Patient Flow In The ED: Phase II—Diagnostic Evaluation .
R E V I E W S & A N A LY S E SPatient Flow in the ED: Phase II—DiagnosticEvaluation through Disposition DecisionMary C. Magee, MSN, RN, CPHQ, CPPSSenior Patient Safety/Quality AnalystPennsylvania Patient Safety AuthorityABSTRACTThe total number of emergencydepartment (ED) visits in the UnitedStates increased 35% between 1995and 2010, according to the Centersfor Disease Control and Prevention.However, according to the AmericanHospital Association, between 1991and 2011, the number of hospitalswith EDs decreased by 647, leavingless EDs to manage increased visits.These factors contribute to ED crowding,which causes bottlenecks in patient flowand creates patient safety hazards. In2013, Pennsylvania hospitals reported23,749 events to the PennsylvaniaPatient Safety Authority in which the EDwas selected as the care area. Of thesereports, 2,495 (10.5%) were submittedas no-harm events requiring monitoring or events resulting in harm or evendeath for patients being seen duringthe period between diagnostic testing and disposition decision. This timeframe consists of several components,of which most are inputs to the diagnostic process leading to the output ofdiagnosis and disposition decision. EDmeasures from the Centers for Medicareand Medicaid Services affect reimbursement. This article is the second in athree-part series that addresses patientsafety related to ED flow, and it focuseson strategies to improve processes ofcare and patient safety during the diagnostic evaluation through dispositiondecision phase of ED care. (Pa PatientSaf Advis 2015 Mar;12[1]:7-18.)INTRODUCTIONIn a survey of departmental chairs and emergency department (ED) medical directors inPennsylvania, 83.0% agreed that crowding was a problem, 84.0% reported that a highproportion of patients leave without being seen, 79.0% stated that quality of care suffers,and 65.0% reported that crowding had worsened in the past two years (the survey wasconducted in 2008).1 EDs are an integral and unique part of the healthcare delivery system. Operationally, the ED is one of the more complex clinical settings in the hospital.2Between 1995 and 2010, the total number of visits to EDs increased from 97 million to130 million (34.0%), and the visit rate, which accounts for changes in population sizeover time, increased from 37 to 43 visits per 100 individuals (16.2%).3 According to theAmerican Hospital Association, between 1991 and 2011, the number of hospitals withEDs decreased by 647.4 In Pennsylvania, 41 hospitals have closed since 2001, according to the Pennsylvania Health Care Cost Containment Council.5 The number of EDvisits continues to rise.6,7The care that is provided in EDs includes both emergency and primary care. ED staffmust maintain the capacity to manage expected variation in patient volume as well asunpredictable surges caused by events such as natural disasters and multivehicle accidents, which may occur with limited or no advance warning.3 This article addressespatient safety related to ED flow, and it focuses on strategies to improve processes ofcare and patient safety during the diagnostic evaluation through disposition decisionphase of ED care.In 2010, the Pennsylvania Patient Safety Authority published an article that delineatedthe patient’s ED stay into the following phases:8—— Phase I: patient arrival in the ED to diagnostic testing—— Phase II: diagnostic testing through disposition decision—— Phase III: disposition decision to departure from the EDThe article discussed utilization, census, and clinical performance metrics and bestpractices to improve patient safety and flow in phase I. Figure 1 depicts the phases,including components and potential hazards to patient safety.Recognizing the challenges in balancing ED flow and patient safety, federal agenciesand quality organizations have defined ED metrics that will affect reimbursement andencourage quality improvement. At present, most EDs have developed dashboards tohelp track quality improvement performance over time.2,3,5,9,10COMPONENTS OF ED PHASE IIPhase II of ED flow, the focus of this article, encompasses much of the patient andcaregiver activity in the ED and comprises key components of inputs (e.g., information)and outputs (e.g., decisions) and related activities, recognizing that these may be iterative and nonlinear processes.InputsScan this codewith your mobiledevice’s QR readerto access theAuthority's toolkiton this topic.Vol. 12, No. 1—March 2015 2015 Pennsylvania Patient Safety Authority————Treatments and procedures (including medication): nursing and physician interventions, including ordering, completing, and patient responseDiagnostic testing: radiologic, laboratory, respiratory (e.g., arterial blood gas),cardiac (e.g., electrocardiogram), or other test ordering, completion, andresults reportingPennsylvania Patient Safety AdvisoryPage 7
