How Nurses Help Relieve ED Overcrowding

By Lynn Hetzle, via Multibriefs

Emergency department (ED) overcrowding threatens access to healthcare and the quality of that care. It can lead to delays in analgesia, thrombolysis, antibiotic therapy, percutaneous coronary intervention and other time-sensitive treatments. Overcrowding in the ED can impair privacy, dignity and completeness of care, and it may also increase the risk for errors as staff struggles to provide care for patients.

International literature suggests consistently that overcrowding exists and that it has significant consequences on care, but these studies are of limited value to practitioners because they do not evaluate interventions.

However, a recent study suggests the implementation of nurse-initiated protocols, diagnostics and treatments prior to treatment from a physician or nurse practitioner can improve flow in the ED, thus reducing overcrowding.

Published in the Annals of Emergency Medicine, the Canadian study describes how nurse-driven protocols cut emergency department lengths of stay for patients with chest pain, fever, vaginal bleeding during pregnancy and hip fractures.

Three main factors contribute to overcrowding: input, throughput and output. Patients who use the ED for nonemergent complaints contribute by input, understaffing slows throughput, and access blocks — like overcrowded ICU units — prevent output.

Lead author of the study, Matthew Douma, a clinical nurse educator at Royal Alexandra Hospital in Edmonton, Alberta, Canada, and his associates performed a controlled evaluation of six nurse-initiated protocols in an urban hospital. Douma and his team measured length of stay in the ED, time to diagnostic test, time to consultation, time to treatment and other outcomes.

The researchers found that implementing the nurse-driven protocols improved a number of outcomes, including:

• Reducing median time for administering acetaminophen to patients with pain or fever by more than three hours (186 minutes)
• Decreasing average time to troponin testing for ED patients with chest pain suspected to be myocardial infarction by 79 minutes
• Cutting average length of stay for patients with suspected hip fracture by 224 minutes and vaginal bleeding during pregnancy by 232 minutes

Emergency departments in the United States logged more than 136.3 million visits in 2011, according to the Centers for Disease Control and Prevention (CDC). More than 34 percent of patients spent more than two but less than four hours in the ED, and nearly a quarter spent between one and two hours in the ED.

More than 40 percent of these patients spent 15 to 59 minutes just waiting to see a doctor, physician's assistant or nurse practitioner; 27 percent were seen by an MD, DO, PA or NP in less than 15 minutes.

"Given the long waits many emergency patients endure prior to treatment of pain, the acetaminophen protocol was a quick win," Douma said. "That said, nurse-driven protocols are not an ideal solution, but a stop-gap measure to deal with the enormous problem of long wait times in emergency departments especially for patients with complex problems.

"Emergency department crowding will continue to require broad and creative strategies to ensure timely care to our patients."

Lynn Hetzler has been a freelance writer for more than 15 years. She has extensive experience in a variety of specialties, including transplantation, oncology, fertility, negligible senescence, laboratory science, addiction, general research and more. Lynn specializes in creating informative and engaging medical content for readers of all levels, from patients to researchers and everyone in between.