sex. They are trained enough to be depended upon to provide services in a wide range of medical afflictions including chronic patients, long-term illnesses, baby care, emergency care and the myriad medical treatments that may be needed. They do not discriminate between the acuteness, urgency or primary health care; in short they are well-rounded and appropriately groomed 'generalists' whose service can be relied upon primarily. They can also be called upon to train people in social health initiatives. The study of ANP's role in providing medical care has revealed a very positive picture of these professionals from the perspective of the patients as well as the medical fraternity. The general dispensations as well as the specialized acumen that these skilled, knowledgeable ANP's possess can be relied upon in cases of emergency care with utmost confidence. There are of course instances when their services need the support of physicians and doctors and use of more advanced diagnostic tools and apparatus to get to the root of the medical problems for detailed diagnoses. It has been observed that ANP's seek to learn more than conventionally taught by keeping in touch with interacting inquisitively with the medical fraternity trained for and possessing deeper insights and having a wider knowledge base (Royal college of nursing, n.d).

A major contribution that the aforementioned ANP's can make significantly to alleviate the deteriorating ED services is by screening the incoming patients for ED admission. Those who do not need ED services can be directed to other sections according to their evaluated needs (Cole and Kleinpell, 2006). The proper segregation and classification of patients needing urgent and Ed attention need to be screened out to reduce the stress on the heavily burdened ED. This practice is being increasingly adopted by more hospitals of late (McGee and Kaplan, 2007). As such, increased use of the services of ANP's are being availed of, by the health care facilities across the nation.

Literature search strategy and methods used to search the literature

The literature review was accomplished using a process of iteration. The data extraction and quality assessment tools were developed based on the established methods that have given substantiated results consistently.

Search Strategy

With consultation, the online web-based searching platforms; OVID Medline and its In-Process and Other Citations were used for searching for studies put into print and other texts and media in last ten years (beginning of 2002 and mid-2012). Using a binary tree progression combination of keywords and health services' titles, I searched for literature that related to and matching 'ED crowding' and the following patient outcome attributes (alternatively called assisting keywords): mortality, desperation, frustration, well-being in patients, and leaving the ED without being attended to. Using the same parameters of time and space, I also searched on the web for relevant values and quantities in the following journals:

Emergency Medicine Journal;

Emergency Medicine;

Journal of Emergency Nursing;

Annals of Emergency Medicine;

European Journal of Emergency Medicine, and Academic Emergency Medicine (Carter, Pouch and Larson, 2014).

To round up the research, I scoured the section on references in relevant articles manually, diligently obtained in the Medline search output and the reference sections of full-text articles and have been included in this exercise

Study Selection

I looked specifically for literature and text headings and titles and abstracts for relevant topics. After doing that, I then independently reviewed all remaining study titles and abstracts. Finally, I estimated objectively the rationale for each articles' acceptance or rejection making use of the established iterative process. Studies that estimated crowding in ED or unequivocally accounted to have exhibited a likeness or similarity to crowding in ED (e.g., duration of stay in ED, volume of ED, capacity of ED, and so on) and calculated one of the effects of interest were included, and the rest were excluded (Carter, Pouch and Larson, 2014). This study additionally comprised studies that explained (a) interventions and procedures to lessen crowding in ED; (b) health care procedures linked with ED crowding; for instance, timeliness of care, ambulance re-routing as well as patient inflow; along with (c) tools to predict, anticipate or calculate ED crowding. This study also overlooked editorials, commentaries, articles published in another language, or those devoid of abstracts. None of the authors were contacted for their opinions or justifications or any other purposes.

Data Extraction

This study utilized a data extraction tool that had already been used successfully previously to address items of relevance in the precis and analysis of articles (Uchida, Pogorzelska-Maziarz, Smith, and Larson, 2013). Fields comprised in this tool were: (1) primary author of the literature and date/year of publication,(2) study design,(3) inclusion criteria along with quantity studied, (4) ED type (e.g. research study for students, urban, etc.), (5) measure made use of to quantify crowding, (6) measure used grade outcome,(7) study results, and (8) study limitations (Carter, Pouch and Larson, 2014). As a researcher, I maneuvered this tool making use of two articles, with high levels of data accumulation agreement (similarities). First, I revisited the remaining studies and thus data extraction was finally accomplished.