R E V I E W S & A N A LY S E S————Monitoring and reassessment:routine observation, nursingreassessments, and physicianreassessmentsConsults: specialists and hospitalistsordering, communicating, andcompleting consults (includingrequests for additional testing andtreatment)Output——Diagnosis and disposition decisions (admit, discharge, or transfer):interpreting and assimilating theinformation from the inputs toreach a diagnosis, then determiningdisposition.Figure 2 provides an illustration of thecomponents of phase II.Figure 1. Emergency Department Flow PhasesPHASE IIPatient Arrival in theEmergency Department(ED) to DiagnosticEvaluationDiagnostic Evaluationthrough DispositionDecisionIncludes:Treatments and proceduresPatient arrival in EDPatient triagePlacement intreatment areaPractitioner arrival/initialassessmentPatient safety hazards:Patients who leavewithout triageUnmonitored patients inwaiting areaRushed or inaccuratetriage processPatients who leave withoutbeing seenUnmonitored patientsin roomsRushed, incomplete, orinaccurate patientassessmentIncludes:Diagnostic testingMonitoring andreassessment (includingcontinued physician andnursing assessments)ConsultsDiagnosing (includingmedical decision making)Disposition Decision toDeparture from the EDIncludes:Monitoring patient untilbed or unit is availableor until the patient isdischargedCommunication orhandoff to next facility,unit, or care settingPatient teaching anddischargeTransportation or transferDisposition decisionPatient safety hazards:Patient safety hazards:Gaps in treatmentresponsibility and oversightPatients who leave withoutbeing seen, leave withouttreatment, or leave againstmedical adviceUnmonitored patients intreatment roomErrors in ordering,executing, and resultingDelays in ordering,executing, and resultingRushed, incomplete, orinaccurate patientassessmentDiagnostic decision errorsor failure to diagnosePage 8PHASE IIIPennsylvania Patient Safety AdvisoryUnmonitored patientsUnmonitored boardersin the EDRushed, incomplete,or inaccurate patientassessmentPoor communicationand handoffsIncomplete patient andfamily educationTransportation ortransfer difficultiesMS15095PHASE IVol. 12, No. 1—March 2015 2015 Pennsylvania Patient Safety Authority
HazardsEach component is susceptible to patientsafety hazards, including (1) rushed,incomplete, inaccurate, or omittedpatient assessments and monitoring; (2)delays and errors in ordering, communicating, executing, and providing results ofdiagnostic tests, treatments, procedures,and consults; and (3) errors in interpreting, assimilating, and diagnosing todetermine the correct disposition for thepatient. Additionally, untoward events—such as falls and patients leaving withoutbeing seen or leaving against medicaladvice (AMA)—may occur, particularlywhen patients are left unattended inexamination rooms or hallways or feelthey have waited too long.ED flow can both impact and beimpacted by these components. A masscasualty incident resulting in a suddensurge in patient volume or other causesof crowding creates an environment moreFigure 2. Phase II: Diagnostic Evaluationthrough Disposition Decision ComponentsINPUTSTreatments andproceduresDiagnostic testingMonitoring andreassessmentConsultsDiagnosing:(interpreting, assimilating,and concluding)MS15096OUTPUTVol. 12, No. 1—March 2015 2015 Pennsylvania Patient Safety Authoritysusceptible to error, and any error ordelay can interrupt or halt patient flow.11When ED crowding occurs, the number of patients can outweigh availableresources, potentially increasing patientsafety hazards.1,12ED crowding is also a hospital-wide problem. Escalation in ED patient populationincreases the demand on hospital resourcessuch as ancillary services, operating rooms,and inpatient beds. Lack of availabilityof inpatient beds may result in admittedpatients being “boarded” in the ED.13METHODSAuthority analysts queried the PennsylvaniaPatient Safety Reporting System (PA-PSRS)database for events reported during calendar year 2013 that identified the ED asthe care area; facilities reported 23,749such events. An illustration of the data analysis methodology, Emergency Department(ED) Flow Phase II Methodology Algorithm,is available exclusively in the online version of this article.Analysts identified events associated withphase II by first excluding reports withkeywords relevant to phases I and III (e.g.,“triage,” “arrived,” and “arrival” [phaseI]; “discharge,” “dispo,” “inpatient,” and“admit” [phase III]). Of the remaining17,561 reports, 14,642 were reported as anunsafe condition or no-harm event, witha harm score of A through C, and wereexcluded from analysis. The Authority’sevent reporting system uses an adaptationof the National Coordinating Councilfor Medication Error Reporting andPrevention harm index and the Veterans’Administration National Center forPatient Safety severity assessment codesystem to distinguish between harm andno-harm events.14,15 The PennsylvaniaPatient Safety Authority Harm ScoreTaxonomy is available exclusively in theonline version of this article.The remaining 2,919 reports submittedas no-harm events requiring monitoring(i.e., harm score D) or as events resultingPennsylvania Patient Safety Advisoryin harm or even death (i.e., harm scoresE through