1

NO BED NONSENSE:

ADDRESSING EMERGENCY DEPARTMENT OVERCROWDING

By

BOBBI GRACE JACKSON

____________________

A Thesis Submitted to The W.A. Franke Honors College

In Partial Fulfillment of the Bachelors degree

With Honors in

Nursing

THE UNIVERSITY OF ARIZONA

DECEMBER2022

Approved by:

____________________________

Dr. Melissa Goldsmith

Department of Nursing
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Abstract

The aim of this thesis is to examine interventions based on research that address the

current issue of emergency department overcrowding. Best practice recommendations to

implement in the emergency department will also be provided based on the evidence presented in

this thesis. Emergency department overcrowding is a current issue that has been exacerbated by

several complicated factors, including the increasing number of Americans living with the

burden of chronic illnesses, a primary care provider shortage, the COVID-19 pandemic, and the

use of the emergency department for non-urgent conditions (Turale & Nantsupawat, 2021). The

prevalence of overcrowding in the emergency department can jeopardize patient safety by

increasing patient wait times and medical errors and by decreasing the quality-of-care patients

are receiving (Yarmohammadian et. al, 2017). The best-practice recommendations developed

within this thesis address the use of modern technology, patient education, fast-tracks, advanced

triage protocol systems, and the Emergency Severity Index triage method to improve workflow

and decrease emergency department overcrowding. Nursing staff is directly impacted by

overcrowding as frontline health care workers, and use of these recommendations may guide

nurses with the knowledge to decrease emergency department overcrowding.

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Chapter One

Introduction And Statement of Purpose

The objective of this thesis is to develop best-practice recommendations to improve the

safety and quality of care patients are receive from medical professionals, including nurses.

Throughout this thesis, evidence-based research will be utilized to establish the focus of the

thesis. To aid in the understanding of this objective, the relevance of this issue within hospitals

will be discussed, and a literature review for the applicable research will be performed. After the

presentation of this information, recommendations based on research studies will be set forth.

Background of Issue Importance

The emergency department (ED) within the hospital is essential in providing care for

individuals in need of urgent medical treatment. The American College of Emergency Physicians

defines emergency care as “the medical specialty dedicated to the diagnosis and treatment of

unforeseen illness or injury” (American College of Emergency Physicians, 2021, para. 1). The

practice of emergency medicine is not dependent on location and can occur anywhere treatment

is necessary for a serious or life-threatening condition. Locations can include, but are not limited

to, urgent cares, vehicles specific to emergency transportation (i.e. an ambulance), telehealth, and

emergency rooms. However, this thesis will focus primarily on the emergency room as the place

of treatment. Within this paper, the terms emergency department and emergency room will be

used interchangeably. The ED assists in cases that may be life-threatening in which immediate

care is needed to avoid patient mortality. According to the Centers for Disease Control, 130

million individuals seek immediate healthcare in the United States each year (CDC, 2021). As

millions of Americans seek care in the emergency room each year and a lack of resources exists,
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overcrowding has become a common problem seen in this specific medical setting.

Overcrowding within the emergency room can be defined as a state in which the functional

capacity of the ED is impaired due to the inability to keep up with the large influx of patients

(Morley et. al, 2018).

With the issues of ED overcrowding, there are several contributing factors that advance

this complicated matter. These factors may include, but are not limited to, the number of patients

that live with chronic illnesses, the aging population, and the decreased availability of primary

care physicians (Young & Horton, 2021). According to the CDC (2022), six in ten Americans

are living with chronic illnesses, such as cancer, diabetes, or heart disease (2022), and 86% of

health care costs are attributed to these chronic conditions (Holman, 2020). As the number of

Americans living with the burden of chronic illness grows and the number of primary physicians

decreases, many may revert to the ED to seek care for their chronic conditions. Fundamentally,

this can contribute to emergency department overcrowding as the ED may not have the resources

to function adequately and meet this demand.

There are several mechanisms by which the emergency room can be overcrowded. This

can include the volume of patients waiting for care, delays in treating or assessing patients that

are already admitted into the emergency department, or delays in patients being discharged from

the unit. Because, patient care is so individualized, it has been difficult to determine sustainable

and effective practices to address and decrease patient overflow. Before 2003, little to no

research was available regarding overcrowding in the emergency department; however, in recent

years more extensive studies have been performed to help develop healthcare practices to

prevent this issue (Morley et. al , 2018).

