DANGER ZONE
VERTICAL PATIENT FLOW: IS IT SAFE AND EFFECTIVE? Authors: Hannah Fenn, BS, Margaret Carman, DNP, ACNP-BC, ENP-BC, and Marilyn Oermann, PhD, RN, ANEF, FAAN, Durham, NC Section Editor: Susan F. Paparella, MSN, RN
Earn Up to 8.5 CE Hours. See page 269.
n elderly man presents to the emergency department on a particularly busy night. When he is called from the waiting room, he is asked to wait in the hallway, seated in a chair. As he is receiving his care, other patients and staff are walking by and able to overhear the conversation between the patient and provider discussing the patient’s health information. Over the many hours he is there, he needs to use the restroom. Unable to ring a call button, he stands up and begins walking. He is quickly disoriented from the bright lights and fast-paced environment around him. A nurse notices the man, but as she is approaching him to help, he trips and falls. ED overcrowding is an ever-growing risk to patient safety and delivery of effective and efficient emergency care in the United States. Professional organizations continue to examine and develop strategies to combat increased wait times, increased mortality rates, and delays in care. In 2008 the American College of Emergency Physicians (ACEP) Task Force on Boarding released a list of high-impact solutions to reduce overcrowding. 1 Many initiatives have been developed and implemented across the country, though institutions need to maintain optimal safety, comfort, and overall satisfaction for persons requiring emergency services. One initiative used in many emergency departments is vertical patient flow (VPF). The term, coined by Liu et al., 2
A
Hannah Fenn is Student, Accelerated Bachelor of Science in Nursing Program, Duke University School of Nursing, Durham, NC. Margaret Carman is Assistant Professor, Duke University School of Nursing, Durham, NC. Marilyn Oermann is Thelma M. Ingles Professor of Nursing and Director of Evaluation and Educational Research, Duke University School of Nursing, Durham, NC. For correspondence, write: Hannah Fenn, BS, 1011 Morreene Road, No. 21, Durham, NC 27705; E-mail: [email protected]. J Emerg Nurs 2015;41:240-1. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.006
240
JOURNAL OF EMERGENCY NURSING
describes the use of nontraditional beds as patient evaluation areas to improve throughput and increase the number of patient visits. Patients remain upright in chairs unless there is a clinical reason for them to recline as they await diagnostic studies, results, or completion of the discharge process. The Institute for Healthcare Improvement illustrates VPF as a leading health care component 3; however, this innovation is not directly described in ACEP’s recommendations, and there is a lack of discussion in current literature. Yet, VPF has been implemented fully or partially or is in progress of implementation in over 70 hospitals in the United States, with little research existing to support its effectiveness. 2 Possible adverse affects have not been studied but may include a lack of privacy and protection of personal health information, patient satisfaction, decreased comfort, and an increased risk of patient falls or injury. 4 The search for information regarding VPF or studies examining the effects and impact of this process change reveals little in the form of objective measurement. Much of the information that does exist indicates limitations in this practice, including no decrease in wait times, lack of availability of medical supplies, and lack of privacy to provide full examinations and discussions. 2,4 Health care providers may also assume that the condition of a patient in a nontraditional bed is less acute, indicating that important shifts in a patient’s health status could go undetected. 4 The aging of the nurse workforce, rise in patient obesity, and higher patient-to-nurse ratios are factors that could increase the likelihood of injury in the hospital setting. 4 With limited evidence on implementation and impact, the use of VPF without careful consideration and planning could increase the chance of injury for nurses and patients. Safe patient handling initiatives have been implemented in hospitals throughout the United States, around the same time VPF was developed. However, there is no information on the impact of VPF on safe patient handling practices. The profession of nursing is consistently ranked as one of the highest in nonfatal injuries in the workplace, exceeding construction and manufacturing in 2011. The chief cause of
VOLUME 41 • ISSUE 3
May 2015
Fenn et al/DANGER ZONE
injuries (48%) is overexertion and bodily reaction, which includes motions related to patient handling. 5 In 2003 the American Nurses Association initiated the Handle With Care campaign, resulting in 11 states passing legislation related to safe patient handling practices in hospitals, including education, training, and availability of lift equipment. 6 After implementation of these regulatory changes in hospitals across the United States, there was a decrease in injury rates for both nurses and patients. The implementation of the VPF model, rise in number of visits, time pressure, spatial restrictions, and general unpredictable and urgent nature all represent potential barriers to safe patient handling practices in the emergency department. 4,7 In addition, proximity to restrooms and methods of movement to diagnostic study locations or discharge areas should be examined to determine when individuals are at the greatest risk of injuries that lead to increased lengths of stay and extensive use of hospital resources. 