Quality Assessment

As of date there is no unanimity over a particular method or tool that should be used for quality assessment in observational studies in spite of the fact that many researchers have used different instruments and tools in this sphere. The Agency for Healthcare Research and Quality (AHRQ) has designed a series of such instruments, tools and methods for different study design (West et al., 2002). I chose to use the logical integrity of observational studies' appreciation criteria used by AHRQ, which assesses whether authors or researches of the work had touched upon the following factors:

(a) Point of inquiry and quantity (i.e., presence of a clear and relevant study question, whether a detailed explanation of the population was furnished, and whether a relevant data sample of the population for calculation was executed);

(b) Interactive measurement of subjects (i.e., whether clear acceptance and rejection factors were defined, whether such groups were relevant to each other);

(c) A measure of the other factors' influence and consequences (i.e., whether the external factors were clearly stated, dependable, and relevant);

(d) Result analysis and determination (i.e., whether the result parameter was clearly stated, ascertainable, and relevant);

(e) Statistical determination and conformation (i.e., whether proper statistical models were employed);

(f) Final outcome (i.e., whether study output depicted appropriate tolerances and point estimates); and (g) Qualitative discussion (i.e., whether the qualitative study deductions were consistent with the quantitative output).

For the obtaining quality appraisal, I excluded the elements of financial factors and intervention. Domains were assessed for categorization of their role; in totality, in part or had altogether ignored that particular aspect and its sub-parts. For example, in critically examining the output/results domain, a study under my observation was awarded a full points if the authors furnished confidence intervals and point estimates of their statistical evaluation and fully depicted the same in all study aims; in assessing the exposure domain, a study was awarded a no score if the ED crowding was not explicitly mentioned and if data regarding the validation, reliability and authentication of method of quantitative assessment was not made available. In the cases where study authors failed to mention one subcomponent of a sector or factor but adequately took note of remaining factors, the study received a score between full and null (Carter, Pouch and Larson, 2014).

Major review of the literature

Emergency Department over-crowding is a global phenomenon. The consequences are being felt by the patients more acutely. In 1986 the Emergency Medical Treatment as well as Labor Act made it mandatory for all those patients who chose to prefer ED in the U.S. To be medically screened, irrespective of their capability to pay for the test. The uniqueness of the part played by the NP of the ED has caused some to name is as the backbone of the medical care system. However, the ever-increasing problem of crowding has stretched this safety net to its extreme limits according to a recent study carried out by the Institute of Medicine. Increase of the ED crowding phenomenon has moved the scholars to seek answers to a number of logical questions; summarized by organized literature opinions. One review projects various definitions of "overcrowding." "Crowding is the situation when the 'need for urgent services is more than the available resources in; the emergency department, healthcare unit, or frequently in both." Emergency department (ED) overcrowding can be seen across length and breadth of the nation.

Currently, more than 9/10ths of hospitals are complaining of ED crowding as a major problem. A basic worry is the possibility for ED crowding to inversely affect quality of care and of use to patients admitted in the ED (Pines et al., 2007).

Causes of Overcrowding in ED

Extreme pain is only one of the major prevalent causes for seeking urgent attention, medically. Apropos to the 2004 National Hospital Ambulatory Medical Care Survey data, close to 32% of emergency department (ED) in-patients complained of either minimal, average or severe pain. All the same, oligoanalgesia, which is observed to be the underlying cause of pain, is a common factor in EDs. Factors causing oligoanalgesia include advanced age, socio-cultural attributes of specific region, doctor's or NP's estimation of the patient's pain, possibility of drug-seeking attitude, and inclination to mask symptoms to ensure a wholesome diagnosis. In this age of ED crowding, another possible cause for oligoanalgesia may be that physicians and doctors are too occupied to appropriately gauge, diagnose and treat ED patients with painful symptoms (Pines and Hollander, 2008). According to Pines and Hollander (2008), increase in ED over-crowding were main cause of failure to treat or late treatment, after taking into account patient-level complexities. Many scholarly research works demonstrate a correspondence between ED crowding and impact on most diagnoses and treatments such as delay to administer analgesia and antibiotics. Deductions of this exercise are important as the ED plays an important part in the U.S. medical healthcare system and is also called its safety net. The persistent scientific inputs of nurses and healthcare organizations are paramount to fully comprehend the impact of ED crowding and to evolve strategies to seek solutions to inhibit ED crowding (Carter, Pouch and Larson, 2014). Increase in numbers of ANPs working in advanced emergency care settings, such as mishaps (accident) and emergency (A and E) departments, superficial injury units, medical diagnostic units, and round-the-clock services, as well as within specialty (dedicated) departments such as:

