The Effectiveness of Protocols in Emergency Departments By ...harrisoneve.weebly.com/uploads/8/4/6/1/84612150/senior_thesis_20… · The Effectiveness of Protocols in Emergency Departments

EFFECTIVE PROTOCOLS IN EMERGENCY DEPARTMENTS 1

The Effectiveness of Protocols in Emergency Departments

By: Hailey Bracey

Central Magnet School

Acknowledgements


I would first like to thank my Biomedical Innovations teacher, Mrs. Eve Harrison, for her

instruction and supervision of my thesis. Mrs. Harrison was always available and qualified to

help format and revise my thesis. This research would not be what it is without her support and

critiques throughout the year. I would also like to thank my English teacher Mrs. Lynne Maxwell

for encouraging me throughout the thesis process and helping me to revise my background

research and introduction. Also, to my advisor Ms. Heather Corban who encouraged me

throughout the year and read over many parts of my thesis.

I would also like to thank Sharon Cox from St. Thomas Medical Center and Cynthia

Adams from Stonecrest Medical Center for being willing to help with my thesis surveys.

Without their willingness to send surveys, I wouldn’t have any as many results as I do now.

Next, I would also like to thank St. Thomas Rutherford Hospital for allowing the

Biomedical Innovations class from Central Magnet to tour their emergency room. The tour really

helped me figure out ideas for my thesis and focus my research. The hospital’s emergency room

layout helped me to see the advantages and disadvantages to many emergency rooms in the

world and also create my own layout.

Finally, I would like to thank MTSU for allowing me to use their private databases for

thesis research. I found multiple articles while at the MTSU library that were very helpful

towards my research and development throughout this paper. My background information would

not be as in depth as it is now without those resources.

Table of Contents

ABSTRACT……………………………………………………………………………………....4


INTRODUCTION……………………………………………………………………………4-11

RESEARCH QUESTION………………………………………………………………………..4

RESEARCH PURPOSE…………………………………………………………………………4

BACKGROUND

INFORMATION……………………………………………………………...5

HYPOTHESIS…………………..……………………………………………………………...11

METHODOLOGY……………………………………………………………………...…..11-12

RESULTS…………………………………………………………………………………....12-15

PATIENT EXPERIENCE SURVEY………………………………………………………..12-

14

PHYSICIAN EXPERIENCE SURVEY…………………………………………………….14-

15

DISCUSSION……………………………………………………………………………..…15-16

CONCLUSION……………………………………………………………………………...16-17

APPENDIX A………………………………………………………………………………..18-19

APPENDIX B…………………………………………………………………………...…...20-22

REFERENCES…………………………………………………………………………..….23-25

Abstract


The purpose of this research is to determine if emergency department protocols are set

accordingly to best benefit patients and if so, how they can continue to be improved. This study

is mainly focused on protocols involving patient flow of information, ER layout, wait time, and

upkeep of facilities. Research shows that emergency departments are always improving and

continuing to grow, but are they doing it to most effectively benefit all types of patients that walk

through the ER doors? Jim Crispino, the president of Philadelphia-based firm Francis Cauffman

believes that the emergency department is a pivotal component to the rest of the hospital's

success. (Dickinson, E. E., 2007) Without an ER, the population in the surrounding area would

be in danger, but also the rest of a hospital would overall be a lot less successful. People of all

ages took part in a survey asking about their personal experiences in an emergency department.

The results showed that most people don’t have a great 5/5 experience, but they also don’t have a

terrible experience either. The participants continued to agree that there are many things that

should be improved in an ER, but most also understood a lot of the limitations that hospitals have

within their emergency departments including things like money and space. Based on all of the

results, there are ways that emergency department can be improved, like implementing a new

design of the ER, a new flow of information, or new ways to get funding for the things they need

to adjust or correct the department. It is important for hospital employees and the surrounding

population of a hospital to know how important an emergency department is to themselves and

the rest of the hospital so it can best benefit the patients who enter on a daily basis.

Introduction

Research Question

How can emergency department protocols and guidelines be improved or altered so all

processes in the department run smoothly and effectively?

Research Purpose

The purpose of this study is to determine if the protocols and layout of emergency

departments are set appropriately to benefit patients in the best way. All protocols in emergency

departments are set reasonably for each patient’s medical experience and their well-being. The

intent of this study is to try and find different ways to alter them for a better patient experience.