I) were included in the analysisto ensure a large enough sample size toreflect the activity of this phase and tocapture events resulting in harm thatwere reported as harm score D. Thesereports were individually analyzed to confirm they were ED events that occurredbetween diagnostic evaluation and disposition decision.Non-ED and additional phase I and IIIreports were excluded (n 90, 84, and221, respectively). There was a small number of reports submitted as “unplannedreturns to the ED” (n 29); these eventscould not be attributed to a single phaseand were also excluded from the analysis.Analysts sorted the resulting 2,495 reportsinto one of the phase II componentsdepicted in Figure 2. Once sorted, analysts identified events associated witha stated or inferred delay (e.g., delay inadministering the medication, wrong testordered) using the key terms in “Typesof Stated or Inferred Delay Key Terms,”available exclusively in the online versionof this article.RESULTSAs can be seen in Figure 3, the predominant number of events reported in phase IIinvolved treatments and procedures (e.g.,errors in ordering and executing, complications, adverse reactions). Stated andinferred delays were not frequently reportedin this component.Diagnostic testing reports comprised thethird largest number of phase II inputevents submitted to the Authority butincluded the largest number of stated orinferred delays, both in absolute termsand as a percentage of total reports ineach category. Reports also includederrors in ordering, executing, and resulting, such as misidentification of patients,delays, contrast infiltrations, and laboratory or radiology test problems.Monitoring and reassessment comprisedthe second largest number of phase IIPage 9
R E V I E W S & A N A LY S E SFigure 3. Stated and Inferred Delays during ED Flow Phase II Events Reported tothe Pennsylvania Patient Safety Authority, 2013 (N 2,495)NUMBEROF REPORTS1,200800EDs face the challenge of managingpatient flow, crowding, and unpredictable surges in volume while maintainingpatient safety. Phase II components comprise much of the patient and caregiveractivity in the ED, often simultaneously(nonlinear) and iteratively (cliniciansoften must restart their care in light ofnew information [e.g., change in patientcondition, new diagnosis]).It is important to ensure patient safetyduring these activities. Delays can impactpatient safety and flow. This is consistentwith data from the survey conductedby Pines et al., which identified several factors affecting ED crowding inPennsylvania hospitals, including ED inefficiency, radiology delays, and delays inconsultation.1 Additionally, Farley et al.studied the use of electronic healthrecord (EHR) systems in the ED and theirimpact on the quality and safety of thecare delivered and reported the potentialharm from an inferior EHR product orsuboptimal execution of that product inthe clinical atmpr enoc tsed anur desDiagnte oststi icngMonre itoas rinse gss anm dent0111200no600Consults comprised the smallest numberof phase II input reports submitted to theAuthority. Stated and inferred delays were50% of the reported consult events. TheTable displays the number of phase IIreports by component and providesexamples of report narratives for eachcomponent. The potential hazards topatient safety are outlined in Figure 1.DISCUSSION1,171ag1,000Reports without delaysReports with stated or inferred delays20Cinput reports submitted to the Authority.Reports included unwitnessed falls withinjury, leaving AMA or without treatmentbeing completed, clinical status changes,equipment malfunctions, unplannedextubations, self-inflicted injuries, andaccidental injuries during care (e.g., skintears, injured body part). Falls comprisedthe largest number of reports in this component (n 494, 77.5%).COMPONENTBecause of the numerous and variedactivities of each component, as seen inthe narratives, general principles are provided to enhance patient safety duringED phase II.InputsThe JointCommission states these general principlesto minimize safety hazards when administering treatments and procedures:17,18Treatments and procedures.————————Use two patient identifiers whenproviding care, treatment, or services, including blood transfusions,and label specimen containers in thepresence of the patient.Check for allergies and, if possible,set alerts in the EHR to warn ofallergies, contraindications, andinteractions.Use checklists when performing complex procedures such as central-lineor chest tube insertions.Reconcile medications.——Reduce the likelihood of patientharm associated with anticoagulantuse, such as by using approved protocols and programmable pumps.——Involve the patient wheneverpossible.Review testing protocolsto assess for opportunities for improvement.For example, in an arterial blood gas needlestudy, larger-gauge needles caused morecomplications and had a poorer success ratethan smaller needles.19 In addition to therecommendations above, the following aregeneral principles to increase the likelihoodof success without incident:Diagnostic testing.——Simplify and standardize patientidentification and specimen labelingprocedures.18,20——Verify the identity of the patientbefore entering orders or performingtesting, especially where laterality isconcerned.18(continued on page 12)Page 10Pennsylvania Patient Safety AdvisoryVol. 12, No. 1—March 2015 2015 Pennsylvania Patient Safety Authority