8 Adequate education and implementation of a multifaceted safe patient handling program for vertical flow patients are necessary to improve both patient and nurse safety. 9 VPF may be one approach to addressing issues in ED throughput. In these attempts, however, the highest priority remains the quality and safety of emergency care given to patients. Whether a department uses a more traditional workflow process, with the use of treatment rooms, or the increased mobility of a vertical flow process, patients and staff are at risk of falls and injury by the nature of this setting. Identification of the temporal and spatial aspects of care using VPF should be examined through systematic study to determine the magnitude of risk in comparison to traditional ED flow, as well as those interventions that may decrease risk while improving patient comfort and satisfaction. Once sufficient evidence exists regarding
May 2015
VOLUME 41 • ISSUE 3
VPF’s effectiveness and safety, hospitals and staff can confidently implement the initiative. REFERENCES 1. American College of Emergency Physicians. Emergency department crowding: high-impact solutions. http://www.acep.org/content. aspx?id=32050. Published April 2008. Accessed May 1, 2014. 2. Liu S, Hamedani A, Brown D, Asplin B, Camargo C. Established and novel initiatives to reduce crowding in emergency departments. West J Emerg Med. 2013;14(2):85-89. 3. Institute for Healthcare Improvement. Getting lean in the ED. http:// www.ihi.org/resources/Pages/ImprovementStories/GettingLeanintheED. aspx. Accessed November 13, 2014. 4. McNaughton C, Self W, Jones I, et al. ED crowding and the use of nontraditional beds. Am J Emerg Med. 2012;30(8):1474-1480. 5. Occupational Safety and Health Administration, US Department of Labor. Worker safety in your hospital: know the facts. https://www.osha. gov/dsg/hospitals/documents/1.1_Data_highlights_508.pdf. Published 2011. Accessed April 21, 2014. 6. American Nurses Association. Safe patient handling and mobility (SPHM). http://nursingworld.org/MainMenuCategories/PolicyAdvocacy/State/Legislative-Agenda-Reports/State-SafePatientHandling. Published May 1, 2013. Accessed April 21, 2014. 7. Perhats C, Keough V, Fogarty J, et al. Non-violence-related workplace injuries among emergency nurses in the United States: implications for improving safe practice, safe care. J Emerg Nurs. 2012;38(6):541-548. 8. Morello R, Barker A, Haines T, et al. In-hospital fall and fall related injuries: a protocol for a cost of study fall. Inj Prev. 2013;19(5):363. 9. Resnick M, Sanchez R. Reducing patient handling injuries through contextual training. J Emerg Nurs. 2009;35(6):504-508.
Submissions to this column are encouraged and may be sent to Susan F. Paparella, MSN, RN [email protected]
WWW.JENONLINE.ORG
241
VERTICAL PATIENT FLOW: IS IT SAFE AND EFFECTIVE? Authors: Hannah Fenn, BS, Margaret Carman, DNP, ACNP-BC, ENP-BC, and Marilyn Oermann, PhD, RN, ANEF, FAAN, Durham, NC Section Editor: Susan F. Paparella, MSN, RN
Earn Up to 8.5 CE Hours. See page 269.
n elderly man presents to the emergency department on a particularly busy night. When he is called from the waiting room, he is asked to wait in the hallway, seated in a chair. As he is receiving his care, other patients and staff are walking by and able to overhear the conversation between the patient and provider discussing the patient’s health information. Over the many hours he is there, he needs to use the restroom. Unable to ring a call button, he stands up and begins walking. He is quickly disoriented from the bright lights and fast-paced environment around him. A nurse notices the man, but as she is approaching him to help, he trips and falls. ED overcrowding is an ever-growing risk to patient safety and delivery of effective and efficient emergency care in the United States. Professional organizations continue to examine and develop strategies to combat increased wait times, increased mortality rates, and delays in care. In 2008 the American College of Emergency Physicians (ACEP) Task Force on Boarding released a list of high-impact solutions to reduce overcrowding. 1 Many initiatives have been developed and implemented across the country, though institutions need to maintain optimal safety, comfort, and overall satisfaction for persons requiring emergency services. One initiative used in many emergency departments is vertical patient flow (VPF). The term, coined by Liu et al., 2
A
Hannah Fenn is Student, Accelerated Bachelor of Science in Nursing Program, Duke University School of Nursing, Durham, NC. Margaret Carman is Assistant Professor, Duke University School of Nursing, Durham, NC. Marilyn Oermann is Thelma M. Ingles Professor of Nursing and Director of Evaluation and Educational Research, Duke University School of Nursing, Durham, NC. For correspondence, write: Hannah Fenn, BS, 1011 Morreene Road, No. 21, Durham, NC 27705; E-mail: [email protected]. J Emerg Nurs 2015;41:240-1. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.006
240
JOURNAL OF EMERGENCY NURSING
