emergency department nursing research article

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Emergency Department Nursing Burnout and Resilience

Affiliation.

1 School of Nursing, Western Carolina University, Cullowhee, North Carolina.
PMID: 35089283
DOI: 10.1097/TME.0000000000000391

Burnout is a significant problem in emergency nursing, and it is associated with higher turnover rates than other disciplines of health care. Emergency nurses are highly susceptible to burnout due to continual exposure to traumatic events, varying work schedules, violence directed at staff, and, in recent times, due to the stressors of the COVID-19 pandemic. This literature review will (1) expose the causes of emergency department (ED) nurse burnout and (2) discuss strategies to build resilience in ED nurses. A systematic review of studies published in academic journals discussing burnout and resilience, specifically related to ED nurses, published in English between 2015 and 2019. The databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Source, Health Source: Nursing/Academic Edition, APA PsycArticles, Military and Government Collection, Gender Studies Database, SocINDEX, and PsycINFO were searched. Sixteen studies were included in this review. Work schedules and shift work, violence toward staff, and lack of management support were factors linked to burnout. Self-discipline, optimism, and goal-oriented behaviors evolved as characteristics of resilient ED nurses. Burnout rates among ED nurses are steep. Shift work, traumatic events, violence, and management support are determinants of burnout. Specialized actions can combat burnout and increase resilience. Nursing management can provide specific education to nurses to assist in this effort.

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Published: 05 April 2024

Emergency department responses to nursing shortages

Nicole R. Hodgson 1 ,
Richard Kwun 2 ,
Chad Gorbatkin 3 ,
Jeanie Davies 4 &
Jonathan Fisher 4

on behalf of the ACEP Emergency Medicine Practice Committee

International Journal of Emergency Medicine volume 17 , Article number: 51 ( 2024 ) Cite this article

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The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage.

We queried emergency department leaders from the American College of Emergency Physicians to examine the impact of nursing shortages on EDs and to gather real-world interventions employed to mitigate the effects of the shortage.

Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing left without being seen rates (90.9%). ED leaders reported a range of interventions, including operational flow changes, utilizing alternative staff to fill nurse roles, recruitment of new nurses, and retention strategies for existing nurses. They employed temporary and permanent pay increases as well as efforts to improve the ED work environment and techniques to hire new nurses from atypical pipelines.

We report a patchwork of solutions ED leaders utilized which may have variable efficacy among different EDs; personalization is essential when selecting interventions during a sudden nursing shortage.

Introduction

Cyclical nursing shortages, both global and localized to the United States of America, existed prior to the COVID-19 pandemic [ 1 ]. The COVID-19 pandemic led to a worsening shortage [ 2 ]; the 2022 National Council of State Boards of Nursing’s National Nursing Workforce Survey revealed a loss of 100,000 registered nurses (RNs) and 34,000 licensed practical and vocational nurses (LPNs/LVNs) due to the pandemic between 2020–2022, with an alarming 28% of nurses planning to retire within the next 5 years [ 3 ]. Nursing shortages, especially in emergency medicine (EM), where nurses face significant burnout rates [ 4 ], are predicted to worsen.

Worsening nursing staff levels correspond with worsening patient satisfaction [ 5 ], deterioration of operational metrics [ 6 ], and increasing patient mortality [ 7 ]. Despite this, literature searches by our American College of Emergency Physicians’ (ACEP) Emergency Medicine Practice Committee (EMPC) revealed a lack of published interventions for emergency departments (EDs) facing a sudden nursing shortage.

We queried national ED leaders to examine the impact of nursing shortages and to obtain information regarding interventions employed to mitigate the effects of these shortages.

We gathered information via an electronic collection tool (Appendix 1 ) from the ACEP Medical Directors ( N = 450) and EMPC ( N = 75) listservs to examine the impact of the nursing shortage on EDs and to collect novel solutions and approaches in an open-ended format. Although the listservs mostly consist of physician leaders, a small number of ACEP administrators as well as resident, medical student, physician assistant, and nurse practitioner representatives serve on the committees and are included in the counts. The Mayo Clinic Institutional Review Board provided an exemption from full review. We performed basic statistical analyses for multiple-choice responses (counts, percentages). For free-text responses, one author (NRH) performed content analysis combining similar responses into categories with counts (Appendix 2 ).

We present demographics from our 66 respondents in Table 1 . All worked in hospital EDs except one, who worked at a freestanding ED.

We report multiple-choice responses in Table 2 .

We report free-text response summaries in Appendix 2 with numbers of respondents noted as (x#). We describe key results from free-text responses below.

When queried regarding ED interventions to reduce demands on nurse/technician staff or to increase capacity of nurse/technician staff or supply of other ancillary services, ED leaders commonly repurposed higher-paid staff for ED RN roles, such as physicians administering medications, placing intravenous (IV) lines, and discharging patients. Conversely, some respondents utilized lesser-paid workers including paramedics, emergency medical technicians (EMTs), LPNs, non-emergency RNs, and patient care technician staff to perform basic RN duties such as IV access, blood draws, and administering medications, within the scope of what state regulations allowed. One ED placed a scribe in triage to replace the triage RN, although the respondent clarified that although scribes recorded vitals and chief complaints, they couldn’t perform Emergency Severity Index (ESI) scores. Another ED used virtual mental health sitters instead of physical RNs for patients requiring monitoring for behavioral concerns. ED leaders attempted to decrease RN work requirements by decreasing documentation burden, decreasing discharge vitals requirements, and changing IV drip medications to oral, IV push, or intramuscular routes. Operational changes to decrease the impact of RN shortages included employing a physician-in-triage (PIT) or teletriage model alongside lobby-based care such as formal vertical care spaces with chairs for administration of IV medications or dedicated areas for physician waiting room (WR) evaluations, lab draws, and discharges. Two ED leaders reported closing ED sections due to lack of RNs.

We asked what changes were made to maintain patient safety during RN shortages, and respondents highlighted above-mentioned interventions along with attempts to obtain new RN staff. Several mentioned operational changes implemented for patient safety, such as vertical flow, PIT, and assigning more RNs to the enlarging waiting room pool. Two new interventions mentioned in response to this question included calling patients ESI 1/2/3 who left without being seen (LWBS) and increasing physician order entry requirements (for example, decreasing use of verbal orders).

Although some ED leaders reported their systems employed no strategies to retain existing nurses, several described RN retention efforts. Many focused on improving RN pay either through temporary (retention or shift/incentive bonuses, internal higher-paid travel programs, time-limited rate increases to match travelers) or longer-lasting (increasing RN base/hourly rates or creating an RN clinical pay ladder or RVU model) improvements. Some described non-financial interventions including improvements in the work environment such as a twice daily physician-led “medical minute” educational huddle, promoting a team environment, and improving nurse-patient ratios.

Attempts at recruitment of new staff mainly focused on financial-related incentives such as sign-on bonuses, pay increases, referral bonuses, and RN tuition reimbursement. However, some ED leaders increased the ED RN pipeline by hiring new graduates and international RNs, creation of or increasing enrollment in an RN ED residency or hospital-affiliated RN school, hiring RN students as externs, cross-training non-ED RNs, and creation of internal traveler programs.

Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing LWBS (90.9%). The shortage impacts both the ED as well as inpatient nurse availability, with 90.9% of respondents attesting that inpatient shortages contributed to boarding in the ED. Most respondents used travel nurses (92.4%), which can be costly to hospital systems, dissatisfying for employed RNs, and potentially harmful to patient safety [ 8 ].

Published literature lacks recommendations for best practices during ED RN shortages. Some hospital systems tried to mitigate the crisis through nurse retention efforts and attempts at hiring new nurses, often by improving reimbursement, which may be beyond the abilities of hospital systems or, depending on employment model, outside the purview of ED directors. Some created RN educational programs such as ED RN residencies or student rotations; however, those solutions take time and may not be beneficial in an acute crisis. Similarly, cross-training RNs for float pools or internal traveler programs takes initial investment. Previous publications support boosting retention by improving the workplace environment and enhancing support systems for ED RNs [ 9 ]; our survey respondents reported implementing a physician-led “medical minute” and promoting a team atmosphere. Building RN mentoring programs and implementing other changes to improve the ED environment may be rapidly accessible by an ED director working closely with nurse leadership and may improve retention rates.

Additional interventions included use of alternative staff to offload RN duties. ED directors should consider individual aspects of their EDs and state regulations prior to experimenting with these changes, as some options considered beneficial at one hospital were not felt to be helpful at others. The practice parameters of alternative staff replacing RNs must be clearly established to be successful in the ED. Though lesser-trained than RNs for emergency medicine departmental work, paramedics completing the National Standard Paramedic Curriculum meet or exceed 90% of knowledge, skills and competencies for Certified Emergency Nurse and Critical Care Registered Nurse board certification [ 10 ]. Non-traditional staff in triage may increase wait times and LWBS rates [ 11 ], although when incorporated into the ED as complementary team members, EMTs and LPNs have helped decrease length of stay (LOS) [ 12 ].

Multiple respondents reported operational changes to improve flow and strive for safe care, which may include accelerated diagnostic pathways, fast track, team triage, and technological enhancements of existing processes, alongside alternative space utilization for clinical care. Although suboptimal, the WR may be the only space available to initiate care [ 13 , 14 ]. WR assessments do not overcome nurse-driven rate-limiting steps but can facilitate diagnostic and therapeutic actions not requiring time-intensive bedside tasks. WR care overlaps with dedicated PIT models, which in certain circumstances can identify and accelerate rate-limiting steps such as advanced imaging or time-sensitive treatment such as early antibiotics or thrombolytics. The rise of WR care may be a symptom of unsafe and overcrowded department conditions, but when used strategically if physician and nurse staffing permits, it can decompress bottlenecks and provide a secondary layer of safety when the department and triage are overrun [ 13 ].

Our study is small and therefore suffers limitations. Response and selection bias may impact our results, as we did experience a low response rate (12.6%). Our study was designed to obtain ED physician leader responses and therefore lacks the perspective of RN leadership. There is a possibility of the same hospital system responding multiple times, as several physicians from the same institution could be contained within the listservs; however, this appears unlikely due to variation in responses. Although our sample size was low, we believe the description of interventions employed will benefit ED directors facing acute nursing shortages. We are unable to isolate the individual impact of each intervention due to our study format and the fact that EDs typically employed combinations of interventions; our report may serve as a launching pad for future research but is only a beginning.

ED leaders reported a variety of interventions, typically employing multiple methods simultaneously; departmental factors should be considered when selecting interventions at the individual ED level. Future research should investigate the impact of isolated interventions to delineate the most beneficial strategies.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Emergency departments

Registered nurses

Licensed practical and vocational nurses

Emergency medicine

American College of Emergency Physicians

Intravenous

Emergency Severity Index

Physician-in-triage

Waiting room

Left without being seen

Length of stay

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Dedicated staff time from the American College of Emergency Physicians (Davies, Fisher).

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Department of Emergency Medicine, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA

Nicole R. Hodgson

Department of Emergency Medicine, Swedish Medical Center, Issaquah, WA, USA

Richard Kwun

Department of Emergency Medicine, Madigan Army Medical Center, JBLM, Lakewood, WA, USA

Chad Gorbatkin

American College of Emergency Physicians, Irving, TX, USA

Jeanie Davies & Jonathan Fisher

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Conceptualization (NRH, RK, CG, JD, JF), data collection (NRH, JD, JF), critical review and evaluation (NRH, RK, CG, JD, JF), primary authorship of the paper (NRH, RK, CG), review and editing of the paper (NRH, RK, CG, JD, JF), study supervision (NRH, JD, JF).

