The Meaning of Boarding in a Swedish Accident & Emergency Department: A Qualitative Study on Patients' Experiences of Awaiting Admission

Emergency department crowding: An examination of older adults and vulnerability

Emergency departments in many nations worldwide have been struggling for many years with crowding and the subsequent provision of care in hallways and other unconventional spaces. While this issue has been investigated and analyzed from multiple perspectives, the ethical dimensions of the place of emergency department care have been underexamined. Specifically, the impacts of the place of care on patients and their caregivers have not been robustly explored in the literature. In this article, a feminist ethics and human geography framing is utilized to argue that care provision in open and unconventional spaces in the emergency department can be unethical, as vulnerability can be amplified by the place of care for patients and their caregivers. The situational and pathogenic vulnerability of patients can be heightened by the place of the emergency department and by the constraints to healthcare providers' capacity to promote patient comfort, privacy, communication, and autonomy in this setting. The arrangements of care in the emergency department are of particular concern for older adults given the potential increased risks for vulnerability in this population. As such, hallway healthcare can reflect the normalized inequities of structural ageism. Recommendations are provided to address this complicated ethical issue, including making visible the moral experiences of patients and their caregivers, as well as those of healthcare providers in the emergency department, advocating for a systems-level accounting for the needs of older adults in the emergency department and more broadly in healthcare, as well as highlighting the need for further research to examine how to foster autonomy and care in the emergency department to reduce the risk for vulnerabilities.

Staff and patient experiences of crowding, corridor care and boarding: a rapid review

The increasing use of healthcare services is leading to issues with hospital overcrowding and this is particularly apparent in emergency departments (EDs). Consequently, patients are being cared for in areas that were not designed for that purpose, such as waiting areas and corridors. This negatively affects nurses' and patients' experiences of care. This article provides a rapid review of the evidence on nurses' and patients' experiences of crowding, corridor care and boarding. The findings highlight three main elements experienced by staff and patients when caring or being cared for in such contexts: stress and frustration; dissatisfaction with care; and safety and coping mechanisms. Enhancing nurse autonomy and improving communication with patients could mitigate some of these negative experiences and thereby improve staff retention, reduce staff-patient conflict and reduce the likelihood of patients leaving the ED without being seen.

Diagnosing an overcrowded emergency department from its Electronic Health Records

Emergency department overcrowding is a complex problem that persists globally. Data of visits constitute an opportunity to understand its dynamics. However, the gap between the collected information and the real-life clinical processes, and the lack of a whole-system perspective, still constitute a relevant limitation. An analytical pipeline was developed to analyse one-year of production data following the patients that came from the ED (n = 49,938) at Uppsala University Hospital (Uppsala, Sweden) by involving clinical experts in all the steps of the analysis. The key internal issues to the ED were the high volume of generic or non-specific diagnoses from non-urgent visits, and the delayed decision regarding hospital admission caused by several imaging assessments and lack of hospital beds. Furthermore, the external pressure of high frequent re-visits of geriatric, psychiatric, and patients with unspecified diagnoses dramatically contributed to the overcrowding. Our work demonstrates that through analysis of production data of the ED patient flow and participation of clinical experts in the pipeline, it was possible to identify systemic issues and directions for solutions. A critical factor was to take a whole systems perspective, as it opened the scope to the boundary effects of inflow and outflow in the whole healthcare system.

Defining Research Funding Priorities: Emergency Nurses Association Foundation

INTRODUCTION

Establishing research priorities provides focus and direction for limited resources among organizations and increasing impact in a focused area. The Emergency Nurses Association (ENA) Foundation sought to identify research priorities to guide funding decisions in its extramural grants program.

METHODS

A modified Delphi research strategy was used to build consensus among ENA members and key leaders to determine research focus areas. Two Delphi rounds were conducted. In the first round, 81 emergency nurses participated in providing a list of potential research foci. In the second round, 221 emergency nurse leaders recommended which research topics should be prioritized. Descriptive statistics (frequencies, percentages) were calculated for each research topic. The topics were clustered together and rank ordered by frequency/percentage.

RESULTS

Eight research priorities were identified: emergency department overcrowding, workplace violence, nurse well-being, appropriate use of the emergency department, new graduate training, mental health care, disaster training, and diversity, equity, and inclusion research.