Pediatrics;

Neonatal care;

Cancer care;

Eye care (Ophthalmology) and;

Bones and joints care (Orthopedics).

In all situations and conditions where patients are likely to benefit from advanced nursing skills and knowledge, the role of ANP becomes all the more noteworthy (Royal College of nursing, n.d).

Pines and colleagues (2009) performed a reflective comparative research to analyze the correlation between ED crowding and negative cardiovascular results (e.g., dysrhythmias, heart failure, cardiac arrest, etc.) in the ED patients admitted to the hospital with Acute Coronary Syndrome (ACS)-related pain in the chest and those without it. These authors found a definitive relationship between inversed cardiovascular outcomes and the several ED crowding factors (Carter, Pouch and Larson, 2014). Pines et al. (2007) found a concrete connection between objective dimension of ED management and flow and in the opinion of both, patient as well as the provider that health care accorded was put to question or ignored by ED over-crowding. Emergency departments (EDs) perform vital functions in the health care system over and above their obvious services as trauma centers and servers of immediate and critical care.

Nurse Practitioners Scope of Practice

NPs have been accepted as a highly skilled and properly endowed, economically viable professionals exhibiting a high level of care. A well researched study has observed that nurses can provide a quality care of the best levels and cause good results for patients but those studies and hence outcomes were those of primary health care solely (Jennings et al., 2009). It is largely established that good quality health care perspectives of patients invariably in positive results for the patients. Patient satisfaction is thus of paramount importance to rid him of his illnesses or at least imbue a thought of well being. The factors that affect patient satisfaction include among others, quality and duration of communication between the patient and the service provider, quality and duration of stay at the facility, the duration and frequency of the providers visits, as also the socio-economic factors. Many of these factors are outside the immediate grasp of the service providers and the facilities. Hence, it is the perception of the patient that is the only measure of his satisfaction. Wherever the NP's have been able to give quality time and care, the satisfaction levels of the patients have been found to be significantly high. In some findings involving patients' feedback and responses, it has been found that the patient were more satisfied with the NP's than with the doctors or specialists, that however is not always the case. Other studies have found that there is no significant difference in satisfaction levels perceived by the patients when NP's were weighed against the doctors. (Jennings et al., 2009).

There is an acute shortage of primary care physicians and a striking absence of round-the-clock doctor availability, patients have been more and more looking for care within emergency departments (EDs) even for basic and primary health care needs. As a matter of fact, it is projected that semi-urgent and non-urgent healthcare patients form about 56.7% of the ED cases. On the other hand, since ED staff have to accord highest preference to cases of urgent nature, those seeking routine and non-critical care are bound to wait for a long duration of time and possibly low quality of care. So as to address this rising concern, EDs in the United States as well as more recently in the UK along with Canada have incorporated nurse practitioners (NPs) to deal with patients who exhibit and hence deserve non-urgent as well as primary healthcare requirements (Thrasher and Purc-Stephenson, 2008).

Those having completed a bachelor's course or master's course in nursing are awarded the degree and certified and are declared Primary Care Nurse Practitioners. Those that have taken their education in institutions in Ontario, Canada in the course named Expanded Services for Patients have been conferred the right to act well beyond the scope of primary nursing. They are authorized to diagnose, suggest medicines and even refer patients for tests and procedures independently like the X-ray, pathology tests and the like.