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Correspondence to Nicole R. Hodgson .

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Hodgson, N.R., Kwun, R., Gorbatkin, C. et al. Emergency department responses to nursing shortages. Int J Emerg Med 17 , 51 (2024). https://doi.org/10.1186/s12245-024-00628-y

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emergency department nursing research article

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Published: 14 August 2024

Overcoming challenges in nursing disaster preparedness and response: an umbrella review

Abdulellah Al Thobaity 1

BMC Nursing volume 23 , Article number: 562 ( 2024 ) Cite this article

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Disaster nursing plays a vital role in addressing the health needs of vulnerable populations affected by large scale emergencies. However, disaster nursing faces numerous challenges, including preparedness, logistics, education, ethics, recovery and legalities. To enhance healthcare system effectiveness during crises, it is essential to overcome these issues. This umbrella review, conducted using the Joanna Briggs Institute (JBI) methodology, synthesizes data from 24 studies to identify key strategies for improving disaster nursing. The review highlights nine key themes: Education and Training, Research and Development, Policy and Organizational Support, Technological Advancements, Psychological Preparedness and Support, Assessment and Evaluation, Role-Specific Preparedness, Interprofessional Collaboration and Cultural Competence, and Ethics and Decision-Making. The review emphasizes the importance of education, technological advancements, psychological support, and interprofessional collaboration in bolstering disaster nursing preparedness and response efforts. These elements are crucial for enhancing patient outcomes during emergencies and contributing to a more resilient healthcare system. This comprehensive analysis provides valuable insights into the various aspects essential for enhancing disaster nursing. By implementing evidence-based strategies within these nine themes, the nursing profession can enhance its capacity to effectively manage and respond to the complex needs of disaster-affected populations, ultimately improving patient care and outcomes during emergencies.

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Introduction

Disaster nursing is a specialized field that focuses on the provision of care and support individuals and communities who are affected by emergencies and crises. Disaster Nursing, emphasizes the critical roles of nurses in addressing the health needs of vulnerable populations who has special needs such as elderly and children during disasters [ 1 ]. Competent disaster Nursing is essential to improve the overall effectiveness and efficiency of healthcare systems during times of crisis by ensuring the well-being and resilience of individuals and communities. However, disaster nursing faces major challenges that must be acknowledged and addressed, including preparedness and planning, logistical, and organizational, as well as education, training, recovery and ethical and legal considerations [ 2 , 3 ]. By exploring these challenges and identifying strategies for overcoming them, nursing profession can continue to evolve and enhance the ability to respond to the complex needs of those affected by disasters.

Challenges related to preparedness and planning in disaster nursing encompass various aspects that can hinder effective crisis response in many countries worldwide [ 1 , 4 , 5 ]. These include limitations in the disaster paradigm, inadequacies in the pre-hospital system, lack of coordination and cooperation among stakeholders, insufficient hospital preparedness, scarce resources and capacities, and gaps in patient knowledge [ 6 , 7 ]. Furthermore, challenges in planning for the unpredictable nature of disasters, disparities in emergency nurses’ preparedness, workplace readiness, and the preparedness of colleagues and institutions (including leadership and peers) contribute to the complexity of the issue [ 8 ]. Limited availability of training opportunities, individual preparedness due to lack of prior experience, absence of a comprehensive disaster plan, insufficient disaster training, and unassigned roles in workplace disaster plans further exacerbate the difficulties faced by nursing professionals in the realm of disaster preparedness and planning [ 8 , 9 , 10 , 11 ]. Addressing these challenges is crucial for enhancing the ability of nurses and healthcare institutions to effectively manage and respond to emergencies.

Logistical, organizational, and managerial challenges pose significant obstacles to effective disaster nursing in numerous countries worldwide. Such as Japan ; China and Iran [ 2 , 12 , 13 ] Logistical challenges, such as constructing and operating hospitals in disaster zones and addressing equipment issues, create difficulties in the provision of care [ 2 ]. Staff challenges, including the orientation of personnel in new and challenging environments, further complicate the situation [ 14 ]. Organizational and managerial challenges encompass the development and implementation of appropriate policies, procedures, and support structures, which are essential for enabling nursing professionals to work effectively under extreme conditions [ 2 ]. Adequate support from hospital administration, the promotion of evidence-based practice research, and the use of evaluation tools to assess and improve performance are crucial in overcoming these challenges. Gaps in these areas can hinder the ability of nurses and health care institutions to manage and respond effectively to emergencies, underscoring the need for comprehensive strategies to address logistical, organizational, and managerial challenges in disaster nursing.

Challenges related to education and training in disaster nursing have far-reaching consequences on the ability of nurses to effectively respond to emergencies [ 15 ]. These challenges encompass the defining roles of nurses, the creation and implementation of educational training programs, and the overall education system. Factors such as the lack of disaster educators, insufficient formal education, inadequate nurse training, and limited disaster experience hinder the development of competent and prepared nursing professionals [ 2 ]. Furthermore, challenges in understanding hospital disaster policies and procedures, and the roles of nurses in disaster management, as well as deficiencies in communication and leadership skills, contribute to the problem. Personal evacuation experiences, a scarcity of studies, the lack of specialized journals, inaccessible programs, and gaps in nursing curricula further exacerbate the difficulties faced by nursing professionals. Addressing these educational and training challenges is essential to equip nurses with the knowledge, skills, and confidence required to effectively manage and respond to disasters.

Ethical and legal challenges in disaster nursing present unique obstacles that nursing professionals must navigate while providing care in crisis situations [ 16 ]. These challenges include addressing patient-related issues, such as cultural differences, language barriers, and follow-up concerns [ 17 , 18 ]. Ethical challenges unique to disaster zones and related to the scope and scale of the disaster, along with more general ethical issues, arise in areas such as justice in resource allocation, privacy and confidentiality, beneficence and non- maleficence. Furthermore, determining appropriate triage, setting treatment priorities, working autonomously, and obtaining informed consent can be particularly complex in disaster settings [ 3 , 18 ]. Conflicts and legal issues such as allocating the resources may also emerge, further complicating the delivery of care during emergencies. Addressing these ethical and legal challenges is vital for ensuring that nursing professionals can provide compassionate and effective care while upholding their professional responsibilities and the rights of the patients they serve.

Conducting an umbrella review on overcoming the challenges faced by disaster nursing is crucial for various reasons. First, it allows for a comprehensive and systematic synthesis of evidence from multiple systematic reviews, identifying studies, evidence, and interventions employed to address these challenges, thus mapping the knowledge landscape and progress made. Secondly, it reveals gaps in the literature, highlighting areas for further research and guiding researchers in prioritizing underexplored topics. Thirdly, it offers valuable insights into effective strategies and best practices, informing policymakers, healthcare institutions, and nursing professionals about evidence-based interventions and policies. Additionally, an umbrella review can facilitate interdisciplinary collaboration by revealing shared challenges and solutions across various fields, foster innovation and the development of integrated approaches to disaster nursing, and ultimately enhancing the efficacy and resilience of healthcare systems in responding to emergencies. Hence, the aim of this umbrella review is to explore the strategies that have been implemented in overcoming nursing challenges in disaster preparedness and response.

This umbrella review was conducted following the Joanna Briggs Institute (JBI) methodology for umbrella reviews. The purpose of this review is to synthesize existing systematic reviews related to the challenges in nursing disaster preparedness and response [ 19 ]. Studies were selected for inclusion in this research based on the criteria outlined in Table 1 .

A comprehensive search strategy was developed using relevant keywords and Medical Subject Headings (MeSH) terms, including “nursing,” “disaster preparedness,” “disaster response,” “challenges,” “interventions,” “strategies,” and “effectiveness,” applied to selected databases (PubMed, CINAHL, Scopus, Web of Science, and PsycINFO) and grey literature sources. Handsearching reference lists of included articles further enhanced the search. Duplicates were removed using EndNote reference management software, and titles and abstracts were screened based on eligibility criteria. Potentially eligible full-text articles were assessed for inclusion, and the study selection process was documented using a PRISMA flowchart Fig. 1 . The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram outlines the study selection process for this review.

PRISMA flowchart of study selection process

Initially, 3,223 records were identified from databases and 68 from registers. Before screening, 1,281 duplicate records and 1,050 ineligible records were removed, leaving 960 records for screening. After excluding 858 records, 102 reports were sought for retrieval, resulting in a final inclusion of 24 studies in the review which involve the flowing : Al Thobaity , Plummer , & Williams , 2017 [ 20 ] ; Kalanlar , 2019 [ 21 ] ; Zarea et al. , 2014 [ 2 ]; Jose & Dufrene , 2014 [ 22 ]; Cong Geng , Yiqing Luo , Xianbo Pei , & Xiaoli Chen , 2021 [ 23 ]; Alice Yuen Loke , Chunlan Guo , & Alex Molassiotis , 2021 [ 5 ] Nejadshafiee , Bahaadinbeigy , Kazemi , & Nekoei-Moghadam , 2020 [ 24 ]; Karin Hugelius & Adolfsson , 2019 [ 25 ]; Veenema , Lavin , Bender , Thornton , & Schneider-Firestone , 2019 [ 26 ]; Labrague et al. , 2018 [ 27 ] Yousefi , Larijani , Golitaleb , & Sahebi , 2019 [ 28 ] ; Varghese et al. , 2021 [ 29 ]; Kalanlar, 2022 [ 30 ] ; Said & Chiang , 2020 [ 31 ]; Pourvakhshoori , Norouzi , Ahmadi , Hosseini , & Khankeh , 2017 [ 32 ]; Hutton , Veenema , & Gebbie , 2016 [ 33 ]; Su et al. , 2022 [ 34 ]; Firouzkouhi , Kako , Abdollahimohammad , Balouchi , & Farzi , 2021 [ 35 ]; Tas & Cakir , 2022 [ 36 ]; Lin , Tao , Feng , Gao , & Mashino , 2022 [ 37 ]; Fithriyyah, Alda, & Haryani, 2023 [ 38 ]; Songwathana & Timalsina, 2021 [ 39 ] and Kimin, Nurachmah, Lestari, & Gayatri, 2022 [ 40 ] Putra , Kamil , Yuswardi , & Satria , 2022 [ 41 ]. The essential information such as: authors, publication year, type of review and key strategies were extracted and summarised in Table 2 .

Data synthesis

In this umbrella review, a single investigator conducted the thematic analysis using a thorough and systematic approach. The process began with familiarization through detailed reading and note-taking, followed by manual coding to identify key concepts. Preliminary themes were developed by grouping similar codes and refined iteratively for coherence. To enhance credibility, feedback was sought from a senior qualitative researcher. Detailed documentation of the process ensured transparency, while reflexive notes and discussions with the senior researcher mitigated potential bias. This approach ensured rigorous and transparent theme identification, enhancing the findings’ reliability and validity. Data from selected studies were synthesized to create a narrative synthesis, organized by strategies for improving disaster nursing. These strategies were summarized into nine key themes: (1) Education and Training; (2) Research and Development; (3) Policy and Organizational Support; (4) Technological Advancements; (5) Psychological Preparedness and Support; (6) Assessment and Evaluation; (7) Role-Specific Preparedness; (8) Interprofessional Collaboration and Cultural Competence; and (9) Ethics and Decision-Making. This approach allowed for a comprehensive analysis of the various aspects of disaster nursing enhancement.

