This paper examines emergency department (ED) overcrowding at a university hospital, identifying the primary causes as insufficient inpatient bed availability and inadequate nursing staff. Drawing on a three-week assessment of admission logs and medication reports, the study found that patients waited an average of 36.29 hours before transfer to inpatient beds. Grounded in Orlando's Nursing Process Theory and supported by a review of current literature, the paper evaluates short-term interventions already attempted and proposes radical long-term solutions—including physical resource expansion, manpower increases, and demand management—aimed at reducing bed-assignment-to-occupancy time to within 30 minutes for at least 60% of patients.
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The paper demonstrates effective use of a theoretical framework to contextualize a practice problem. By invoking Orlando's Nursing Process Theory, the author connects abstract nursing theory to concrete operational challenges—showing how theory can guide bedside decision-making under conditions of resource constraint and overcrowding. This technique of anchoring applied research in nursing theory is a standard expectation in healthcare quality improvement writing at the undergraduate and early graduate levels.
The paper follows a standard quality-improvement report format: it opens with a problem statement and objectives, then grounds the issue in nursing theory, reviews relevant literature on patient flow strategies, describes a short observational methodology, presents findings from a three-week ED assessment, and closes with both short-term and long-term recommendations. Each section builds on the previous one, moving from theory to evidence to practice.
Prolonged or increased waiting time for patients at the Emergency Department (ED) leads to an increase in both morbidity and mortality among critically ill adult patients admitted for inpatient beds. A review of ED records at the study institution, aimed at developing a report on overcrowding, identified the main causes as the lack of available inpatient beds and the lack of nurses available to care for patients. Long-term solutions are identified and suggested.
Patients with assigned medical/surgical beds from the Emergency Department take too long to move from the ED to their inpatient beds. Prolonged boarding times at the ED increase morbidity and mortality risks among critically ill patients. The objective of this project is to decrease the time from the assignment of inpatient beds until they are occupied to within 30 minutes for 60% of patients.
Overcrowding at the ED occurs primarily because of overwhelmed ED manpower and the sheer physical incapability created by the massive number of patients requiring or receiving care. Overcrowding, lack of ED staff, delays in transfer to assigned beds, the lack of physical beds, and untimely discharges all lead to increased boarding times at the ED.
Orlando's Nursing Process Theory lists the basic concepts for nurses in meeting patients' immediate needs. Overcrowding and delays in transfer complicate a nurse's task of assessing critical patients and addressing their basic and immediate needs. The theory helps streamline nursing tasks to focus on immediate needs until patients are moved to their destination.
Institutions report that 50% or more of hospital admissions go through the ED, considered the "front door" of the hospital (Harrell, 2012). Patient flow through the ED is characterized by bottlenecks, confusing communication, and the commingling of self-arriving patients and those brought in by emergency vehicles. Poorly conceived first-encounter systems, queuing problems, and poorly designed treatment areas lead to delays in treatment or management of patient records, increasing stress among patients and hospital staff alike. Poor and inefficient patient throughput leads to costly and error-prone operations and, ultimately, patient dissatisfaction. When beds are all full, a nurse conducts an initial assessment at a triage station. The emergency staff determines the priority of care, and the patient waits in the inner waiting area with family members (Harrell, 2012).
Bramwell (2012) describes three strategies that helped improve patient throughput at Good Samaritan Hospital of New York and increased hospital revenues in the process. These were the opening of a logistics center, the use of an electronic bed board, and fast-tracking ED triage. The Pennsylvania Patient Safety Authority (ECRI, 2010) suggests a predictive model of staffing; optimizing low-census or low-utilization times at the ED while preparing for busier periods; monitoring ED capacity in real time; an accurate and reliable triage methodology; alternative triage strategies; appointing a patient flow manager; fast-track or urgent care treatment areas; and adopting environmental ED principles.
The 2007 Emergency Department Benchmarking Alliance Annual Data Survey enumerated several recognizable trends in ED data: total arrivals increase from midmorning through noon, hold steady until midnight, and then decrease; pediatric arrivals occur earlier and decrease sooner than adult arrivals; senior citizens arrive in the late afternoon and wait longer; Saturdays and Mondays are the busiest days; the busiest months are July–August and December; and the most common complaints are abdominal pain, chest pain, and orthopedic injuries (ECRI, 2010).
The University Medical Center of Tucson, Arizona, increased its hospital capacity and improved patient flow through a comprehensive approach (Enriquez et al., 2009). The hospital has since been guided by four keys to success: 100% support from and involvement by senior executives; engagement of the key participants in patient flow; perseverance; and deciding whether to implement changes independently or through a partnership with outside organizations. H&HN (2009) suggests improving patient flow through industry-wide solutions, including improved scheduling, simplified bed management, tracking of patients, staff, and assets, and improving patient perception through interactive patient care.
DeLia (2007) argues that ED trends are most heavily influenced by the inaccessibility of primary and specialized care outside the hospital. Rationalizing ED output is most often hampered by reimbursement disparity between elective surgeries and other hospital services. Critical areas of concern include the inability to track patients through the entire hospital in real time, coordinating discharge schedules with incoming inpatients, and coordinating the use of resources between elective surgery and ED patients. DeLia (2007) recommends that public policy include regular surveillance of hospital patient flow.
The chronic issues identified in this assessment require radical long-term solutions, including the frank increase of physical resources and manpower and demand management. These measures are deemed sufficient to decrease wait time from bed assignment to occupancy to within 30 minutes for 60% or more of patients. Short-term fixes have provided some relief, but systemic and sustained improvement at the ED requires a comprehensive commitment to expanding capacity and rationalizing patient flow at the institutional level.
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