Studies have shown specific changes in emergency departments are effective. This study will

offer a few aspects of the emergency department, rather than just being focused on one. Patient

experience versus physician responsibility is taken into account along with the difference

between pediatric and adult protocols and emergency department layout. The emergency


department is very functional and always developing; this research is introducing possible

improvements to its protocols and layout.

Background Information

There is a common theme throughout all of the sources and studies in this research of

how emergency rooms function. Whether emergency departments are functioning poorly or

remarkably, there is always room for improvement. A study was done at a University Medical

Center in Germany to implement new protocols in their emergency rooms. After analyzing the

existing protocols in their emergency rooms, the department of anesthesiology of the Medical

University of Gottingen (UMG) developed new emergency room protocols that were

department-specific. As as result, they created 13 different sections to represent the protocol and

its contents; general characteristics, emergency event, initial findings and interventions, vital

parameters, injury pattern, vascular access, hemodynamics, hemogram/blood gas analysis

(BGA), coagulopathy, diagnostics, emergency interventions, termination of ER treatment and

final evaluation. (Ross, Hinz, Mansur, Mielck, Roessler and Quintel, 2015) This study is useful

because it gives a completely different perspective of hospital emergency rooms and the list of

things they choose to improve. These improvements succeeded in the UMG emergency room,

but in the United States, there is still a lot of question about what could work to best benefit

American health systems.

Jim Crispino, the president of Philadelphia-based firm Francis Cauffman believes that the

emergency department is a pivotal component to the rest of the hospital's success. The

emergency department is the beginning of many patients’ hospital experience, so the

consultation they have there is critical. Crispino also says that the ER is becoming hospitals’ new

front doors. “Usually for a regional medical center or a community hospital, 25 to 30 percent of


people go to the emergency department first,” he says. “Of the people admitted to the hospital,

over 50 percent are generally coming in from the emergency department.” Crispino has designed

health care facilities for many years; his clients are starting to question the relationship between

the emergency department and hospital. Francis Cauffman has done evidence-based design

studies to explore how the physical environment of an emergency department impacts patient

outcomes and staff efficiency as cited in (Dickinson, E. E., 2007). These techniques have helped

improved emergency rooms, but there is of course always room for more improvement.

A prevailing problem that continues to arise in emergency departments is the ability to

pay. It is required by law for emergency departments to treat everyone who walks through the

door. A lot of patients who enter the emergency department don’t need the extensive care an ED

can provide, but they go anyways because they have no insurance plan to get in anywhere else.

This population of people would be much better off going somewhere like a walk in clinic, but

since they have no insurance that is not an option for them. In the article The Crisis in America's

Emergency Rooms and What Can Be Done, O’Shea says, “Misusing the ED to provide primary

medical care is more costly than providing the same care in a physician's office, and primary

medical care received through the ED is of poorer quality.” A question that policymakers and

physicians might ask is whether or not it’s worth it to continue letting uninsured people walk into

the emergency department. It is worth considering making a separate facility for uninsured

patients. (O’Shea, 2007)

The priority of care is most often based on triage categories. Triage of patients is

determined based on the urgency of their situation when they walk into an emergency

department. Triage decision making must be persistent to have a successful health care delivery

to all of the patients that come through an emergency department. Knowledge and experience are


crucial to give a definite patient assessment. Both nurses and physicians are responsible for

knowing triage categories so they can in turn give a correct patient diagnosis and pinpoint an

illness. The treatment of pediatric patients versus adult patients is very different, so knowing

these triage categories is important in diagnosing each type of patient. Pediatric patient’s pattern

of illness should be treated differently than that of an adult. Since pediatric patient treatment is so

particular compared to other ages, a normal emergency department doctor must be able to care

for both pediatrics and adults. Presenting symptoms of patients that walk into an E.D. vary for all

ages, so when making and assessing protocols, physicians and/or policymakers must consider

different ages. (Maldonado & Avner, 2004) The methods conducted in the study written in

Triage of the pediatric patient in the emergency department: are we all in agreement? by

Theresa Maldonado and Jeffrey R. Avner consider 12 pediatric scenarios that physicians in

pediatrics and general emergency departments were asked to try. They were also asked to use a