This umbrella review aims to explore and emphasize the diverse strategies implemented to address nursing challenges in disaster preparedness and response. By synthesizing findings from the included studies, the discussion is organized into the nine key themes previously mentioned. Through a narrative synthesis of these themes, the review provides a comprehensive understanding of the various approaches used to enhance disaster nursing. Examining these strategies is intended to inform future research, policy, and practice, ultimately leading to improved disaster preparedness and response, better patient care, and enhanced outcomes during emergencies.

Education and training

Improving disaster nursing locally and worldwide requires a multifaceted approach, starting with enhancing nurses’ understanding of core competency domains [ 10 ]. Integrating these domains into training and disaster drills helps reinforce practical skills, ensuring efficient and effective responses in real-life disaster situations [ 10 , 22 ]. Expanding undergraduate and graduate disaster nursing education on national and international levels creates a well-prepared workforce capable of addressing diverse challenges in disaster management [ 21 , 22 , 23 ]. Effective training programs can address existing gaps in education by providing ongoing professional development opportunities for nurses. Establishing dedicated organizational units within healthcare systems to prepare for and respond to disasters by educating healthcare providers, including nurses, enhances disaster preparedness by encouraging collaboration and resource sharing. Moreover, a focused approach to improving education and training in disaster nursing is crucial worldwide [ 5 , 21 , 23 , 42 ]. Developing educational content for disaster nursing requires a tailored approach that considers the unique needs and challenges of the field. This includes accounting for various types of disasters, impacted healthcare settings, and the diverse roles that nurses play in disaster situations. By addressing these distinct aspects, educational materials can better equip nurses with the skills and knowledge needed to respond to emergencies and deliver high-quality patient care in disaster preparedness and response contexts [ 3 , 42 ]. Lastly, incorporating interprofessional education promotes teamwork, communication, and coordination among different healthcare providers, ultimately contributing to enhanced disaster preparedness worldwide [ 43 ].

Research and development in disaster nursing

Research and development (R&D) are critical for advancing disaster nursing. They generate evidence-based knowledge that guides clinical practice [ 5 , 44 ]. By involving nurses in research focused on competencies, studies become more relevant and applicable, as they are rooted in real-world experiences [ 44 ]. It is essential to optimize resource allocation in order to be more efficient and effective for both disaster preparedness and response [ 5 ]. Rigorous research, combined with addressing limitations in study design and methods, enhances the quality of the evidence base, which then informs best practices in disaster nursing [ 5 , 44 ]. One area of research with significant potential is the application of simulation in disaster care. High-level studies in this field can reveal innovative training methods, improving nurses’ readiness and performance during crises [ 21 , 23 ]. Additionally, exploring practical approaches in areas such as psychosocial support, holistic health assessments, disaster nurse management, and minimizing distress for deployed nurses can contribute to comprehensive and integrated strategies. These strategies ultimately promote optimal patient care and nurse well-being during disaster response efforts.

Policy and organizational support

Policy and organizational support are crucial in strengthening disaster nursing by fostering collaboration among nursing staff, health care organizations, and governments. Key strategies include formalizing relationships between nursing staff and disaster organizations, which is essential for seamless communication and coordination during large scale emergencies [ 21 ]. Implementing robust hospital policies that promote disaster preparedness through regular drills and training can significantly enhance the readiness of healthcare facilities [ 26 ]. Investing in comprehensive disaster nursing education programs at both national and international levels addresses global nursing shortages and ensures that nurses are adequately prepared for disaster response [ 24 ]. Offering competitive salary packages, particularly in low- and middle-income countries, can improve nurse retention rates and maintain a skilled workforce capable of effective disaster management [ 27 ]. These strategies not only improve disaster response outcomes but also enhance hospital preparedness and the overall resilience of the healthcare system.

Technological advancements in disaster nursing

The integration of technological advancements presents a significant opportunity to revolutionize disaster nursing, impacting education, access to specialized care, and the efficiency of healthcare response during emergencies. As highlighted in the literature, incorporating innovative educational technologies like virtual reality and e-learning platforms can significantly improve disaster nursing training [ 23 , 34 ]. These technologies offer immersive and engaging learning experiences, allowing nurses to practice critical skills in simulated disaster scenarios without real-world risks. This is particularly crucial given the need for continuous improvement in training for diverse disaster situations [ 34 ]. Furthermore, telenursing emerges as a promising solution to address the shortage of specialized nurses in disaster-stricken areas [ 37 ]. By leveraging telecommunication technologies, experienced nurses can provide remote consultations, triage, and support to frontline healthcare workers, ensuring timely and specialized care for disaster victims. Mobile health applications and electronic health records can further enhance disaster response by streamlining communication and decision-making during crises [ 37 ]. These technologies facilitate real-time data sharing, patient tracking, and resource allocation, ultimately leading to a more coordinated and effective response.

Realizing the full potential of these technological advancements requires a collaborative effort. Nursing educators must embrace and integrate these technologies into their curricula, while healthcare organizations need to invest in the necessary infrastructure and training for their staff. Researchers play a crucial role in evaluating the effectiveness of these technologies and identifying best practices for their implementation in disaster settings. By fostering collaboration and innovation, we can leverage technological advancements to enhance disaster nursing preparedness and response, ultimately improving patient outcomes and saving lives.

Psychological preparedness and support

Psychological preparedness and support play a vital role in disaster nursing, contributing to the well-being and resilience of healthcare professionals and impacted communities. Implementing strategies like the HOPE model, proactive psychological interventions, flexible support, and including mental health provisions in disaster preparedness plans can effectively address nurses’ emotional and psychological needs during emergencies. The HOPE model for disaster nursing is a framework emphasizing holistic health assessment, immediate response, professional adaptation, and recovery [ 25 ]. Studies have highlighted the importance of psychological preparedness, emphasizing the need for proactive psychological interventions and mental health provisions in preparedness plans due to the mental health impact of the COVID-19 pandemic on nurses [ 29 ]. It is essential to improve nurses’ psychological preparedness and prioritize education to enhance their ability to respond effectively to disasters [ 31 ]. Some scholars emphasize the need for targeted training that incorporates psychological support [ 32 , 35 ], while others discuss strategies to address the complexities of disaster contexts, including psychological readiness [ 39 ]. By prioritizing psychological preparedness and support, healthcare organizations and policymakers can equip nurses to better handle challenges during disasters, ultimately resulting in enhanced patient care and a more robust healthcare system.

Assessment and evaluation

Assessment and evaluation play a crucial role in disaster nursing, offering key insights into the preparedness and abilities of the nursing workforce. By broadening the scope of existing scales, creating comprehensive assessment tools, and emphasizing improvements in nurses’ psychological preparedness, knowledge, and skills, healthcare organizations and educators can gain a deeper understanding of the strengths and weaknesses in current disaster nursing practices. For instance [ 27 ], systematically reviewed literature to gauge nurses’ preparedness for disaster response, identifying gaps and areas for improvement. Similarly [ 28 ], conducted a systematic review and meta-analysis to assess the knowledge, attitudes, and performance of Iranian nurses regarding disaster preparedness, highlighting key areas needing enhancement. Furthermore [ 29 ], explored the mental health outcomes of nurses globally during the COVID-19 pandemic, underscoring the importance of psychological preparedness. Additionally [ 26 ], assessed nurse readiness for radiation emergencies and nuclear events, providing critical insights into preparedness gaps and specific roles and responsibilities. These studies collectively underscore the necessity for rigorous assessment and evaluation frameworks in disaster nursing, enabling the implementation of targeted interventions to boost nurses’ capacity to deliver effective care during disasters, thereby fostering a more resilient and responsive healthcare system.

Role-specific preparedness

Role-specific preparedness is vital in disaster nursing, ensuring that nurses possess the required knowledge and skills to effectively manage diverse emergencies, such as radiation and nuclear events [ 20 ]. underscore the importance of identifying core competency domains through a scoping review to enhance disaster nursing. Similarly, [ 21 ] highlights the challenges and opportunities within disaster nursing education in Turkey, emphasizing the need for integrative training approaches [ 2 ]. Focus on the unique roles of nurses in disaster management in Iran, advocating for role-specific training tailored to regional needs [ 22 ]. Argue for incorporating disaster preparedness competencies into the undergraduate nursing curriculum, suggesting that suitable instruction methods are crucial for effective education. Moreover [ 23 ], map the application of simulation in disaster nursing education, demonstrating that simulation-based training can significantly enhance nurses’ preparedness for handling radiation and nuclear emergencies. By incorporating these findings into educational and training programs, healthcare organizations and policymakers can better equip nurses to deliver specialized care during such critical events, leading to a more efficient and coordinated healthcare response.

Interprofessional collaboration and cultural competence

Interprofessional collaboration and cultural competence are crucial for effective disaster nursing, fostering a comprehensive and inclusive approach to emergency response. Interprofessional collaboration involves coordinated efforts among different healthcare professions, enhancing communication, reducing redundancies, and ensuring a more efficient and cohesive response to emergencies. By integrating cultural competence into disaster relief planning and public health research, and by educating and training nurses in both interprofessional collaboration and cultural competence, healthcare professionals’ ability to work cooperatively with diverse populations during emergencies is significantly enhanced. This dual focus not only improves therapeutic relations but also ensures that all aspects of patient care are addressed effectively in a multidisciplinary context. Training in these areas is essential, as it enhances disaster response capabilities. Encouraging cultural understanding and fostering interprofessional collaboration ensure that disaster nursing practices are more adaptable and responsive to the distinct needs of various communities. These practices ultimately lead to better emergency management and care outcomes. Studies emphasize the importance of these elements in improving disaster response. Hugelius and Adolfsson, through their systematic review of real-life experiences, highlight the necessity of interprofessional collaboration, while Lin et al. propose a framework for cultural competence in disaster nursing [ 25 , 37 ]. These findings underscore the critical role that targeted training in cultural competence and interprofessional collaboration plays in effective disaster response.

Ethics and decision-making

Ethics and decision-making are fundamental components of disaster nursing, guiding healthcare professionals as they navigate the complexities and challenges that emerge during emergencies. By recognizing potential ethical dilemmas, pinpointing factors that encourage ethical decision-making, devising strategies for implementing ethics, and evaluating the impact of ethical practices in disaster settings, healthcare organizations and educators can better prepare nurses to make well-informed and morally responsible choices under pressure. Integrating ethics into nursing education, institutional policies, and disaster preparedness plans empowers nurses to maintain ethical standards and provide empathetic care, even amid the most demanding situations. Nurses prepare for and respond to emergencies, disasters, conflicts, epidemics, pandemics, social crises, and conditions of scarce resources. The safety of those who receive care and services is a responsibility shared by individual nurses and the leaders of health systems and organizations. This involves assessing risks and developing, implementing, and resourcing plans to mitigate these. Several studies underscore the importance of ethics and decision-making in disaster nursing. For instance, a model for disaster nursing was developed through a systematic review of real-life experiences, highlighting the ethical challenges faced by nurses during disaster response. Their findings emphasize the need for robust ethical frameworks and support systems to guide nurses in making difficult decisions [ 25 ]. Similarly, core competencies in disaster nursing, which include ethical decision-making as a crucial domain, were identified. It is suggested that integrating ethical training into disaster preparedness programs can enhance nurses’ ability to handle ethical dilemmas effectively [ 20 ].They suggest that integrating ethical training into disaster preparedness programs can enhance nurses’ ability to handle ethical dilemmas effectively.