These advanced level NP's can act as medical professionals where the specialist physician or doctor can't be accessed (Thrasher and Purc-Stephenson, 2008). The patients need not be kept waiting or suffer.

ACNP practice

Acute care nurse practitioners are trained and empowered to take care of aged patients afflicted with debilitating illnesses that require appropriate skills and deep insights and understanding of medical practices within the ED facilities (Cole, 2003). The ACNP's are the more evolved brethren of the NP's and are taking up the nursing and health services to more specialized avenues of the ED's, ICU's, Critical care sectors in the hospitals, trauma Centers, and even the more specialized oncology department, cardiology, mental diseases, organ donation and implantation and even the evolving science of neurology. ACNP's are proving to be increasingly helpful in the complex and critical health care services that include those of terminal illnesses, too. (Cole and Kleinpell, 2006).the regions in health care that the ACNP's have significantly contributed include those patients with chronic illnesses, advanced stages of critical maladies and the most challenging cases that require deft handling with deep insights. The spheres that ACNP's now provide services in encompass most illnesses that require such help. They are no longer restricted to primary and secondary stages of illnesses; their expertise is being used in tertiary cases, too.

ED ACNP practice

Emergency Nurses Association Scope of Practice has recognized know how in advanced physical evaluation, capability to triage and prioritize, contingency preparations, crisis situation management, stabilization and resuscitation and fluency on the overall care continuum as the fundamental features of practice. The first graduates from The University of Texas Health Science Center at Houston, School of Nursing, in Emergency Nurse Practitioner (ENP) program were trained to give urgent, non-urgent, emergent care which consists of stabilizing critical and dangerous conditions with the help of lifesaving methods. These methods consist of:

Chest decompression

Central line insertion

Lumbar puncture

Thoracentesis

Cricothyrotomy

Trachestomy

Chest tube insertion

The ED's addresses patients from all age groups having numerous health care issues; hence the students were trained to tackle different conditions; even complicated ones like those of pregnancy. The first graduates earned their ANCP certificates and carved a path for other NP's to work within the ED domain.

Cole and Ramirez (2000, 2002) conducted a research for the purposes of providing a profile NP's employed in ED's. The research has shown that certain NP's are employed in fast track areas, rest of the NP's are employed in central ED tending to severe and critically ill patients in an attempt their ailments and critical care conditions. Both researches showed the most of the NP's employed in ED's had worked in this area as registered nurses (RN) prior to earning their NP certificates. Apart from that, most of the NP's employed in the ED's are family nurse practitioners (FNP's), which may show that FNP programs has precedence over ENP and ACNP programs. ACNP has a unique obligation in ED's domain since the focus is on stabilizing the emergent conditions, primary prevention measures and managing different states of illness (Thrasher and Purc-Stephenson, 2008; Cole and Kleinpell, 2006).

Emergency Nurse Practitioners

The ENP nurses are authorized to evaluate and deal with patients arriving in Accident and Emergency (A and E) department. In case of England, the first department to initiate a regular ENP service is Old Church Hospital in Essex back in 1986. Comparing with the statistics in 1986, the number of A and E. departments has increased exponentially. According to a survey conducted for A and E. departments in England in 1996, Tye et al. (1986) concluded that 36% of the departments had ENP facilities available. During 1998, a survey conducted in Scotland in 1998 (consisting of even smaller community hospital), 47% departments were known to house nurses trained in ENP's.

Synopsis

With ED crowding on the rise, the emergency services are in huge demand and rising, whilst resources are depleting fast to tend to them. Research has shown that ED crowding is a worldwide issue and paves way for decreased quality care and heightened number of patient deaths. Multiple solutions have been suggested to combat crowding, but ED crowding is elevating and becoming critical. Multiple researches have shown ED crowding vs. poor quality care relationship, poor services as well as long waiting time. Given the relevance of heightened ED usage and well-known association of ED crowding and low quality care, the comprehension of the relationship between patient outcome and ED crowding is necessary. The general proposed solutions in case of ED crowding are:

Increased resources

Demand management

Added resources include more workers, personnel and supporting resources for usage. Demand management consists of methods for appropriate allocation of patients and support proper utilization. The research concluded higher levels of patient contentment and quality clinical documentation due to NP-based care. The research concludes patient's contentment with NP implemented care by measuring waiting time and pinpointing factors of patient contentment.