3-tier triage system (emergent, urgent, nonurgent) to assess the patients in these scenarios. The

male and female patients were a variety of ages below 12 years of age. Within these 12

scenarios, triage of children, time to termination of resuscitation efforts, sedation use, treatment

of a febrile child, & management of febrile seizures are all taken into account. The 12 scenarios

were created according to each patient’s chief complaint which included, fever(3 cases), head

trauma, barking cough, wheezing, seizure abdominal pain, not drinking, fever and decreased oral

intake, chest pain, and not walking. Triage categorization from both pediatric emergency

medicine (PEM) and general emergency medicine (GEM) doctors was evaluated in this study. In

most circumstances, the two parties agreed on the level of triage for a patient, their response rate

was very successful at 99%. “GEM participants were more likely to triage children with certain

febrile illnesses at higher acuity levels as compared with their PEM counterparts.” (Maldonado


& Avner, 2004) Emergency department doctors must be prepared for any case that comes

through the door. Since pediatrics is handled so differently, they must know and practice the

correct protocols for not only adult patients, but also pediatric patients.

For a well functioning emergency department, physicians must be prepared for any case

that may come through the door. All ages enter the emergency room every day, therefore there

must be correct equipment to care for any type of patient at any age. Certain supplies and

equipment are required to care for pediatrics, just like in Triage of the pediatric patient in the

emergency department: are we all in agreement? by Theresa Maldonado and Jeffrey R. Avner,

how there must be specific protocols when assessing and diagnosing a pediatric patient. The

emergency department is the starting place for many patients, so the equipment must be able to

adapt to each patient’s needs. An effective ED must have the necessary resources to serve

pediatrics since their care is so different compared to an adult. Some guidelines were created by

the American College of Early Physicians (ACEP) for pediatric patients that may enter an

emergency department. “Although resources within emergency and trauma care systems vary

locally, regionally, and nationally, it is essential that hospital ED staff and administrators and

EMS systems’ administrators and medical directors seek to meet or exceed these guidelines in

efforts to optimize the emergency care of children they serve” (ACEP, 2009) Hospital EDs must

constantly be prepared to treat pediatric patients. In Guidelines for Care of Children in the

Emergency Department, ACEP lists major protocols and guidelines that should be followed by

administration, physicians, nurses, and other health care providers. There are also guidelines

regarding patient safety, quality improvement (QI), performance improvement (PI), policies,

procedures, support services, equipment, supplies, and medications all pertaining to pediatrics. It

is very important to be well prepared to follow all of these guidelines when working in an


emergency department. Since the majority of people that come into the ED are not children, the

use of these guidelines could come at any time of the day. “This relatively infrequent exposure of

hospital-based emergency care professionals to seriously ill or injured children represents a

substantial barrier to the maintenance of essential skills and clinical competency” (ACEP, 2009)

Emergency physicians should be prepared to treat whoever walks through the door. These

guidelines will train physicians to strive for improvement and provide the care that is necessary

for any patient. Care of children in the emergency department: guidelines for preparedness.

(American Academy Of Pediatrics) also states how different pediatric care needs to be in an

emergency department. A lot of components to emergency care are made for children, but aren’t

limited to children. The statement in this article provides guidelines for pediatric patients so they

can get the best care. “It is imperative that all hospital EDs and EMS agencies have the

appropriate equipment, staff, and policies to provide high quality care for children.” Is a big idea

to consider when improving EDs. (American Academy of Pediatrics, 2001)

The layout of an emergency department is crucial to how successful it can function. If

there is a poor layout, patient flow of information won’t move as efficiently throughout the

emergency department as it could with a more convenient layout. Emergency departments are

continually faced with rising and unpredictable patient visits while at the same time striving to

improve their efficiency and quality in their day to day work. There is always room for

improvement in an emergency department, especially when considering layout. In Best Of 2014:

Rethinking The Emergency Department by John F. Wheary, the goal of this ED renovation was

“to develop an innovative design solution, adopting a model designed for the rapid assessment

and evaluation of emergency patients: a rapid assessment unit (RAU).” (Wheary, 2014)

Healthcare is constantly changing, so emergency departments must also be changing and further


improving their layout to continue to treat patients in the best ways. Patient information and care

can only be improved with innovative thinking and designs. Lehigh Valley Hospital–Muhlenberg

(LVH-M), a community hospital in Bethlehem, PA, was the first hospital to undergo a new type

of emergency department layout. In this approach, patient volume and ED capacity was the main

focus. Through this approach, they found that better patient outcomes can be achieved when

there is not constantly a space issue.