This umbrella review examines strategies to tackle nursing challenges in disaster preparedness and response, consolidating the findings into nine key themes: Education and Training, Research and Development, Policy and Organizational Support, Technological Advancements, Psychological Preparedness and Support, Assessment and Evaluation, Role-Specific Preparedness, Interprofessional Collaboration and Cultural Competence, and Ethics and Decision-Making. To enhance disaster nursing, Education and Training should emphasize core competency domains and integrate them into curricula and drills, while Research and Development should be nurse-centric, improving resource allocation and evidence quality. Policy and organizational support should encourage collaboration among nursing staff, healthcare organizations, and governments, reinforcing hospital policies and addressing global nursing shortages. Technological advancements, such as virtual reality and e-learning, hold the potential to transform disaster nursing education. Psychological preparedness and support are essential for nurses’ well-being and resilience, and assessment and evaluation frameworks are crucial for identifying gaps and areas for improvement. Role-specific preparedness equips nurses with the necessary knowledge and skills for various emergencies. Interprofessional collaboration and cultural competence promote a comprehensive and inclusive approach to emergency response, and ethics and decision-making guide healthcare professionals in navigating complexities during disasters. This review aims to inform future research, policy, and practice, ultimately enhancing disaster preparedness and response, patient care, and outcomes during emergencies.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The auther would like to encourage the deanship of graduate studies and scientific research, Taif University for funding this study.

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The effectiveness of an emergency department nursing intervention on psychological symptoms and self-care capacities

A randomized controlled study protocol.

Lou, Xiaoyu MB; Xu, Hua MB ∗

Department of Emergency, Huzhou Central Hospital & Affiliated Central Hospital Huzhou University, Zhejiang, China.

∗Correspondence: Hua Xu, Department of Emergency, Huzhou Central Hospital, 313000, Zhejiang, China (e-mail: [email protected] ).

Abbreviation: ED = emergency department.

How to cite this article: Lou X, Xu H. The effectiveness of an emergency department nursing intervention on psychological symptoms and self-care capacities: a randomized controlled study protocol. Medicine . 2021;100:21(e24763).

Science and Technology Project of Health Commission of Zhejiang Province (Z9209182).

Registration number: researchregistry 6477.

The authors have no conflicts of interests to disclose.

The datasets generated during and/or analyzed during the current study are publicly available.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Background:

We carried out a randomized trial of an emergency department (ED)-based nursing intervention to evaluate the impact of an ED nursing intervention on ED revisits, patient perceptions of continuity of care, illness perceptions, self-care capacities and psychological symptoms.

Method:

We conducted a randomized controlled trial to compare the ED-based intervention with usual care. The protocol was reviewed and approved by the Research Ethics Board of the Huzhou Central Hospital & Affiliated Central Hospital Huzhou University (K901923-021), each participant signed a written consent before participating, and SPIRIT guidelines were followed throughout. To be eligible, patients ready for discharge from the ED had to be at risk for ED return based on 2 criteria: at least one ED visit during the year prior to the initial visit, and current treatment with at least 6 medications. Exclusion criteria included cognitive problems (e.g., dementia) that would preclude provision of informed consent either noted in the medical chart or identified based on the clinical judgment of the project nurse. To avoid multiple interveners for the same patient, we also excluded patients already receiving other regular follow-up (e.g., at a specialized clinic in the hospital or from external resources). The major outcomes were assessed with the Heart Continuity of Care Questionnaire, the Illness Perception Questionnaire-Revised, the Therapeutic Self-Care Tool, the Hospital Anxiety and Depression Scale, and the Self-Reported Medication-Taking Scale.

Results:

Two hundred patients who met the inclusion criteria were included in our study, Table 1 showed the effects of nursing intervention on measures of clinical outcomes.

Discussion:

The ED is a major entry point into the health care system of many countries. Unnecessary ED revisits may result in overcrowding, increased waiting time, and failure to provide appropriate emergency care. The ED-based interventions literature focuses primarily on service use and ways to reduce ED revisits, with very little focus on impacting secondary outcomes. Because of their potential link with health service utilization, secondary outcomes such as perceived continuity of care, illness perceptions, self-care capacities, psychological symptoms and medication adherence might influence ED revisits. Future research was needed to better understand the complex relationship between ED utilization and a variety of intermediary factors in order to develop interventions that will optimize ED utilization.

1 Introduction

Emergency department (ED) revisits are a major concern in health care systems around the world. [1–3] ED revisits contribute to overcrowding, increased waiting times, and impaired quality and safety of care to those in urgent need. [4,5] Extensive empirical evidence documents that most medical EDs serve a relatively small number of frequent users who account for a disproportionately large number of ED visits. [6] Frequent users are typically found to be a socially disadvantaged group with multiple medical and psychiatric disorders and myriad social problems. [7–9] From all perspectives, frequent use of the ED is an undesirable pattern of service use for this vulnerable patient population. Patients receive care that is suboptimal because it is fragmented and episodic, ED health care providers are frustrated by their limited ability to meet frequent users’ many complex needs, and health care systems are burdened by the high costs of excess use of expensive acute services. Shumway et al [10] found that an intervention delivered by a social worker to frequent emergency department users with psychosocial problems improved secondary outcomes such as peer and social service support, while also reducing emergency department revisits. Two other emergency department-based intervention studies [11,12] observed some impact on secondary outcomes but did not observe effects on emergency department revisits.

As yet there is no firm evidence about the types of intervention that can reduce emergency room revisits. However, the literature on emergency room revisits suggests patient difficulties with managing their health problems and treatments after discharge may play a role. Based on the controversy, we carried out a randomized trial of an ED-based nursing intervention to evaluate the impact of an ED nursing intervention on ED revisits, patient perceptions of continuity of care, illness perceptions, self-care capacities and psychological symptoms.

The randomization sequence was generated by an independent statistician using computer. The statistician provided opaque envelopes containing randomization assignments to the project nurse who was blinded to study group until opening the envelope. After the envelope was opened and the patient assigned to the intervention or usual care group, neither the nurse nor the participant were blind to the study group allocation. However, the research assistant who collected outcome measures data by telephone was blinded to study group assignment.

2.2 Study setting and participants

The study was conducted in adult patients at the ED of our hospital. To be eligible, patients ready for discharge from the ED had to be at risk for ED return based on 2 criteria: at least 1 ED visit during the year prior to the initial visit, and current treatment with at least 6 medications. Exclusion criteria included cognitive problems (e.g., dementia) that would preclude provision of informed consent either noted in the medical chart or identified based on the clinical judgment of the project nurse. To avoid multiple interveners for the same patient, we also excluded patients already receiving other regular follow-up (e.g., at a specialized clinic in the hospital or from external resources).

Potential participants received usual care from their regular bedside nurse until the ED medical discharge signature was obtained and discharge information was given by the bedside nurse. The study was explained to eligible patients and after they gave informed consent, a self-report questionnaire was administered to collect baseline data before discharge. All patients responded to the sociodemographic questionnaire.

2.3 Interventions

In the control group, the project nurse repeated the advice already given by the bedside nurse that patients should contact regular healthcare resources such as telephone health hotlines, family physicians, cardiologists, or emergency services as needed after discharge. No specific intervention was provided to the control group in order to assure that their care was as similar as possible to the usual care in the ED.

We developed the intervention for the experimental group to avoid unscheduled ED revisits, clinical stability should be assured prior to ED discharge, and patients should be prepared to deal with potential postdischarge concerns. For the sake of parsimony and future transfer to clinical practice, and because there was no clear evidence suggesting that a longer intervention would be more powerful than a shorter 1, we developed a short-term intervention that included 3 encounters: one at discharge, and 2 telephone follow-ups at 2 to 4 days and 7 to 10 days postdischarge. The intervention provided by a project nurse was individualized with the potential concerns of each patient assessed using a 19-item clinical disease management tool developed and refined in past studies with similar clients. The assessment evaluated patients’ capacities to cope with:

1. worries about readiness to return home;
2. disease and symptom management;
3. treatment management;
4. activities of daily living and instrumental activities of daily living management;
5. emotions and cognition;
6. informal resources; and
7. the health care system.

For each of the 19 items patients were rated as “no risk”, “presence of risk, but coping strategies in place”, “at risk”, or “not evaluated”. All items had to be evaluated, unless not clinically relevant. When a patient was rated as at-risk for any item, nurses’ interventions included:

1. teaching;
2. normalizing;
3. listening;
4. reassuring;
5. reframing;
6. confronting;
7. providing advice, recommendations;
8. warning;
9. giving positive feedback;
10. referring to external resources; and
11. reinforcing-external resources (e.g., increasing dosage or frequency of resource).

After each encounter, the project nurse checked off which nursing intervention was retained in response to the specific concerns expressed by patients. Because the intervention was individualized, each patient received a different intervention package. Patients were allowed to call the nurse between the planned encounters if they had any questions or concerns. Because the project nurses had access to the hospital chart, they were aware of ED visit characteristics including diagnosis, procedures and treatment, medications, discharge planning, and any other special issues-and could therefore personalize the intervention according to the patient's clinical condition. Four project nurses worked on the project. All project nurses held a bachelor's degree and had at least 5 years of experience in clinical cardiac care, though not necessarily in the ED.

2.4 Outcomes measure

The major outcomes were assessed with the Heart Continuity of Care Questionnaire, the Illness Perception Questionnaire-Revised, the Therapeutic Self-Care Tool, the Hospital Anxiety and Depression Scale and the Self-Reported Medication-Taking Scale. In addition to being assessed at baseline in patients who were able to fill out the questionnaires, these measures were readministered by telephone at 30 days postdischarge.

	Experimental group (N = 100)	Control group (N = 100)	value
Revisits
Heart Continuity of Care Questionnaire
Illness Perception Questionnaire-Revised
Therapeutic Self-Care Tool
Hospital Anxiety and Depression Scale-Anxiety Subscale
Self-Reported Medication-Taking Scale

4 Discussion

The ED is a major entry point into the health care system of many countries. [13,12] Unnecessary ED revisits may result in overcrowding, increased waiting time, and failure to provide appropriate emergency care. [14,15] The prevalence and persistence of frequent ED use has increased interest in interventions that reduce overuse of the ED by providing patients with more appropriate and consistent medical and social services. A variety of interventions that differ in complexity and intensity have been evaluated in preliminary studies, with promising results. [16,11,4] The ED-based interventions literature focuses primarily on service use and ways to reduce ED revisits, with very little focus on impacting secondary outcomes. Because of their potential link with health service utilization, secondary outcomes such as perceived continuity of care, illness perceptions, self-care capacities, psychological symptoms and medication adherence might influence ED revisits.

This study had several limitations:

1. only patients with cardiovascular disease were included, however, several patients were consulting the ED for non-cardiac problems, this nevertheless limited generalizability of the results;
2. the sample size was based on the primary outcome of ED revisits, and no power analysis was performed for the secondary outcomes examined in the present paper;
3. the most significant threat to validity was the number of patients lost to follow up in the present sample.

These losses were more frequent in the control group than the experimental group. Future research was needed to better understand the complex relationship between ED utilization and a variety of intermediary factors in order to develop interventions that will optimize ED utilization.

Author contributions

Xiaoyu Lou plans the study design. Hua Xu collects data and reviews the protocol. Xiaoyu Lou writes the manuscript. All authors approve the submission

Conceptualization: Xiaoyu Lou.

Data curation: Xiaoyu Lou.

Funding acquisition: Hua Xu.

Writing – original draft: Xiaoyu Lou.

Writing – review & editing: Hua Xu.

