Abstract
Practice Problem: Emergency department crowding inhibits the ability to provide safe patient care to chest pain patients and negatively impact patient outcomes. A Veteran Affairs emergency department has identified a similar concern and implemented a nurse-initiated protocol to decrease the length of stay and improve patient outcomes. PICOT: This evidence-based practice (EBP) project was guided by the following PICOT question: In the emergency department (ED), how does a nurse-initiated protocol (NIP) for chest pain (CP) patients compared to no protocol use influence length of stay (LOS) in the ED over 8 weeks? Evidence: The reviewed literature supported the evidence of effective use of a nurse-initiated protocol in reducing the length of stay in the emergency department. Eleven articles met the inclusion criteria and were used for this literature review. Intervention: The evidence-based nurse-initiated protocol is an intervention to provide objective clinical practice guidelines for chest pain patients resulting in improved earlier diagnostic results and decreased length of stay in the emergency department. Outcome: Post-implementation conclusions revealed no reduction in length of stay after using the protocol but achieved a clinically significant decrease in the time of completion for 12-lead EKGs. Conclusion: Staff education and the implementation of an evidence-based NIP for CP established positive outcomes on reducing EKG times. The results were also clinically significant to validate the implementation of nursing protocols in the ED for decreasing LOS and improving patient outcomes.
Highlights
R (VAMC) deals with crowding and extended length of stay (LOS) issues daily
Applying filters using the Boolean Operators, including “AND” and “OR” to form relevant statements that included decreased length of stay, chest pain, nursing protocols and emergency department narrowed the results to 252 citations and articles
An analysis of pre and post nurse-initiated protocol (NIP) implementation determined the reduction in emergency department (ED) LOS among chest pain (CP) patients during the project
Summary
R (VAMC) deals with crowding and extended LOS issues daily. ED crowding has been a growing factor for nearly two decades in the United States and worldwide (Fay et al, 2018). A before-and-after study performed in an academic ED of over 50,000 annual visits studied nursing strategies for avoiding and minimizing crowding in the ED while improving patient outcomes and ED LOS (Ro et al, 2015). Triage-based orders followed with timely clinical treatment found a significant decrease in ED LOS (Ro et al, 2015). Morley et al (2018) state when the ED is under stress from crowding, patients with urgent clinical needs, such as cardiac issues or severe pain, do not always receive appropriate, timely care. Another review proposed nurse-initiated protocols (NIP) to reduce ED LOS and overcrowding, especially when radiology orders are needed (Burgess et al, 2018). In a prospective, randomized controlled trial (RCT), over one-year, a tertiary teaching facility showed triage nurse-initiated radiographs reduced median ED LOS by 20 minutes (Lee et al, 2016). It is crucial to have a wellorganized and evidence-based chest pain protocol in the ED to avoid adverse outcomes related to any delays in the identification and treatment of ACS or MI diagnosis (Bunch et al, 2016)
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