Significance of the Problem

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Often the only difference between life and death in a medical emergency is time. Time is

an extremely scarce resource in an overcrowded emergency department where patients rely on

the efficiency of healthcare workers to meet their medical needs. When overcrowding occurs,

often the staff is unable to meet patients’ healthcare needs in a timely manner (Rezaei et. al,

2017). Congested emergency departments continue to present as a major concern the affects the

quality-of-care patients receive when arriving at the ED. Although emergency rooms were

created to treat emergency medical conditions, it is commonly found that a large portion of cases

presenting to the ED are classified as a non-urgent medical situation. The definition of an

emergency medical condition is a condition, whether it is an illness, symptom, or injury that has

the potential to cause severe harm and even fatality to an individual without efficient, proper

medical treatment (HealthCare, n.d.). An example of this would be a myocardial infarction, as a

person’s heart may experience critical damage without immediate medical care and attention.

More specifically, it was found across several studies that patients with non-urgent medical

issues can contribute up to 37% of the patient presentations to the emergency room. (Andrews &

Kass, 2018). CDC data shows that in the United States, there are 130 million ED visits made per

year. When compared to the number of hospital admissions that occur yearly from the ED, only

12.5% of the ED visits result in admission to the hospital. This data speaks to the facts presented

here, showing that use of the ED for non-urgent medical matters contributes to the issue of

overcrowding. Exceeding the maximum capacity of an ED can contribute to a decrease in quality

and efficiency of care for patients, including an increased length of stay, increased number of

medical errors, increased wait times for patients, and an overall decreased level of patient

satisfaction (Yarmohammadian et. al, 2017). Because of these consequences, overcrowding in

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this hospital setting has become a major issue and topic of concern among healthcare workers

and patients.

As mentioned above, overcrowding is of major concern in the emergency department and

negatively affects the quality of care that patients receive. As emergency departments were

already experiencing overcrowding problems prior to 2020, the COVID-19 pandemic has

worsened the severity of this problem. Because of the uncertainty and illness severity of this

virus, large patient surges and supply shortages overburdened several hospitals (Turale &

Nantsupawat, 2021). Additionally, many hospitals lost experienced nurser when nurses chose to

retire early or work in roles with less occupational stress. Nurses also left the profession

altogether due to the substantial physical and emotional burden of the pandemic. With less

staffing, overcrowding became a more prevalent issue. According to a study analyzing this topic,

63% of 246 participating hospitals alerted Health Pulse of emergency room overcrowding at

least one time between March 7, 2020, and April 20, 2021 (Sandhu et. al, 2022). Because of the

further exacerbation of emergency department overcrowding related to the COVID-19 pandemic,

this emphasizes the need for this problem to be addressed.

Relevance to Nursing

Nurses are on the frontline within emergency departments. As the overcrowding of

emergency departments continues to increase, so does the possibility of an increase in negative

patient outcomes and adverse events, such as medication errors or lack of recognition of a

declining patient. Overcrowding may result in an increase of the patient to nurse ratio, clinical

errors, supply shortages, and occurrence of sentinel events in the hospital. This can create unsafe

working conditions for nursing staff and hazardous circumstances for patient care. Protocols and

guidelines for managing emergency department overcrowding are necessary to ensure that a
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sufficient number of resources are available, and that adequate care is being given and received.

With the prevalence of this problem, best-practice recommendations for safe, quality, efficient

patient care within the emergency department are necessary to improve the workflow overall.

Summary

Healthcare organizations must address the topic of overcrowding in the emergency

department to protect patients, increase the quality of care, and decrease adverse events. This

literature review will address the causes of this issue in depth, as well as the results of

overcrowding, best practices for prevention of this problem, and methods to reduce patient

congestion.
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Chapter Two

Review of Literature

Emergency Room Overcrowding

Within chapter two, literature addressing the topic of overcrowding within the emergency

room will be discussed. Research articles selected date between the years of 2013 and 2021.

PubMed and Google Scholar were utilized to find research addressing causes of emergency room

overcrowding, consequences of emergency room overcrowding, and interventions to decrease

this issue. Key words and phrases essential in finding these sources included “emergency room,”

“overcrowding,” “handoff,” “current emergency room practices,” and “patient education.”