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Presentation Type: Poster

Abstract: Registered nurses in the critical care setting often encounter traumatic events throughout their career. The literature search was conducted to find effective ways to debrief in the emergency department following a critical event and why it was important. The goal of this project is to educate emergency room nurses on the importance of a consistent debriefing process after traumatic events. We created an education session and have a handout that will include the benefits of debriefing on mental health, how it improves practice and teamwork, and how to implement debriefing tools in the workplace. A pre and post-test will be administered to assess the knowledge before and after our information is presented. Our results are pending. We anticipate that the ED staff will realize the benefits of debriefing and will be compelled to implement a consistent debriefing process in their practice.

Article Details

Casey finegold.

Major: Nursing

Rylie White

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Emergency Department Visits Among Patients With Cancer in the US

1 Summerlin Hospital, Las Vegas, Nevada
2 Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
3 Digital Media Editor, JAMA Network Open
Original Investigation Potentially Preventable Emergency Department Visits Among US Patients With Cancer Amir Alishahi Tabriz, MD, PhD, MPH; Kea Turner, PhD, MPH, MA; Young-Rock Hong, PhD, MPH; Sara Gheytasvand, MD; Benjamin D. Powers, MD, MS; Jennifer Elston Lafata, PhD JAMA Network Open

Unsurprisingly, patients with cancer have a number of symptoms and complications related to their cancer and treatments that often require health care services. Although many of these issues can be and are managed in the outpatient setting, patients with cancer sometimes seek care in the emergency department (ED), often at the direction of their care team, and many are subsequently hospitalized. Tabriz and colleagues 1 estimated the number of ED visits by patients with cancer that are potentially preventable, using a Centers for Medicare & Medicaid Services (CMS) quality measure definition. 1 , 2 Using the 2012 to 2019 National Hospital Ambulatory Medical Care Survey, they estimated that ED visits by patients with cancer increased from 3 734 101 in 2012 to 6 240 650 in 2019 (5.4% of all ED visits that year) and that more than one-half of these visits were potentially preventable.

As noted by Tabriz et al, 1 the ED is far from the optimal setting for patients with cancer, putting them at risk for complications, including nosocomial infections, and potentially costing more than other settings, as we will discuss later in this article. Although the desire to identify and reduce unnecessary ED visits is a laudable and common effort, it is a far trickier endeavor than it may seem. 3 Notably, the CMS definition used by Tabriz et al 1 includes a range of primary diagnoses (eg, anemia, emesis, and pain), as well as acute life-threatening conditions (eg, pneumonia and sepsis). Conceptually, we split these into 2 groups: first, conditions for which patients with cancer need care, such as pain or vomiting and dehydration, which may be better managed in an outpatient setting; and second, conditions like sepsis that require hospital-based care but might have been averted with optimal outpatient care. This may include optimizing preventive care, such as vaccination for pneumonia, influenza, and COVID-19, as well as early recognition and treatment before pneumonia becomes sepsis. Of course, patients with cancer are often at high risk for severe complications, and achieving a 0 rate of sepsis in patients undergoing chemotherapy is likely unrealistic; however, much like other CMS measures, such as hospital readmissions, current rates are too high, and we can do better. Similarly, the first group of conditions can likely be optimized with better access to outpatient care and symptom management (ie, palliative care).

Differentiating between these 2 groups of potentially avoidable ED visits is problematic for a number of reasons. For example, how accurately can we expect a patient to determine whether their vomiting is a benign adverse effect of chemotherapy that is safe to manage with outpatient medications vs a sign of developing sepsis? Raven and colleagues 3 have previously shown that the link between general presenting ED complaints and discharge diagnoses is minimal. Patients should not be expected to tell whether their symptoms are low acuity vs life-threatening, given that physicians often cannot tell even with our wide range of diagnostics, clinical training, and experience.

Although ED care may be more expensive than care in other settings, care in other settings may not be available, particularly beyond standard business hours. Furthermore, is it more efficient for a health system to have all-hours outpatient access to oncology specialists (and palliative, surgical, transplant, and countless other specialties) when the ED is always open and staffed and has access to innumerable diagnostics, therapeutics, and clinical specialties? Furthermore, Raven and Steiner 4 found that 1 in 4 general patients in the ED were referred by a medical professional; thus, even access to outpatient care does not mean patients can get the care they need outside an ED. Similarly, the capabilities of outpatient care sites can vary tremendously; it is no surprise that patients are sent to the ED if the alternatives do not have the staff or diagnostic and therapeutic capabilities the patients need. 5

Also unsurprisingly, because a majority of patients with advanced cancer will report pain, 6 Tabriz and colleagues 1 found the most common reason for ED visits for patients with cancer is pain, accounting for 36.9% of ED visits; however, only 23.5% of those patients were admitted. Patients at risk for having uncontrolled pain could potentially be identified earlier, and steps could be taken that would address their pain and help prevent acute care visits. Palliative care referral is associated with improved quality of life and pain scores, 7 as well as improved caregiver satisfaction. 8 Some studies have specifically shown that palliative care referral early for a patient with cancer will result in less ED utilization. 9

Unfortunately, palliative care is often confused for hospice. Although both services focus on quality of life, patients do not need a terminal diagnosis to receive palliative care, and patients receiving palliative care can also continue curative-intent, disease-oriented treatments such as chemotherapy. Although misperceptions about palliative vs hospice care appear to be improving among emergency physicians, they are still a barrier to referral for some patients. 10 Fortunately, recent years have seen an increase in attention to palliative needs of patients in the ED, as well as increased training of emergency physicians in palliative care, including shorter format courses and fellowships sponsored by the American Board of Medical Specialty (including the American Board of Emergency Medicine). 11 This increased attention and training have led to both informal and formal integration of palliative care consultation in EDs, although room for improvement remains.

Most patients with cancer, however, are unable to choose whether the ED to which they present, or the emergency physician who treats them, has formal systems or training in palliative care. Despite our best efforts, pain is often, but not always, adequately treated in the ED; support systems such as clinical pathways and decision trees for pain management for patients with cancer may help optimize their care in the ED. Efforts to streamline the process of early palliative referrals from the ED, 11 as well as the necessary changes in clinician mindset and culture, can help EDs identify patients who would benefit from early palliative referral. Preventive measures seem much more likely to optimize care, and early palliative care involvement seems much more promising and patient-centered than simply hoping that EDs do better.

Similarly, it is easy to say that health systems should simply build always-accessible infrastructures for outpatient oncology and palliative care; again, there are intuitive efficiencies in EDs serving as the universal site of acute unscheduled care. However, as anyone who has entered a busy ED in recent years can tell you, ED crowding is not just unpleasant, but it also can put patients at risk for worse outcomes. 12 Importantly, ED crowding is a symptom of hospital crowding, as admitted ED patients are unable to move to inpatient care spaces, mostly because of dysfunctional financial incentives that effectively “compel hospitals to set inpatient census goals at levels that predictably result in ED access block. Crowding will occur when hospital occupancy exceeds 85%–90%.... [In] most institutions, ED gridlock is assured when inpatient occupancy exceeds 90%.” 12 Full hospitals mean full EDs, but also mean that well-intentioned outpatient care such as oncology and palliative care triage offices do not have an option for direct hospital admissions and will need to send patients to the ED regardless. Delgado-Guay and colleagues 13 previously found that ED visits by patients sent from oncology and palliative clinics are less likely to be potentially preventable, suggesting that oncology and palliative care clinicians are leveraging their expertise to minimize unnecessary ED referrals in the patients who are able to access their outpatient care.

Preventing unnecessary ED visits is a laudable goal if doing so means better care for patients (ie, by optimizing outpatient symptom management and access to acute unscheduled care when needed). In an effort to improve often suboptimal symptomatic care for patients receiving chemotherapy, CMS developed measure OP-35, 2 which, like other quality metrics, attempts to encourage better care, first through reporting and then later by adjusting hospital and physician reimbursements on the basis of patient outcomes (ie, ED visits and hospital admissions that may have been averted through better outpatient care). In theory, this will provide financial incentives to provide better symptom management and overall care for patients with cancer. In practice, will this be yet another promising effort to save money while improving care, yet effectively penalize hospitals and physicians that care for medically and socially high-risk patients? 14 Value-based payments offer promise, but policy makers and CMS need to ensure equity while improving disparities in care; we need to continue to adapt our approach to value-based care as we learn more about how well-intentioned payment models affect patients and health systems, and continue to modify our metrics by accounting for patient heterogeneity and improved risk adjustment, minimizing gaming by systems with resources and de facto penalties for those who provide care to the most vulnerable. 15 The goal is not to eliminate ED visits for their own sake; rather, the goal is better care of patients with cancer, and secondarily, in a manner that is cost-effective. We are hopeful that optimized care would also mean that fewer patients need to spend untold hours in EDs.

Published: January 19, 2023. doi:10.1001/jamanetworkopen.2022.53797

Corresponding Author: N. Seth Trueger, MD, MPH, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario, Ste 200, Chicago, IL 60611 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

Disclaimer: N. Seth Trueger is digital media editor of JAMA Network Open , but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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Majka ES , Trueger NS. Emergency Department Visits Among Patients With Cancer in the US. JAMA Netw Open. 2023;6(1):e2253797. doi:10.1001/jamanetworkopen.2022.53797

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Scand J Trauma Resusc Emerg Med

Strategies to measure and improve emergency department performance: a scoping review

Elizabeth e. austin.

Australian Institute of Health Innovation, Macquarie University, Sydney, Australia

Brette Blakely

Catalin tufanaru, amanda selwood, jeffrey braithwaite, robyn clay-williams, associated data.

All data generated or analysed during this study are included in this published article and its supplementary information files.

Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs’ capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance.

Methods and findings

We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/ ). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies’ titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains.

Conclusions

ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.

Introduction

Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide [ 1 ]. EDs must continue to provide care during periods of crowding, and respond to expected changes (e.g., seasonal increase in demand) and unexpected changes (e.g., unanticipated events and varying demand) [ 2 ]. However, crowding impedes ED staffs’ capacity to provide timely, safe and quality care. It extends the time patients spend in ED, and threatens patient outcomes [ 3 ].

Crowding in EDs is the product of input, throughput and output factors such as the volume of patients arriving to be seen, the time taken to assess and treat patients, and the availability of beds in hospital wards [ 4 ]. Interventions (e.g., decision-making structure, resource allocation, procedures) to address these factors have been widely implemented, with mixed results [ 5 – 8 ]. Identifying effective interventions known to have improved care can support the uptake of those interventions in different contexts. Understanding the characteristics of those interventions and their limitations can inform the development of new strategies to address common patient flow problems.

Ideally, the design and selection of performance measures should align with the system’s purpose and improvement strategy in order to identify the extent to which the system is working effectively. It is unsurprising then that input, throughput and output measures such as wait-time, length of stay and patient satisfaction have been used to report on EDs’ performance [ 4 , 9 ]. Understanding how ED performance has been measured in the past will support the selection of measures and inform the development of new measures to address gaps in performance knowledge.

The purpose of this scoping review was to map the research evidence provided by reviews on strategies to measure and improve ED performance. The review questions addressed were: (1) how is ED performance measured, (2) what are the interventions used to improve ED performance and (3) what is the role(s) of patients in improving ED performance, and (4) what are the outcomes attributed to interventions used to improve ED performance.

Study design

We conducted a scoping review of the literature from inception of bibliographic databases to July 2019 related to strategies to measure and improve ED performance. The study protocol was prospectively registered in December 2018 in the Open Science register ( https://osf.io/73r4t ). This protocol guided the review in adherence with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA) [ 10 ].