Table. Report Narrative Examples from Emergency Department (ED) Flow Phase II Reports Submitted to the Pennsylvania Patient SafetyAuthority, Calendar Year 2013 (N 2,495)NO. OFREPORTSCOMPONENTNARRATIVE EXAMPLES1,191Treatments andproceduresThe tech reported that the patient weighed 22 kg, which was [used to administer aweight-based medication]. Before giving the next medication, [staff] realized the patientweighed 22 pounds not kg. The [electronic medical record] was corrected, and therewere no adverse reactions.Patient was emergently intubated, and upon reviewing x-rays, a tracheal tear [wassuspected]. [Patient was taken to surgery,] and tracheal tear repaired. [There wereseveral] IV [intravenous] attempts, causing delay in [administering] IV medications,hydration, and CT [computed tomography] scan.623Diagnostic testingA patient had an EKG [electrocardiogram] performed, which was read by the resident.The EKG was misplaced. It was not until the final reading of the EKG, which wasavailable electronically [about two days] later, that it was discovered that the EKGwas [abnormal].Respiratory therapist drew an ABG [arterial blood gas], which resulted in a largehematoma formation.[Lab] specimens were in one bag with two different [patient identification] labels.Specimen[s] were re-collected.Due to [multiple other patients], there was a [four-] hour delay in having a CT scanperformed on the patient.Specimen tubes were sent to lab via the [pneumatic] tube system; however, lab neverreceived them. After waiting [nearly an hour] for maintenance to repair system, had toredraw patient’s blood work.637Monitoring andreassessmentPatient was [found unresponsive] while toileting. Patient required intubation andadmission.A noise was heard in patient’s room. The patient was found on the floor. A CT scanshowed a subarachnoid bleed and [nasal] fractures.Patient was waiting for results, became tired of waiting, and left with the IV [line] inplace. Unable to reach patient by phone, and police were notified. Police unable tolocate patient.Monitor alarming and pulse ox decreased and heart rate correlated; however, theoxygen tank ran out, and patient was [experiencing] of shortness of breath.22ConsultsA [cardiac arrest alert] was called. Calls were placed to two different cardiologists whostated they were not on call. This resulted in a 12-minute delay in getting the patient tothe cath lab.Neurology consult was not called in when ordered [resulting in a delay].Patient was assigned to a physician who was not on duty in the ED at the time. Thisresulted in a critical test result not being reported to a physician.22Diagnostic decisionprocessThe ED read the EKG as [normal] without significant changes, and cardiology read as ST[segment] elevation, possible ACS [acute coronary syndrome].A patient was diagnosed with hypertension and Bell palsy. Patient returned with nocontrol of right arm, and CT scan [showed] an infarct in left frontal parietal region.Patient was diagnosed with fractured ribs. X-rays [done and read by the ED] stated nopneumothorax. [Radiology] read the x-ray as [positive for] pneumothorax.Vol. 12, No. 1—March 2015 2015 Pennsylvania Patient Safety AuthorityPennsylvania Patient Safety AdvisoryPage 11
R E V I E W S & A N A LY S E S(continued from page 10)Protocolsand toolkits are available to evaluateand improve patient monitoring andassessments. A falls risk assessment isconsidered best practice, regardless of theclinical setting, including assessing forrisk of injury, screening for a history offalls within the previous 12-month period,asking about gait or balance problemsin patients who have not had a fall inthat time period, and performing simplemobility testing (e.g., Timed Up andGo).21-25 Effective falls prevention interventions are multifaceted and can be tailoredto patient characteristics, risk factors, andclinical settings.22-24Monitoring and reassessment.Patients requiring mechanical support ordevice-related monitoring (e.g., ventilator,telemetry, pulse oximetry) require expertcare and ongoing monitoring of theirclinical status. Monitoring failures such asalarm fatigue and limitations of monitoring systems have been discussed in theliterature. Being aware of the monitoringdevice limitations, tailoring device defaultsettings to the individual patient, usingunit-wide alarm notification, and ensuri
Diagnostic Evaluation through Disposition Decision PHASE II Includes: Monitoring patient until bed or unit is available or until the patient is discharged Communication or handoff to next facility, unit, or care setting Patient teaching and discharge Transportation or transfer Patient safety hazards: Gaps in treatment responsibility and oversight
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