Ultimately, this compilation of research articles described the current issues and practices

involving patient saturation within the emergency department and were reviewed based upon

their ability to present this information. Results from this literature review inform best practice

recommendations within Chapter Three of this thesis.

To guide research, a focused search was completed based on the focused PICOT question

of “In patients presenting to the emergency department, how does the implementation of the

educational, technological, and triage interventions in comparison to no implementation of these

interventions, prevent overcrowding in the emergency room?”. The articles found and utilized

within this paper consist of randomized controlled trials, systematic reviews, observational

studies, as well as literature reviews. In summary, many of these research articles address

interventions that may benefit the overcrowding in the emergency department, while others focus

on a triage protocol.
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Issues Related to Emergency Room Overcrowding

While this chapter will mainly focus on interventions that aid in decreasing emergency

room overcrowding, this study addresses the causes, repercussions, and solutions of this issues.

As a systematic review, this study identified 102 studies for utilization in the analysis of

overcrowding in the emergency room. These articles were identified through the search of three

major databases, including CINAHL, EMBASE, and Web of Science. Of these 102 articles,

many were the retrospective cohort study types with the majority implementing model-based

solutions to overcrowding. These solutions included extended hours of primary care as well as

methods to increase efficiency of the workflow within the emergency department. This study

also addressed the consequences and causes of this problem. For consequences, it was found that

emergency department overcrowding led to substandard patient outcomes and inability of the

staff ability to follow guidelines and protocols for treatment. Causes included prolonged

discharge, increased presentation to the emergency department by the elderly, and increased

presentation of low acuity cases. This being said, the issue of emergency department

overcrowding is complex and involves a variety of causes; however, there are interventions that

may be implemented to help address this issue (Morley et. al, 2018).

Emergency Room Interventions to Improve Time Efficiency

The purpose/objective of the first study was to determine if an electronic asynchronous

handoff for a patient from the emergency department to the emergency department observational

unit was more efficient than a verbal offer handoff. A retrospective cohort observational study

was utilized to establish if there was a difference between these handoffs by analyzing the time it

took to transfer a patient from the emergency department to the emergency department

observational unit. This study took place at an emergency department designated as a level one
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trauma center as well as an “urban quaternary care academic center” (Tasi et. al, 2021).

According to the article, 14,996 emergency department observation unit (EDOU) stays were

analyzed, and three interventions were implemented including an automatic paging system, a

nursing pull-through technique, and a clinical pull-through technique. Data was collected

through patient data retrieval from electronic medical records from patients sent from the

emergency department to the emergency department observational unit between August 1, 2017,

and March 31, 2019. With data analysis, percentages and frequencies were utilized to summarize

categorical variables, and standard deviation, mean, and interquartile range were utilized to

summarize continuous variables. For assessment of the interventions, a multivariable linear

regression was implemented for analyzation of its effect on time from patient transfer from the

ED to the EDOU (Tasi et. al, 2021). To determine statistical significance, p < 0.05 was utilized.

Researchers found that the results of the interventions were statistically significant as the

time using the automatic page method reduced the mean time by 10.1 minutes (p < 0.001), the

nurse pull-through technique reduced the mean time by 3.57 minutes (p < 0.0299), and the

clinician pull-through technique reduced the mean time by 14.67 minutes (p < 0.0001). The

study included limitations or weaknesses, such as having a set time that for handoff that may

have increased the pace at which handoffs were performed and the study did not provide

assessment of changes of rates of patient admissions or complications patients experienced with

handoffs which may have contributed to differing results. The study did provide strengths in

validating its credibility by providing results consistent to other similar studies.

Emergency Room Patient Education

Prior evidence suggests that patients often use the emergency department for non-

emergent reasons (Tasi et. al 2021), thus determining patients’ conceptual understanding of what
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constitutes an emergent illnesses is important. The purpose of this study was to provide

clarification on whether patients are more likely to report an increased illness severity rating in

comparison to the physician to help analyze the reason for overcrowding within the emergency

room. This is a cross-sectional study and utilized a convenience sampling method of 117 patients

(nine patients declined out of 126 patients). This took place at Penn State Hershey Medical

Center Emergency Department between July 2015 and August 2016. All patients categorized to

the emergency room fast track and age 21 years plus were included, and participants’ eligibility

to participate in the study was determined by a research team member. After obtaining consent, a

survey was completed identifying the patient’s reason for coming to the emergency room,

demographic information, and the patient’s self-reported illness severity using the Illness

Severity Scale. After the patient completed the survey, a physician then rated the patient’s

estimated Illness Severity Scale using the same scale and the two scores were compared.