To successfully improve an emergency department, there must be a cost effective plan in

place. Without thinking about the expenses that come with improving and creating a new

emergency department layout, any plans that are made won’t be successful. Everything comes

with a pricetag, so to improve an ED, price and time must be considered. In COST

EFFECTIVENESS OF A PHYSICIAN DESIGNED PROTOCOL IN THE EMERGENCY

DEPARTMENT, William J. Beach, J. L. Skolnick, H. L. Phelps and P. Cerrito, wrote about a

study pertaining to shortness of breath and respiratory care. It sought out to see if respiratory care

practitioners (RCP) using a physician designed protocols (PDP) would “produce the same patient

outcomes more cost-effectively than individual physicians orders (IPO)” (William J. Beach, J. L.

Skolnick, H. L. Phelps and P. Cerrito, 1999) They concluded,”A PDP, administered by an RCP

staff, promotes cost effective treatment of patients in the ED with c/o SOB (shortness of breath),

compared to an IPO model, with equal or better outcomes.” (William J. Beach, J. L. Skolnick, H.

L. Phelps and P. Cerrito, 1999) Hourly costs of treating a patient in the emergency department is

costly, but RCP variable costs add an additional amount on top of the price you receive from an

emergency department. Using PDP’s from RCP’s would result in savings of a few hundred hours

per year, then leading to a lower possible cost. (William J. Beach, J. L. Skolnick, H. L. Phelps

and P. Cerrito, 1999)


Hypothesis

Based on the research above, there is always room for improvement in emergency

departments. If protocols, guidelines, and layout of the general emergency department are altered

and improved, then a more efficient ED can be developed to care for patients of all ages.

Methodology

Emergency departments function to most benefit patients. To further improve day to day

events in emergency departments, two points of view must be considered. The best way to do

that for this research is to make surveys that ask questions about patient experience and

physician experience in the emergency department. Two surveys were given asking questions

about emergency department protocols. The first survey was created to identify physician’s

opinions and ideas about emergency department protocols during their everyday job. The second

survey was directed towards the public about emergency department experiences as a patient or

as an assistant to a patient.

The first survey solely asked about patient experience and patient opinions. Many

questions throughout the survey were directed towards each patient’s experiences, and some

questions asked more directly about any protocols that each patient noticed while they were in an

emergency department and their individual opinions of them. These survey questions are listed in

Appendix A.

A second survey in Appendix B asked emergency department physicians about their

everyday routine and what protocols they must follow or abide by while attending to patients in

the emergency departments.

The design and layout of an emergency department will likely determine how effective it

can function. An ideal emergency department layout will be considered and drawn. If an ideal


layout for the emergency department is made, many of the protocols in the ER can be improved.

The results from the first, patient survey will aid in the process of creating a new, ideal layout

that will function well for most emergency departments.

After all of the survey results and research was collected an ideal emergency department

layout was created. The design had all the components that an emergency department would

need to function to its best ability. It was created as if there were no limitations to the new

design.

Results

For the patient experience survey, there were a total of 193 responses. For the first

question in Appendix A, 66.8% of participants answered they were the patient in their

emergency department visit, 29.5% answered that they accompanied the patient, and 3.6%

answered other, which in all cases meant they had experienced the emergency department both

ways.


The majority of people for question 2, in Appendix A, answered 3 or 4, but there are still a

significant amount of lower scores (1 or 2) and higher scores (5).

Question 3 in Appendix A resulted in a variety of answers. They all dealt with either wait times,

the behavior of the staff, how their needs were taken care of once they were admitted,

organization/layout of the emergency department, or a combination of these. In Appendix A, for

question 4, 86.5% of participants answered that they entered the emergency department through

the emergency room while only 8.8% came on an ambulance. 4.7% answered other which in all

cases meant both.

All 193 answers of question 5 in Appendix A were varied, but 166 answered N/A. Of the

remaining answers, 15 answered positively and 12 answered negatively about their experiences.