Hospitals are either shutting down or merging whilst establishing ED services, as the amount of patients requiring emergency aid continues to rise, the NP has become a medical screener in ED departments.

Problems with ED crowding

For the last twenty years, crowding in emergency department (ED) has been a problem growing and becoming severely acute. Timely care is a strong factor in patient contentment while waiting duration is the biggest factor contributed to patient contentment. At major Emergency Medicine (EM) conferences, it has become a heated debate especially those hosted each year by Society for Academic Emergency Medicine and the American College of Emergency Physicians (Derlet and Richards, 2008).

ED crowding decrease care quality

ED's are basically afflicted with tremendous stress and risks. With full capacity, the chances of an error rise as well. According to Institute of Medicine (IOM) six aspects of quality care are:

Timeliness

Patient centeredness

Efficiency

Equity

Effectiveness

Safety

All of these factors are compromised when patients stands for long durations for their doctor's appointment, ED is boarded by patients and when ambulances aren't patient-hospital proximity centered. During the recent researches, most have shown that ED crowding is a huge factor in poor patient quality care (McHugh et al., 2012).

NP care and patient contentment

With the inception of new roles assumed by healthcare personnel, assessment of their impact on patient satisfaction and its care of quality is required. Level of quality care is determined by the extent the patient is satisfied with respect to health care services (Cole and Kleinpell, 2006). A heated discussion persists regarding what entails and measures patient satisfaction. Latest research agrees with the fact that improved health should be the final goal in mind (Laschinger, Almost, and Tuer-Hodes, 2003), compliance based on recommendations; focus on medical treatment and punctual keeping of appointments (Moore, Saywell, Thakker, and Jones, 2002; Williams, 1994), less usage of healthcare resources and avoid legal proceedings (Bowers, Swan, and Koehler, 1994; Thompson, Yarnold, Adams, and Spacone, 1996). New research establishes that patients are content with receiving NP-based care.

Suggestions and conclusion

ED is an abbreviation for Emergency Department. Due to ED crowding, the healthcare providers and patients are overloaded. It is a key cause in delays pertaining to mortality, care and declining patient contentment. Reason for ED crowding is multifaceted and it is presumably deemed as secondary to input, factors of output and throughput. The scheme for lessening the ED crowding for all levels has been examined in detail in literature. Increasing the staff (throughput) is one of them. Nurse Practitioners are being used for treating various conditions. In recent times, nurse practitioners are being targeted for primary care environment. Considerable research has been done in case of nurse practitioners for emergency and accidents (A and E) and minor injury settings (Sakr et al., 2003).

ED crowding is a huge issue and postpones effective care for the patients as well, hence crowding elevates. The staff members and ED doctors while diagnosing and evaluating ED patients are sidetracked by the requirement of more patient's accommodation. The admitted patients are given inpatient services; apart from that they also need back end care from ED personnel (Ganapathy and Zwemer, 2003). The extended patient contact time allotted with the NP encounter as well as enhanced communication; less duration of admittance seems to have translated into patient satisfaction. Patients on the whole are content with the NP care given, which is an extra feature of NP in an ED. In case of the American health care model, a prime customer service ingredient and marketing catch phrase is wait time. Small injury patients comprise of a huge chunk of ED visits. Due to the present system, they have longest waiting time durations. Most of the ED's making use of NP's to attain new wait time scales provided that they don't require the need of certified doctors to treat such patients. With NP added to ED, the long waiting line of patients with small injury patients decreased.

Instituting ACNP practices in ED environment has huge potential since the primary focus is on treating the critically ill patients, health promotion and preventing illnesses. ANCP should be well aware of the difference between the philosophy of hospital provided care and emergency care, step down units and intensive care, surgical-medical units and special physician personnel which assist in averting legal proceedings and putting hospital in a tough spot. ED practice gives ACNP's practice prospects a greater area while remaining in the NP practice domain.