describes the use of nontraditional beds as patient evaluation areas to improve throughput and increase the number of patient visits. Patients remain upright in chairs unless there is a clinical reason for them to recline as they await diagnostic studies, results, or completion of the discharge process. The Institute for Healthcare Improvement illustrates VPF as a leading health care component 3; however, this innovation is not directly described in ACEP’s recommendations, and there is a lack of discussion in current literature. Yet, VPF has been implemented fully or partially or is in progress of implementation in over 70 hospitals in the United States, with little research existing to support its effectiveness. 2 Possible adverse affects have not been studied but may include a lack of privacy and protection of personal health information, patient satisfaction, decreased comfort, and an increased risk of patient falls or injury. 4 The search for information regarding VPF or studies examining the effects and impact of this process change reveals little in the form of objective measurement. Much of the information that does exist indicates limitations in this practice, including no decrease in wait times, lack of availability of medical supplies, and lack of privacy to provide full examinations and discussions. 2,4 Health care providers may also assume that the condition of a patient in a nontraditional bed is less acute, indicating that important shifts in a patient’s health status could go undetected. 4 The aging of the nurse workforce, rise in patient obesity, and higher patient-to-nurse ratios are factors that could increase the likelihood of injury in the hospital setting. 4 With limited evidence on implementation and impact, the use of VPF without careful consideration and planning could increase the chance of injury for nurses and patients. Safe patient handling initiatives have been implemented in hospitals throughout the United States, around the same time VPF was developed. However, there is no information on the impact of VPF on safe patient handling practices. The profession of nursing is consistently ranked as one of the highest in nonfatal injuries in the workplace, exceeding construction and manufacturing in 2011. The chief cause of
VOLUME 41 • ISSUE 3
May 2015
Fenn et al/DANGER ZONE
injuries (48%) is overexertion and bodily reaction, which includes motions related to patient handling. 5 In 2003 the American Nurses Association initiated the Handle With Care campaign, resulting in 11 states passing legislation related to safe patient handling practices in hospitals, including education, training, and availability of lift equipment. 6 After implementation of these regulatory changes in hospitals across the United States, there was a decrease in injury rates for both nurses and patients. The implementation of the VPF model, rise in number of visits, time pressure, spatial restrictions, and general unpredictable and urgent nature all represent potential barriers to safe patient handling practices in the emergency department. 4,7 In addition, proximity to restrooms and methods of movement to diagnostic study locations or discharge areas should be examined to determine when individuals are at the greatest risk of injuries that lead to increased lengths of stay and extensive use of hospital resources. 8 Adequate education and implementation of a multifaceted safe patient handling program for vertical flow patients are necessary to improve both patient and nurse safety. 9 VPF may be one approach to addressing issues in ED throughput. In these attempts, however, the highest priority remains the quality and safety of emergency care given to patients. Whether a department uses a more traditional workflow process, with the use of treatment rooms, or the increased mobility of a vertical flow process, patients and staff are at risk of falls and injury by the nature of this setting. Identification of the temporal and spatial aspects of care using VPF should be examined through systematic study to determine the magnitude of risk in comparison to traditional ED flow, as well as those interventions that may decrease risk while improving patient comfort and satisfaction. Once sufficient evidence exists regarding
May 2015
VOLUME 41 • ISSUE 3
VPF’s effectiveness and safety, hospitals and staff can confidently implement the initiative. REFERENCES 1. American College of Emergency Physicians. Emergency department crowding: high-impact solutions. http://www.acep.org/content. aspx?id=32050. Published April 2008. Accessed May 1, 2014. 2. Liu S, Hamedani A, Brown D, Asplin B, Camargo C. Established and novel initiatives to reduce crowding in emergency departments. West J Emerg Med. 2013;14(2):85-89. 3. Institute for Healthcare Improvement. Getting lean in the ED. http:// www.ihi.org/resources/Pages/ImprovementStories/GettingLeanintheED. aspx. Accessed November 13, 2014. 4. McNaughton C, Self W, Jones I, et al. ED crowding and the use of nontraditional beds. Am J Emerg Med. 2012;30(8):1474-1480. 5. Occupational Safety and Health Administration, US Department of Labor. Worker safety in your hospital: know the facts. https://www.osha. gov/dsg/hospitals/documents/1.1_Data_highlights_508.pdf. Published 2011. Accessed April 21, 2014. 6. American Nurses Association. Safe patient handling and mobility (SPHM). http://nursingworld.org/MainMenuCategories/PolicyAdvocacy/State/Legislative-Agenda-Reports/State-SafePatientHandling. Published May 1, 2013. Accessed April 21, 2014. 7. Perhats C, Keough V, Fogarty J, et al. Non-violence-related workplace injuries among emergency nurses in the United States: implications for improving safe practice, safe care. J Emerg Nurs. 2012;38(6):541-548. 8. Morello R, Barker A, Haines T, et al. In-hospital fall and fall related injuries: a protocol for a cost of study fall. Inj Prev. 2013;19(5):363. 9. Resnick M, Sanchez R. Reducing patient handling injuries through contextual training. J Emerg Nurs. 2009;35(6):504-508.
Submissions to this column are encouraged and may be sent to Susan F. Paparella, MSN, RN [email protected]
WWW.JENONLINE.ORG
241