Inclusion criteria

Systematic reviews of primary research studies, reviews of reviews (umbrella reviews), and other research syntheses not fulfilling all criteria for systematic reviews published in the English-language peer-reviewed literature were included that met the following additional criteria: (1) review studies involving clinicians, patients, and/ or administrators in the ED or review studies that measure ED performance without involving participants (e.g., Length of Stay or patient mortality retrieved from aggregate hospital data); (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on studies in a hospital ED context in any country or healthcare system.

Search strategy

To identify eligible studies, we developed a comprehensive search strategy using medical subject headings and text words for the general concepts of performance measures, interventions, and patient involvement. Cochrane Database of Systematic Reviews, Scopus, Embase, CINAHL and PubMed were searched on 14 January 2019. No date limits were used. English only publications were considered. An updated search was completed on 9 July 2019 and included a date filter (publications from 1 January 2019 to 31 December 2019). The full search strategy for all databases is shown in Appendix A (See Additional file 1 ).

An example, illustrating the search strategy for PubMed, is as follows:

((((emergency Service, Hospital [mh]) OR emergency department [tw])) AND (((((quality of health care [mh]) OR quality improvement [mh]) OR quality [tw]) OR improvement [tw]) OR performance [tw])) AND ((((((((review [ti]) OR systematic review [ti]) OR meta-analysis [ti]) OR meta-synthesis [ti]) OR scoping review [ti]) OR integrative review [ti]) OR overview [ti]) OR umbrella review [ti])

Study selection

The results of the searches were entered into EndNote citation management software (version 8.2; Thompson Reuters, New York, NY), and duplicates were removed. For each review, title, abstract, and full-text were independently screened by pairs of reviewers for inclusion according to pre-established criteria. Disagreements were resolved via discussion. Abstracts flagged as potentially relevant by reviewers underwent full-text review.

Data extraction and quality assessment

The data was extracted by independent reviewers by using an extraction tool specifically designed for the review. The data extraction form was piloted for usability prior to data extraction. The extraction form included information on Author(s), year of publication, country where review was conducted, type of review, review objectives and questions, number of studies included, types of intervention/s, intervention characteristics, type of measure used and/ or type of outcome measured.

The quality of the included papers was assessed using the Risk of Bias in Systematic Reviews (ROBIS) tool for assessing the risk of bias in systematic reviews [ 11 ]. The purpose of this assessment was only to allow for the quality of the included reviews to be mapped/ described. Prior to critical appraisal, the ROBIS was piloted on a sample of reviews. The quality of included reviews was explored by pairs of independent reviewers. Disagreements were resolved via discussion.

Data processing and analysis

A narrative synthesis was performed for this review, including numerical statistical summaries, textual commentaries, and tabular and graphical representations.

The combined searches yielded 4981 articles, including 1996 duplicate articles. Of these, 2985 abstracts and 134 full-texts were reviewed with 77 articles meeting inclusion criteria. Figure 1 illustrates the PRISMA diagram for the identification, screening, and inclusion processes.

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PRISMA flow diagram for study selection

An additional table outlines the characteristics of the included articles addressing ED performance measures (See Additional file 2 ). An additional table outlines the characteristics of the included articles addressing interventions, and patient role in ED performance (See Additional file 3 ). An additional table outlines the evidence contribution of the included reviews to each review question (See Additional file 4 ). Distribution of included reviews published per year (2000–2019) is provided in Fig. 2 . Figure 3 shows the distribution of locations where published reviews were conducted (based on the country affiliation of the first author).

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Distribution of published reviews over time

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Distribution of published reviews by country affiliation of first author

Quality assessment

Using the ROBIS tool, 31 reviews were assessed as being low bias, 31 as high bias, and 15 as unclear bias. The ROBIS risk of bias assessment results for each domain and the overall risk of bias for individual reviews are presented in an additional file (See Additional file 5 ). Figure 4 displays a summary ROBIS assessment across all included reviews, graphically presenting the results of the ROBIS assessment for each domain and the overall rating.

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Graphical presentation for ROBIS results across all included reviews. 1 study eligibility criteria prespecified and appropriate for the review question. 2 sensitivity of the search. 3 rigour of the data collection process. 4 appropriateness of the synthesis for the review question. 5 overall risk of bias. “Low”, “high”, or “unclear” represents the rated level of concern about bias associated with each domain [ 11 ]

How ED performance is measured

Three reviews reported on ED performance measures [ 12 – 14 ]. Madsen (2015) extracted evidence for 202 individual indicators of ED performance from 127 articles, categorising them into process (e.g., time to diagnosis, physician workload), outcome (e.g., mortality, ambulance diversion), satisfaction (e.g., rate of complaints, patient participation in own care), structural/ organisational (e.g., admission rate, resources) and equity (e.g., weekday/weekend variation, sex, race, age) performance measures. Data sources used to generate the indicators are ED information technology, questionnaires, chart reviews, and multihospital databases [ 12 ]. Sørup (2013) identified 55 different performance measures and categorised ED performance measures into patient related measures focusing on safety (e.g., medication errors, unplanned reattendance), patient centeredness (e.g., complaints, left-without-being-seen), and satisfaction; employee related measures focusing on occupational profile (e.g., educational positions), and work environment; and operational performance focusing on planning (e.g., occupancy rate), utilisation (e.g., number of ECG’s taken, number of consultations), efficiency (e.g., ED admission transfer rate, length of stay), and time intervals (e.g., time to registration, triage, treatment). Stang (2015) examined crowding measures linked with quality of care including ED volume, number of patients in the waiting room, and ED length of stay.

Interventions used to improve ED performance and their characteristics

The remaining 74 articles addressed interventions used to improve ED performance. Interventions to improve ED performance address either practices and processes or team composition. Interventions addressing how tasks were performed in ED were identified as practice and process interventions. Interventions addressing the discipline or training of professionals practicing in ED were identified as team composition interventions.

Practices and processes

Six domains of clinical practice and processes have been targeted for interventions. They are: triage, care transitions, process re-design, point-of-care testing, observation units, and technology.

Designed to expedite care, triage processes sort patients according to urgency or type of service required [ 15 ]. Twelve reviews examined interventions relating to triage systems and processes. Triage based interventions included having a physician present [ 8 , 16 – 19 ] also called a triage liaison physician [ 20 ], a triage team consisting of at least 2 medical personnel (nurse or physician) [ 21 , 22 ], dedicated triage resources (e.g., ECG machine and ECG technician [ 23 ]), triage education [ 23 ], variations of basic triage [ 15 ], triage protocols [ 24 , 25 ], and nurse-led triage services [ 26 ]. A description of the characteristics for each type of triage intervention is provided in Table 1 .

Triage interventions and intervention characteristics

Intervention	Intervention Characteristics
	Designed to allow for rapid medical intervention and care escalation, senior doctor triage/ team triage involves the presence of a (senior) emergency doctor (physician) in triage to identify potential emergencies, initiate diagnostics and treatment prior to patients being seen in ED [ , – ].
	Dedicated triage resources include a dedicated ECG technician and machine, and the creation of a dedicated ECG room with two stretchers beside triage [ ]
	Staff education about atypical presentations, signs and symptoms, as well as how to perform ECGs have been implemented [ ]
	Variations in triage systems include prioritising patients without providing treatment, prioritising patients while providing simple treatment and formal triage systems [ ]
	Triage protocols procedures for specific symptoms and treatments, for example, nurse-requested radiograph protocol outlines the rules and procedures under which nurses can/ should request radiographs for patients at triage [ ]
	Nurse-led-triage involves triage by a Nurse Practitioner, Advanced Nurse Practitioner, Emergency nurse Practitioner, or ED nurse [ ]

Care transitions (handover processes)

Care transitions involved patient handover, which is the process of transferring accountability and responsibility for patient care to another person [ 27 ]. Seven reviews examined interventions relating to patient handover processes and transitions in care. Patient handover processes and transitions in care interventions include handover tools [ 27 – 30 ], bedside registration [ 19 , 31 ], discharge planning [ 31 ], discharge communication [ 32 ], process protocols and guidelines [ 27 , 29 , 30 ], handover training [ 29 ], dedicated offload nurse for triaging and assessing EMS patients [ 30 ], nurse discharge coordinators [ 33 ]. A description of the characteristics for each type of care transition intervention is provided in Table 2 .

Care transition interventions and intervention characteristics

Intervention	Intervention Characteristics
	Handover tools standardise communication using a structured information template performed either verbally or nonverbally [ ]. For example, Identification, Situation, Background, Assessment, Requirements and Requests (ISBAR) is a tool for face-to-face beside handover [ – ]. Other tools include Situation, Background, Assessment, Responsibilities and Risks, Discussion and Disposition, Read-back and Record (SBAR-DR) model for verbal handoff, Mechanism of Injury/Illness, Injuries, Signs, observations and monitoring, and Treatment given (MIST; DeMIST includes Demographic information to the handover), hospital developed handover tools, as well as written handover, handover added to patients paper chart, and an eSignout step added to the ED dashboard [ – ].
	Bedside registration immediately following tirage involves, when beds are available, patients are brought immediately through to the patient care area following triage where they are registered by a clerk whilst simultaneously being assessed by medical staff [ , ].
	At a clinical level, discharge planning involves the early planning of patients’ care after discharge [ ]
	Discharge communication should include important information about the illness, verification of comprehension, and tailoring discharge instructions to address areas of misunderstanding [ ]. Interventions to improve discharge communication include education or the sharing of information with patients and the different modes through which information is delivered (e.g., video, interactive websites, written, face-to-face), overcoming existing barriers, or providing additional support to encourage a specific behaviour [ ].
	Closely linked with handover tools, process protocols and guidelines outline procedures and rules clarifying the transfer of responsibility, as well as a structure for handover [ , , ]. Handover training lasting 3 h, covered five rules of communication, case scenario simulation and a handover protocol [ ]
	A new clinical role in the form of a dedicated offload nurse for triaging and assessing EMS patients [ ]. Another role developed to facilitate handover is the nurse discharge coordinator [ ]. The nurse discharge coordinator intervention involves the role discussing with the patient, their health care needs, education, referral to outpatient facility, 24 h nurse follow-up, back-up consultation 1 week after discharge [ ]

Process re-design

Process re-design refers to changes in how tasks are performed. Twenty-three reviews examined interventions relating to process re-design. Processes that have been re-designed included clinical guidelines and protocols [ 25 , 31 , 34 – 36 ], patient assignment and referral processes [ 4 , 31 , 36 – 38 ], organisational processes (e.g., communication, administration) [ 19 , 25 , 35 , 39 , 40 ], nurse-initiated care processes [ 8 , 17 , 21 , 41 – 44 ], clinical decision supports [ 45 – 47 ], and lean management/ lean thinking interventions [ 48 – 50 ]. A description of the characteristics for each type of process re-design intervention is provided in Table 3 .

