Staffing only one element in quality challenges
Errors can occur easily in emergency care
[Editor's note: In 1999, the Institute of Medicine (IOM) published a report, To Err is Human: Building a Safer Health System, that led to a radical shift in the way health care organizations and agencies address patient safety. Now the IOM has turned its attention to the nation's emergency care system. Its three-year "Future of Emergency Care" project has resulted in the publication of three reports totaling more than 800 pages.
The reports — on hospital-based emergency and trauma care, emergency medical services (EMS), and pediatric emergency care — were derived from 11 studies commissioned by recognized experts in emergency care. The overall themes were quite broad, focusing on the key issues of coordination, regionalization, and accountability.
Among the reports' major sub-themes were, not surprisingly, quality and patient safety. The following article, adapted from a special IOM report in our sister publication, ED Management, focuses on some of the key quality and safety challenges in emergency care today, and strategies that can help address these challenges.]
As outlined in the Institute of Medicine report, there are three major issues hindering patient safety and quality in our nation's emergency health care system, says Mary M. Jagim, RN, BSN, FAEN, internal consultant for emergency preparedness planning at MeritCare Health System in Fargo, ND. Jagim identifies these issues as environment, staffing, and competency.
"Overcrowding and boarding issues make the ED a place in which errors would easily occur, whether they are medical errors, missing changes in a patient's condition, or a misdiagnosis because some X-ray or lab was not read in the chaos or someone left before they could read it," she says. "It's a recipe for disaster."
The problem with staffing, she says, is that appropriate staff levels are not always being achieved. "If you do not provide appropriate levels of staffing, this will be a safety issue," she asserts. One of the reasons there is a shortage of ED nurses goes back to the environment, she says. "If you feel you can't care for a patient appropriately, if patients swear at you and swing at you, why would you want to work there?" she poses.
The study also points out that there are varying levels of competency across EDs — be it nurses, physicians, nurse practitioners, or physician assistants. "If you care for a population with certain needs, you have to demonstrate a core level of competency for caring for them," says Jagim. "The vision of this report was that we create a system that is coordinated, regional, and accountable, and core competency is part of accountability."
Crowding, being understaffed, and an often striking lack of access to informatics contribute to a reputation of the emergency department as an unsafe environment, says Arthur Kellerman, MD, MPH, professor and chairman of the Department of Emergency Medicine at the Emory School of Medicine in Atlanta, GA. "The report also points out understandable distractions: interruptions, acuity, and other factors that conspire to undermine the kind of safety we want," Kellerman says.
Learn flow techniques
Looking to the future, Jagim has several recommendations. "If managers don't have knowledge in [patient] flow management techniques, they need to learn them," she asserts. "If they don't have a good method for determining the most appropriate level of nursing staff, they need to learn that."
Another of the report's recommendations is the development of national core competency standards for emergency staff, says Jagim. Even before those standards are developed, however, managers still must focus on this important issue. "As an ED manager I looked at the populations I served," she shares. "We are a level II trauma center, so I looked for staff who had taken the Trauma Nursing Core Course. In pediatrics, you want staff to have taken the Emergency Nurse Pediatric Course. For emergency response, you look for training in areas such as HAZMAT awareness."
Kellerman adds that ED managers must have access to decision support systems and monitoring technology — "communications systems that don't require you to leave the department to get your results. Elements of that sort can significantly improve quality," he asserts.
Also, the ED should not be turned into a holding department for other units, Kellerman maintains. "That is a mission placed on many EDs by default, perhaps because we've been dumb enough to accept it."
Rub your hospital's nose in the boarding problem, adds Robert L. Wears, MD, professor of emergency medicine at the University of Florida (UF) College of Medicine and director of medical informatics at UF Emergency Medicine, both in Jacksonville.
"The report gives a lot of support for the contention that nothing of value can be accomplished until the boarding problem is resolved," Wears says. "It should be raised in every venue and at every opportunity until some action occurs."
In addition, managers might look for "mini-catastrophes" that can be publicized to dramatize the issue, he says. This strategy is potentially risky and might be best employed internally, Wears advises. "But there is a need to counterbalance the feeling that, yes, there are lots of complaints, but no one is dying," he says. "For example, one might begin reporting overcrowding episodes as sentinel events to [the Joint Commission on Accreditation of Healthcare Organizations] or state reporting systems."
The one report recommendation that will really help ED managers in the short run is the "command" to stop boarding patients in the ED, and to stop ambulance diversions, says Wear. "However, saying 'stop it now' is not much good without providing some sort of mechanism to actually do it."
For more information, contact:
Mary M. Jagim, RN, BSN, FAEN, Internal Consultant for Emergency Preparedness Planning, MeritCare Health System, Fargo, ND. Phone: (701) 234-4898. E-mail: [email protected].
Arthur Kellerman, MD, MPH, Professor and Chairman, Department of Emergency Medicine, Emory School of Medicine, Atlanta,. Phone: (404) 778-2602. E-mail: [email protected].
Robert L. Wears, Professor of Emergency Medicine, University of Florida College of Medicine, Director of Medical Informatics, University of Florida Emergency Medicine, 655 W. Eighth St., First Floor Clinical Center, Jacksonville, FL 32209. Phone: (904) 655-2631. E-mail: [email protected].
The reports on hospital-based emergency and trauma care, emergency medical services (EMS), and pediatric emergency care were derived from 11 studies commissioned by recognized experts in emergency care. The overall themes were quite broad, focusing on the key issues of coordination, regionalization, and accountability.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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