DISCUSSION

These identified research priorities offer direction for determining ENA Foundation funding priorities. In addition, the research priorities provide strategic direction to emergency nurse researchers to promote a rich depth of research that can make a meaningful impact to science and emergency nursing practice.

Clinicians' Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being

BACKGROUND

The aim of this study was to describe clinicians' insights into the quality and safety of patient care delivered to emergency department (ED) boarding patients, as well as clinician safety and satisfaction related to ED boarding.

METHODS

This was a single-site, mixed methods sequential explanatory study. Quantitative data were obtained from a cross-sectional survey sent to ED attending physicians, resident physicians, advanced practice providers, and nurses. Semistructured focus group interviews with a subsample of participants sought to add depth to the interpretation of survey data and identify areas of improvement in boarding care. Chi-square and Wilcoxon rank sum tests were used to evaluate for response differences between groups. Qualitative data were thematically coded and analyzed.

RESULTS

A total of 94 questionnaires were obtained for a response rate of 34.1%. Clinicians reported that boarding highly contributed to the perception of burnout. All groups reported high rates of perceived verbal and/or physical abuse from boarding patients (86.8% of nurses, 41.1% of providers, p = 0.0002). A total of 39 clinicians participated in focus groups regarding boarding care, and six themes were identified, including patient safety concerns, lack of knowledge/resources/training, and poor communication. Key themes identified as possible solutions to improve care included standardization of care, proactive planning, and culture change.

CONCLUSION

Clinicians identified many concerns regarding patient safety and the quality of care delivered to boarding patients and identified several areas for improvement. Clinicians also felt that boarding negatively affected their satisfaction and safety.

Fast track to stroke unit for patients not eligible for acute intervention, a case-control register study on 1066 patients

Stroke patients not eligible for acute intervention often have low priority and may spend long time at the emergency department (ED) waiting for admission. The aim of this retrospective case-control register study was to evaluate outcomes for such "low priority" stroke patients who were transported via Fast Track directly to the stroke unit, according to pre-specified criteria by emergency medical service (EMS). The outcomes of Fast Track patients, transported directly to stroke unit (cases) were compared with the outcomes of patients who fulfilled these critera for Fast Track, but instead were transported to the ED (controls). In all, 557 cases and 509 controls were identified. The latter spent a mean time of 237 min in the ED before admission. The 90-day mortality rate was 12.9% for cases and 14.7% for controls (n.s.). None of the secondary outcome events differed significantly between the groups: 28-day mortality rate; death rate during hospitalisation; proportion of pneumonias, falls or pressure ulcers; or health-related outcomes according to the EQ-5D-5L questionnaire. These findings indicates that the Fast Track to the stroke unit by an EMS is safe for selected stroke patients and could avoid non-valuable time in the ED.

Healthcare professionals' perceptions of interprofessional teamwork in the emergency department: a critical incident study

BACKGROUND

Interprofessional teams contribute to patient safety during clinical care. However, little is known about how interprofessional teams manage and cope with critical incidents in the emergency department (ED). Therefore, the study aimed to describe healthcare professionals (HCPs) perceptions of critical incidents linked to the enablers of and barriers to interprofessional teamwork in a high-risk setting, the ED.

METHODS

Individual interviews with HCPs regarding events at the ED were held during the period of May 2019-January 2020. The Critical Incident Technique approach was used to guide the interviews and the qualitative analysis. Data were analyzed inductively using qualitative content analysis.

RESULTS

Interview participants (n = 28) included 7 physicians (25%), 12 registered nurses (43%), 7 nurse assistants (25%) and 2 administrators (7%). Overall, 108 critical incidents were described. Eight categories that described functional and dysfunctional experiences within interprofessional teamwork were identified: salience of reflection; professional experience makes a difference; demanding physical and psychosocial work environment; balancing communication demands; lacking management support, structure, and planning; tensions between professional role and responsibility; different views on interprofessional teamwork; and confidence in interprofessional team members.

CONCLUSION

Findings of this study indicate that poor ED-specific communication and limited professional experience are essential factors in handling critical incidents related to interprofessional teamwork. An important aspect of critical incident management is the ergonomics of the physical work environment and how it enables interprofessional teamwork. This study emphasizes the factors enabling interprofessional teamwork to manage critical incidents in the complex working environment of the ED.