Process re-design interventions and intervention characteristics

Intervention	Intervention Characteristics
	Process redesign also refers to changes to existing or the introduction of evidence-based clinical practice guidelines for specific conditions [ ], protocols (pathology: [ ]; treatment: [ ]; medication: [ , ], mandating the redundant reading of emergency CT scans [ ].
	Patient assignment processes [ ], and referral processes [ , , ]. Case management involves the identification of appropriate providers and services for individual patients based on a continuous, integrated medical and psychosocial model of care [ , ].
	Communication and consultation intervention between radiologists and ED physicians to reduce patient call backs to the ED [ ], administrative interventions (e.g., outsourcing environmental services, [ ]), the addition of administrative, clinical and ancillary personnel [ ], logistical changes in radiology and laboratory [ ], rearranging bed zones [ ], performance targets (e.g., the 4 h rule, disposition [ , ];.
	Nurse-initiated care processes consist of various interventions relating to nursing activities [ ] Reviews examined interventions relating to nurse-initiated care processes in ED including medication [ , ], x-ray [ , , , , ], protocols [ ], and diagnostic tests [ ].
	Clinical decision supports refers to the use of a validated clinical decision rule to assess the pre-test probability of the diagnosis [ , ] or tool to assess the need for diagnostic investigations [ ]. For example, tools to assess the need for imaging in adult patients include the National X-radiography Utilization Study (NEXUS) criteria, and the Canadian C-Spine Rule (CCR [ ];).
	Lean management/ thinking is a suite of concepts, methods and tools developed by Toyota Motor Corporation [ – ]. Lean processes are designed to improve productive capacity and reduce waste [ – ]. Three reviews examined Lean interventions in ED [ – ]. Lean has been applied in a number of ways. For example, designing a detailed map of the process (Value Stream Map – VSM) to identify waste and bottlenecks [ ], streaming patients according to severity, dedicating different ED spaces for different types of patients [ ] with dedicated nurse and physician for the different areas [ ]. Other lean interventions included computer systems implantation, changes in roles and responsibilities, flow managers and screening nurses [ ]. Kaizen events moderated by lean consultants or lean specialist (VSM, leadership involvement, boot camp, reallocation of staff, commitment of the department chairperson, communication board, periodic electronic communication [ ];). Process changes such as new processes and related operating procedures including eliminating outdated policies, fast-track process for low complexity patients. System changes include data collection and monitoring (e.g., weekly review, quality improvement measurements taken and shared with staff), education/ training (orientation to the new process, posting process map in public areas), tools/ technology (standardised forms, checklists), communication and teamwork (communication tools, team assessment of patient history), staffing reassignment/ new roles/ responsibilities (reassignment to match peak patient volume or arrival rates, dedicated ECG and laboratory technician in ED, reassignment/ reorganisation of space (e.g., space reallocated for rapid assessment and holding patients, designated physician examination rooms), other changes (stocking done as needed, improved signage, celebrating goal achievements) [ ]. Lean intervention team composition included, hospital management team or the head of ED, physicians, nurses, staffs and external counsellors, as well as external consultants (experts in lean [ ];.

Point-of-care testing

Point-of-care testing refers to laboratory analysis located in the ED [ 8 , 21 ]. Five reviews examined point of care testing in ED [ 8 , 19 , 21 , 51 , 52 ]. Point-of-care testing has been used for a range of diagnostic tests including cardiac troponin [ 51 ], metabolic [ 19 ], urinalysis, pregnancy testing, cardiac markers, glucose [ 19 ], influenza, and respiratory syncytial virus [ 52 ].

Observation units

Observation Unit interventions refer to ED-based observation units [ 31 ]. Twelve reviews examined observation units in ED [ 4 , 8 , 17 – 19 , 25 , 31 , 39 , 53 – 56 ]. ED based observation units have been developed for specific clinical needs such as Chest pain and Asthma [ 31 , 39 ], for specific processes such as assessment and procedures (e.g., Rapid Assessment Zones/ Pods) [ 18 , 55 ], medically stable patients likely to require admission (e.g., Medical Assessment Units) [ 4 , 8 , 17 ], or further investigations (e.g., Short Stay Units) [ 8 , 17 , 54 , 56 ], management for more than 4 h (e.g., ED managed Acute Care Unit) [ 19 ], or to manage referrals from GPs (e.g., Quick Diagnostic Units) [ 18 ]. A description of the characteristics for each type of process re-design intervention is provided in Table 4 .

Observation Unit interventions and intervention characteristics

Intervention	Intervention Characteristics
	For example, Chest Pain Observation Units are for patients presenting with chest pain who are a low risk of acute myocardial infarction to undergo a short period of monitoring with serial ECGs and cardiac enzymes before further testing and discharge [ ].
	Rapid Assessment Zones/ Pods (also referred to as Minor Injury Units) are spaces in ED adapted for clinician assessment and procedures for patients whose therapeutic needs exceed typical fast-track criteria, but can still receive investigations/ therapy in a chair and require limited observation [ , ]. In Rapid Assessment zones/ pods, investigations are initiated, patients wait for results and/ or receive treatment in a chair or stretcher [ ].
	Medical Assessment Units are areas in ED for patients with complex medical conditions who will likely require admission [ , , ]. Medical Assessment Units involve fast-tracking care of medically stable patients [ ].
	Short Stay Units are spaces in ED for patients who require a short period of observation, treatment (e.g., blood transfusions), or further diagnostic investigations that may take several hours to resolve without occupying ED beds or being admitted [ , , , ].
	ED managed acute care unit is a space physically remote from ED but staffed by ED for ED patients who require observation or management for more than 4 h [ ].
	Quick Diagnostic Units have been introduced to ED to manage referrals from GPs to EDs and are staffed by internal medicine specialists [ ]. ED-based observations similar to the Quick Diagnostic Unit include Clinical Decision Units, Medical Assessment and Planning Units, Rapid Assessment and Planning Units, Observation bays, Express Admission Units [ ].

Technology has been increasingly integrated into the ED [ 57 ]. Seven reviews examined interventions addressing technology in the ED. Technology has been introduced into EDs in the form of health information technology such as computerised clinical support systems (e.g., decision supports and provider entry forms) [ 45 , 58 ], mobile devices [ 57 ], and telecommunication technology [ 59 ], computer simulation [ 60 ], and eHealth records access [ 61 , 62 ]. A description of the characteristics for each type of technology intervention is provided in Table 5 .

Technology interventions and intervention characteristics

Intervention	Intervention Characteristics
	Computerised physician order entry [ ] and computerised provider entry forms provide clinicians with timely electronic access to patient information and electronic decision support (e.g., alerts, reminders, order sets [ ];).
	Different types of mobile devices/ workstations have been employed in ED including hand held personal digital assistant, wireless computers/ mobile work stations, iPod® device [ ].
	Telecommunication technology (e.g., transmission of video, images, radiological studies, physiological data, and pathology results) to provide care to a patient typically distal from the provider [ ].
	Computer simulation and modelling interventions use simplified representations of reality to analyse ED patient flow and resource capacity planning [ ].
	Electronic health records use health information technology to allow virtual health information management and exchange [ ]. Two reviews examined eHealth records access in ED [ , ]. Shared electronic health records (e.g., summary of care records, virtual health record) involved making patient care records (e.g., GP records) available to providers of emergency care [ ]. Health information exchange programs can include the sharing of laboratory and imaging tests associated with episodes of care [ ].

Team composition interventions

Different roles and specialties have been integrated into the ED. These included advanced nursing roles, physiotherapy, general practitioners, scribes and physician assistants, pharmacy, and mental health services, as well as the development of professional skills.

Advanced Nursing Roles . Seven reviews examined interventions relating to advancing nursing roles in the ED. Advanced nursing interventions primarily include the nurse practitioner role [ 17 , 18 , 63 – 66 ] sometimes called advanced nurse practitioner/ advanced clinical practitioner/ advanced practice nurse [ 66 , 67 ], clinical nurse specialists [ 65 ], certified registered nurse anaesthetists [ 65 ], and Clinical Initiatives Nurse (CIN [ 17 , 68 ];. Advanced nursing roles typically require further education and require a minimum of 2 years emergency nursing experience [ 68 ]. A description of the characteristics for each type of advanced nursing role intervention is provided in Table 6 .

Advanced Nursing Role interventions and intervention characteristics

Intervention	Intervention Characteristics
	An ED Nurse practitioner in an independent practitioner whose knowledge and skills allow them to make assess, diagnose, treat, prescribe and refer patients to other health specialties [ , , ]. Nurse practitioners may be required to be covered by their own malpractice insurance and own license [ ]. Nurse practitioner practice, and therefore interventions, vary considerably [ ]. Nurse practitioners generally manage patients presenting with minor injuries or illnesses [ , ].
	Clinical Nurse Specialists are midlevel practitioners who are certified in a speciality [ ]
	Certified Registered Nurse Anaesthetists are midlevel practitioners with qualification and accreditation to administer anaesthesia [ ]
	Clinical Initiative Nursing roles provide as early as possible, assessment, initiation of diagnostics, and implementation of management strategies for patients with a range of conditions in ED waiting rooms, prior to being seen by a medical officer [ ]. The CIN role in ED supports triage nurses and utilises advanced nursing practices such as nurse-initiated activities (e.g., analgesia, and x-rays [ ];).

Physiotherapy

Three reviews examined interventions relating to physiotherapy roles in ED [ 69 – 71 ]. The role of physiotherapists in ED includes the assessment and management of acute and subacute musculoskeletal conditions, recent burns and diabetic wounds, provision of in-service training to other ED staff, liaising with nursing, medical, and allied health staff, and ensuring safe discharge from ED including arranging community services [ 69 – 71 ]. Physiotherapists have also been trained to read and request imaging and to prescribe a limited number of medications [ 69 , 70 ].

General practitioners

Two reviews examined interventions relating to general practitioner roles in ED [ 72 , 73 ]. There are different models in which general practitioners have been introduced into ED [ 72 , 73 ]. General practitioners have been used to staff non-urgent (rather than urgent) streams when patients are triaged into separate streams [ 72 , 73 ]. General practitioner services are also available onsite next to the ED and patients self-select or are redirected to these services from the ED. General practitioners have also been involved in the triage of patients presenting to the ED [ 72 , 73 ]. General practitioners have also been fully integrated into ED, providing care jointly with ED staff on a range of primary care and higher acuity emergency cases [ 72 , 73 ].

Scribes and physician assistants

Four reviews examined interventions relating to models of care using support staff such as scribes and physician assistant roles in ED [ 8 , 18 , 74 – 76 ]. A description of the characteristics for scribes and physician assistants interventions is provided in Table 7 .

Scribe and Physician Assistant interventions and intervention characteristics

Intervention	Intervention Characteristics
	Scribes are non-licensed health care team members that follow ED doctors during patient care to concurrently document patient history, physical examination, and procedures in an accurate manner as it is being done by the ED doctor [ , ]. Scribes keep track of laboratory findings and radiological studies, prompt doctors to review test results, assist with referrals, and record other pertinent information [ , ].
	Physician Assistants are fully licensed medical practitioners who are trained to provide care under the direction and supervision of a doctor [ ]. While the doctor is ultimately responsible for the patient and established the degree of supervision, physician assistants have autonomy in medical decision making [ ]. Typical duties include history taking, physical examination, evaluating laboratory data, instituting treatment, performing procedures screening ED patients with routine problems, admitting certain patients and communicating with consultant services [ ].

Intervention

Intervention Characteristics

Scribes are non-licensed health care team members that follow ED doctors during patient care to concurrently document patient history, physical examination, and procedures in an accurate manner as it is being done by the ED doctor [ , ]. Scribes keep track of laboratory findings and radiological studies, prompt doctors to review test results, assist with referrals, and record other pertinent information [ , ].

Physician Assistants are fully licensed medical practitioners who are trained to provide care under the direction and supervision of a doctor [ ]. While the doctor is ultimately responsible for the patient and established the degree of supervision, physician assistants have autonomy in medical decision making [ ]. Typical duties include history taking, physical examination, evaluating laboratory data, instituting treatment, performing procedures screening ED patients with routine problems, admitting certain patients and communicating with consultant services [ ].