110/193 people answered N/A to question 6, and all of the remaining responses were positive


and beneficial to this research. Question 7 in Appendix A had a different result for each

submission. Most participants were generous with their answers. A lot of the results from

Question 8 in Appendix A were similar to the responses to previous questions that asked about

positive or negative protocols/situations they experienced. Question 9 in Appendix A was very

open-ended, all the results were varied, but were beneficial to my hypothesis and other research.

The second survey in Appendix B only got 2 responses. Both participants work in an

emergency department as a medical professional and both answered that they have thought about

the effectiveness of emergency department protocols and think there are some that could be

improved. They each answered differently for question 4 in Appendix B. Every answer was

chosen except “flow of patient information.” In Appendix B, question 5, both answered

concerning the triage of patients. Both participants answered ‘no’ in question 6 and sometime in

the afternoon for question 7 in Appendix B. Neither participant thinks there are protocols that

should never change. Question 8 in Appendix B was very open-ended also. The results from it

were beneficial to my research.

Lastly, an ideal emergency department layout was created. This ER also specializes in

pediatrics because the treatments for children can be completely different in many medical

situations. There are 2 waiting rooms, one for urgent patients and one for any nonurgent patients.

This separation is beneficial for the more urgent patients. There are four pods (I nonurgent, II

urgent, III emergent, and a pediatric pod) and normal rooms in each pod. (NR: nonurgent room,

UR: urgent room, and trauma rooms for emergent.) There are also 5 psych rooms, 2 rape or

physical abuse rooms, 5 fast track rooms, 2 negative rooms, 5 burn rooms, 2 security rooms, 3 x-

ray rooms, and 1 big and 2 small storage rooms. This ER also has a tube system to connect with

the rest of the hospital, easily to see clocks, and 12 ft hallways for easy access.


Discussion

Not many people have unpleasant experiences, but many don’t have perfect ones either.

If things like wait time or layout were improved, the patient experience ratings would most likely

go up. Most of the open-ended questions throughout the survey match up to what this research is

trying to get at. A few questions in the surveys, especially the patient one, had the option of

choose “other” or “n/a.” These were appropriate for these survey questions because many people

would rather not shared their opinion or they just might not have noticed protocols throughout

their experience. For example, question 5 or 6 in Appendix A. Most participants listed at least

one idea that could have made their experience faster and/or more effective. Question 7 was

simply asked out of curiosity. It is interesting to compare a person’s experience at their ER visit

with what they answered in the survey questions. Many people who had a serious problem and


needed treatment right away didn’t notice long wait times or unnecessary questioning, etc. The

participants who went to the ER for a mild condition or less severe case had to wait a lot longer.

If their case wasn’t urgent, there were many things that were able to happen between their arrival

and their diagnosis.

Both medical professionals who took the second survey said that ER protocols can

always be improving. Each gave their opinion on what should or could be done to aid emergency

departments to function to the best of their ability. A limitation to this research is the lack of

participants in the second survey for physicians. Dues to privacy rules and other factors, it was

difficult to distribute this survey to the people who could take it. The information for the two

participant was beneficial, but it doesn’t provide enough credibility to draw conclusions from.

Not making some questions in the first survey required is another limitation. Some participants

didn’t answer a couple of the survey questions. It is unethical to make all of the questions

required, but they could've been reworded for participants to better understand and answer to the

best of their ability instead of leaving them blank.

If emergency departments implement a new constructed design, the flow of information

and all other concerns could be greatly improved. One limitation in creating a new emergency

department layout would be the expenses of remodeling an entire emergency department. If a

hospital were to have those expenses, the time of remodel would be another limitation. A

hospital without an emergency department will altogether not function to the best of its ability.

The hospital would need to make plans to inform the public of their time without an emergency

department or figure out a way to function as they are also remodeling. It would be ideal to stay

accessible while remodeling at the same time.

Conclusion


All emergency department protocols and guidelines can be improved to better benefit

patients than they do now, but there are many limiting factors to completely improving an

emergency department. There are many solutions to the issues hospitals have within their ERs,

but they’re all easier said than done. Many of them take a lot of time and money and emergency

departments don’t have time to stop what they are doing and remodel. The best fix for

emergency departments that face the issues of long wait times, poor flow of patient information,

lack of facilities, etc. is to slowly improve one thing at a time. Regular day to day processes

won’t be entirely interrupted and even though it would take time, it could be done efficiently.

/ 1


Appendix A

Patient Experience Survey


Appendix B


Physician Survey



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