Doctor of Nursing Practice

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Advanced Practice Providers Impact Quality and Throughput in an Adult Emergency Department

Melissa King
University of Mississippi Medical Center
Degree track: DNP
Degree awarded: August 2016
DNP Project Chair: Robin Christian, DNP, FNP-C
DNP Project Team Member: Sheila Keller, PhD, RN


Emergency Department (ED) overcrowding and the negative impact on ED flow has been well documented over the past decade (Welch et al., 2010). With current mandates from the public, payors, Centers for Medicaid and Medicare Services (CMS), and the Affordable Care Act (ACA) stating all patients have the right to cost effective, timely and quality care, hospitals in the United States (US) are not only under pressure for healthcare reform; but, also experiencing financial and operational stress (Wiler et al., 2010). In order to continue increasing quality, hospitals need to find new and innovative ways to serve a patient population with worsening chronic illness have outpaced the general population (Emeny, 2013). Additionally, quantitative quality outcome measures for emergency medicine (EM) have been endorsed by the National Quality Forum (NQF) and include left without being seen (LWBS) and length of stay (LOS) (Welch et al., 2010). Therefore, finding methods to improve workflows, processes, and treatments to decrease the strain of wait times and LOS have become an area of focus for healthcare organizations. Specifically, EDs need front end operational improvements and redesign to deliver patient centered quality care and decrease amount of time patients have to wait to be seen by a healthcare provider (Hayden, et al., 2014). Prior to this quality improvement (QI) initiative of an advanced practice provider (APP) in triage at the University of Mississippi Medical Center (UMMC), the adult ED was following the national trend of being well outside the recommended quality metrics for EM. In an effort to improve ED throughput and quality, an APP was placed in triage as an addition to the current staffing model of two registered nurses (RN) and an ED technician to decrease LOS and LWBS. To determine the impact of this intervention, all adult ED encounters during a 17 month timeframe (January 2014 - June 2015) were considered for initial analysis. A pre and post timeframe were designated for this project. January, February, and March, 2014 are considered the pre-intervention timeframe and April, May, and June, 2015 are considered the post-intervention timeframe. An APP was placed in ED triage April 1, 2014. Therefore, April 1, 2014 through March 31, 2015 is considered the intervention timeframe. Data was extrapolated from generated monthly reports, de-identified, placed into an excel spreadsheet, and converted to SPSS for statistical testing and analysis. The data was grouped for analysis into groups that included LWBS, LWBT, and AMA/discontinued care to calculate LWBS rate. The second group was divided into admit, discharge, or admit and discharge to calculate overall LOS. Parametric independent t-tests were performed to compare means of LOS and LWBS rates. LOS significantly decreased in all groups (p < 0.05). The rate of LWBS pre and post intervention was not statistically significant. However, there was an overall decrease in LWBS which indicates clinical significance. These findings suggest implementation of an APP in ED triage is a logical and innovative strategy to decrease LOS and LWBS to improve ED throughput and quality. This process simultaneously accommodates for today's increasing volume of a sicker patient population while maintaining decreased wait times, increasing quality care, and improving clinical outcomes. However, a better understanding of quality care and gold standard of what is required to run, maintain, and improve quality of care in a high performing ED is crucial for optimization of resources and a health care organization's growth and sustainability (Bolch, 2008).