Two reviews examined interventions relating to pharmacy roles in ED [ 77 , 78 ]. The scope of pharmacy roles in the ED varied. In the ED, pharmacists conduct consultations including interpreting results and providing pharmacotherapy recommendations [ 77 , 78 ]. ED pharmacy programs also included pharmacists tracking patients medication due times for repeat medications, completing medication histories, documenting patient body weight, height, and allergies [ 77 , 78 ]. Pharmacists have also been involved ED patient follow-up on culture and susceptibility results, adjusting or discontinuing therapy as needed [ 77 , 78 ].

Mental health services

Two reviews examined interventions relating to mental health services in ED [ 79 , 80 ] including Liaison Mental Health Services [ 79 , 80 ], co-located Psychiatry Liaison Personnel/ Spaces [ 80 ], Psychiatry Specialist Services [ 80 ]. A description of the characteristics for each type of mental health services intervention is provided in Table 8 .

Mental Health Services interventions and intervention characteristics

Intervention	Intervention Characteristics
	Liaison mental health services have been located in general hospitals outside of ED, but also located inside EDs [ ]. Liaison team composition varies and can include nurses, social workers, psychologists, and psychiatrists [ ]. Liaison mental health services see clients directly (most referrals involve 60 min of contact with clients) in both initial and follow-up face to face contact with clients [ ]. Liaison mental health services also perform administrative, supervision, audit and research, teaching, and meetings [ ]. Some models of liaison mental health services include the integration of extra specialist mental health staff (mental health nurses rather than upskilled ED trained staff) as part of the full time ED team and involved in patient triage, mental health patient assessment, management, referral and liaison with other services [ ].
	co-located psychiatry liaison personnel or spaces for patients [ ] are not integrated into the normal ED team, but could be called upon to see mental health patients in the ED or in a bespoke space [ ].
	Psychiatry specialist services review and care for ED mental health patients [ ]. These teams include social workers, psychiatrist and psychologists who come to the ED after referral from the ED staff [ ]. Daily rounds by a psychiatrist in the ED has also been implemented [ ].

Professional development

Nine reviews examined professional development interventions in ED. Professional development interventions included eight-hour customer service training related to applying industry customer service principles to health care, benchmarks, and taught customer service skills such as negotiating agreement and resolution of expectations [ 31 , 39 ]; and a 10 week medical Spanish language course [ 39 ]. The provision of audit/ feedback (from a supervisor/ colleague/ external coder) on clinical practice has been implemented in a variety of formats including weekly case specific, every 6 weeks individual feedback with group discussion; or individual feedback provided via email, written, verbal, electronic, and combination of media, one on one, group, (e.g., patient outcomes, quality of documentation [ 81 – 83 ]. Other interventions include cross-training nurses to care for patients in a designated area [ 25 ], monthly staff education/ workshops about hand hygiene with elements of targeted feedback [ 84 ], and clinical education to improve nurses’ and medical staffs’ knowledge of pain management through an education program [ 42 , 85 ].

The role(s) of patients in improving ED performance

Patients are consumers of healthcare services provided by EDs. The delivery of healthcare depends on the relationship between clinicians and patients and the degree to which patients play an active or passive role [ 86 ]. Two reviews examined the role of patients in improving ED performance [ 42 , 86 ]. Patients’ role in improving ED performance has been primarily addressed by involving patients in shared decision making. Shared decision-making involves active patient involvement with the clinician, sharing information and collaboratively taking steps to reach agreement about which treatment to implement [ 86 ]. Shared decision making has been addressed through decision supports [ 86 ], and education [ 42 ]. A description of the characteristics for each type of patient role intervention is provided in Table 9 .

Patient Role interventions and intervention characteristics

Intervention	Intervention Characteristics
Decision Supports	Decision support interventions are designed to support patient involvement in decisions about care for bactremia and associated complications in febrile children, laceration repair in children, rehydration options, and risk of acute coronary syndrome [ ]. Paper based decision support interventions convey aggregate level information on risks and benefits of treatment options [ ]. The use of computerised methods to generate outcome probabilities for individual patients using embedded statistical models [ ].
Education	Parental/ family education has also been implemented through a pain management booklet and bookmark, a ‘pain passport’ which actively engaged parents and children in pain management discussions with nurses encouraging children and parents to monitor and track the child’s pain score during their ED stay [ ].

The outcomes attributed to interventions used to improve ED performance

The outcomes attributed to interventions used to improve ED performance identified by the review can be categorised into five key areas: Time, proportion, process, cost, and clinical outcomes. Time-based measures record time stamps/ intervals, and sub-cycle intervals [ 25 ]. Measures of time intervals varied, however, the most commonly used were length of stay (LOS) in ED and waiting time. Proportion-based measures record elements of ED performance rates [ 25 ]. Measures of proportion-based measures varied widely and included admissions, resource use, and treatment follow-up rate. Process-based measures document elements of ED process performance [ 25 ]. Direct and indirect measures of quality of care, including left without being seen, did not wait, as well as patient and provider satisfaction, were commonly reported ED process performance measures. Cost-based measures indicate the financial implications of health care provided. Measures of cost varied and lacked detail, and were often reported simply as “costs” [ 18 , 51 , 62 ]. Clinical-based measures indicate the medical outcomes for patients of the health care provided. Measures of clinical outcomes reported varied, however, and the most commonly used were adverse events and readmission.

Overall, time-based and process-based outcome domains were the most widely used measures for interventions with 24 out of the 30 individual interventions reporting at least one of each of these domains. Proportion-based outcomes were similarly well reported on for interventions with 21 out of the 30 interventions reporting proportion-based measures. Cost-based and clinical-based outcomes were the least utilised domains with only 12 and 17 interventions respectively reporting at least one outcome in these domains.

Team composition

The time-based outcome was the most widely used domain for team composition interventions, with 10 of the 13 interventions reporting at least one time-based measure. Proportion-based measures were reported for nine of the 13 interventions with process-based and clinical-based measures reported for 8 of the interventions. Cost-based outcomes were the least utilised, with six interventions reporting at least one outcome in this domain. An additional file provides a full list of intervention performance measures reported for the included interventions (See Additional file 6 ). Figure 5 displays a summary of the types of interventions within practices and processes and team composition, as well as graphically presenting the proportion of the total number of outcome measures reported for each domain for each intervention.

An external file that holds a picture, illustration, etc.
Object name is 13049_2020_749_Fig5_HTML.jpg

Overview of the outcome measures used for ED interventions. The rich picture summarises the types of interventions identified by this review. The graphs for each intervention present the proportion of outcome measures reported for each domain for each intervention. Each proportion was calculated as the number of identified outcome measures in the domain divided by the total number of outcome measures for the intervention. CNS, clinical nurse specialist; CRNA, certified registered nurse anaesthetist; CIN, clinical initiatives nurse; RAZ/RAP, rapid assessment zone/ rapid assessment pod; MAU, medical assessment unit; ED, Emergency Department; QDU, quick diagnosis unit

In this review we aimed to map the research evidence of strategies to measure and improve ED performance. There was strong alignment between how ED performance is measured, the types of ED interventions implemented, and the outcome measures used to assess effectiveness of those interventions.

While EDs worldwide may share a common purpose [ 87 – 89 ], the differences and complexity within each ED system is reflected in the vast number of measures used to understand different aspects of ED performance. Similarly, the different ways these measures have been categorised reflects differences in the interpretation of that common purpose. For EDs and the communities they serve, the selection of performance measures is critical to ensuring a comprehensive, accurate and precise picture of ED performance is developed. It is equally important to develop a shared understanding how ED performance data is collected to ensure that measures used for performance assessment or comparison are valid.

The results of our review show that the delivery of care in ED has evolved over the last 20 years with the implementation of a wide range of interventions to improve ED performance. The interventions identified by this review address very specific aspects of how care is provided in ED, suggesting that a systems perspective has not been applied. Crucially, EDs are complex adaptive systems and any intervention implemented to improve performance is likely influenced by existing models of care, as well as a variety of contextual factors such as funding, availability of skilled workforce, and the physical space available.

Changing patient involvement in the provision of care also plays a role in ED performance. The small number of reviews identified by this review that involved patient perspectives suggests that care delivery in the ED is likely driven by clinicians and protocols, with patients as passive consumers of care. In the crowded and frantic ED context, achieving patient-centred care is likely a challenging task [ 33 ]. Our findings suggest that achieving active participation by patients in ED care delivery is possible, but more research is needed on the implications for ED performance and patients’ clinical and psychosocial outcomes.

Intervention outcome measures allow us to determine if the intervention to improve ED performance was successful or if it had unintended outcomes. While the use of all five types of outcome measures synthesised in our review would provide clinicians, hospital administrators and researchers with the most insight into ED performance and intervention effectiveness, implementation of the full suite of measures may not be possible in some contexts. Most studies reported the use of three or fewer types of outcome measures. Measures of time were commonly combined with proportion or process measures. The use of time, proportion and process measures provides insight into the speed of healthcare provision, the quantity of resources used (e.g., diagnostic tests), and the quality of patient management (e.g., clinical documentation). However, intervention implementation decisions are often made based on department budgets or the availability of funding. As such, the inclusion of cost measures is increasingly important to inform clinicians’ and administrators’ decisions about ED performance and intervention effectiveness. Finally, measures of clinical outcomes are also important for examining the assumption that system changes in healthcare provide improved patient safety and clinical outcomes, and this is a neglected area for many interventions.

Limitations

This scoping review is the first, to our knowledge, to synthesise the many review articles to comprehensively describe the different strategies that have been used to measure and improve ED performance. Limitations of the current study include our pragmatic choice to only include reviews published in English and the potential biases of the included studies. The published reviews examining the effectiveness of interventions in the ED context might have suffered from publication bias, with negative results less likely to be published. As a result of this publication bias, it is unclear what interventions are unsuccessful or if particular context characteristics result in unsuccessful interventions, or negatively impact on patient care.

Over the last two decades, the way care has been delivered in ED has changed dramatically in response to increased demand and increasing complexity, and it is likely that it will continue to change over the next two decades. In turn, the way we measure ED performance has changed with our capacity to collect and analyse data. We need to think critically about the performance measures we use to define ED performance to ensure we are capturing a complete and dynamic picture that accurately reflects how an ED is performing. As shown by this review, a number of different strategies have been used to improve ED performance. As both internal and external pressures on ED continue to grow, future intervention initiatives will be needed to ensure the tragic consequences of crowding in ED are avoided. Crucially, a comprehensive range of meaningful outcome measures for interventions needs to be used to accurately establish the effectiveness of ED interventions and inform system changes and decision-making.

Supplementary information

Acknowledgements.

We would like to acknowledge and thank Ms. Teresa Winata for providing support in the proof-reading process. We would also like to acknowledge and thank Mr. Drew McTavish for providing support in the development of Figures.

Authors’ contributions

EEA, BB, JB and RCW made substantial contributions to the conception of the work. EEA, CT and AS made substantial contributions to the acquisition, analysis and interpretation of the data. All authors approved the submitted version and have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

This project was not funded.

Availability of data and materials

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Not applicable.

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Competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information accompanies this paper at 10.1186/s13049-020-00749-2.

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Overcoming challenges in nursing disaster preparedness and response: an umbrella review

Introduction

Data synthesis

Education and training

Research and development in disaster nursing

Policy and organizational support

Technological advancements in disaster nursing

Psychological preparedness and support

Assessment and evaluation

Role-specific preparedness

Interprofessional collaboration and cultural competence

Ethics and decision-making

Data availability

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BMC Nursing

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The effectiveness of an emergency department nursing intervention on psychological symptoms and self-care capacities

Background:

Method:

Results:

Discussion:

1 Introduction

2.2 Study setting and participants

2.3 Interventions

2.4 Outcomes measure

4 Discussion

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Conclusions

Introduction

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