Additionally, physicians were asked if the patient’s emergency department visit was necessary.

For data analysis, data was summarized with frequencies/percentages, medians, means, and/or

standard deviations. Researchers assessed continuous variable distribution through histograms

before analyzing and utilized the Spearman correlation to compare patient and physician scores.

A two-sample t-test was then implemented to compare the difference (average) between the two

categories of results, and statistical significance was determined with p < 0.05.

After data analysis, it was determined that mean patient estimation of illness severity was

5.22 and the mean physician estimation of illness severity was 7.57 (less severe) which had a

difference of 2.35 and proved to be statistically significant as p < 0.0001. With this, emergency

room patients overall estimated that their illness was more severe than the physician believed it

was. The study presents weaknesses/limitations as the utilization of a survey may cause bias in
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responses, the scale used to estimate illness severity was created for the study and has otherwise

not been validated, and the opinion of the physicians are considered subjective and may not be

an accurate tool for measuring illness severity.

Telehealth Communication

The objective of the study was to address the problem regarding emergency department

overcrowding and the many challenges that come with this issue. Conflicts that arise with

overuse of emergency rooms include extended wait times, lower patient satisfaction levels, and

the potential for compromised patient safety. Within this research, healthcare professionals

implemented an “ED Telehealth Express Care Service” (McHugh et. al, 2018, p. 472) and aimed

to analyze its effects on overcrowding in the emergency department. To conduct this research, a

multidisciplinary team of healthcare professionals introduced an organized telehealth care system

into a New York City emergency department where patient overflow contributed to conflict

among patients and healthcare workers. Upon arrival to the emergency department, patients were

greeted by an emergency room registered nurse who determined which patients qualified for the

telehealth care program. They were examined/evaluated by a nurse practitioner or physician’s

assistant to officially determine the patient’s eligibility. Common patient presentations that met

the requirements for the telehealth care program included nasal congestion, rash (non-

disseminated), abrasions, wound checks, sunburns, requests for medication refills, and bug bites.

If the patient did qualify, they could then accept a “virtual consultation” (McHugh et. al, 2019, P.

473) with an ER physician, and upon acceptance, patients were assessed, diagnosed, provided

with a care plan and prescriptions as needed. There was no set sample size for this convenience

sample method as the hospital implemented this intervention for qualifying patients that walked

into the emergency room.

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Results have demonstrated the implementation of this intervention decreased congestion

within this emergency department, while increasing patient satisfaction scores to the 99th

percentile. More than 1,850 patients were seen through this telehealth care program; however,

this study is still ongoing. Limitations of this study are that a more rigorous investigation may be

needed to determine the effectiveness of the ED telehealth care as well as analysis of the

emergency department efficiencies in comparison to the efficiencies of the workflow typically

used. More research may need to be conducted to find consistent results to strengthen the

findings of this research. This study also demonstrated strengths regarding collecting patient

satisfaction data.

For older individuals, falls are the leading cause to emergency room visits, and this next

study aimed to investigate if a six month “telephone-based patient-centered program” (Barker et.

al, 2019, P. 1), also known as RESPOND, would impact the number of falls and fall-related

injuries presenting to the emergency department. This study utilized a convenience sample of

adults between the ages 60-90 years old that came to the ER after a fall and were discharged

within 72 hours were from two participating emergency departments in Australia. These patients

were only eligible for this study if they could use a phone, ambulate without assistance, and had

no cognitive impairment. If patients qualified, they were randomized to either the RESPOND

intervention or control group, which received the usual care. The RESPOND intervention

included an assessment for fall-risk at home, six months of education utilizing

telecommunication, goal setting, coaching, and support based on the patient’s risk factors, as

well as “linkages to existing services” (Barker et. al, 2019, P. 2). The number of participants that

were randomized to the RESPOND intervention was 217 and 213 participants were randomized
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to the control for primary outcome analysis. Outcome data through “postal-calendars, telephone

follow-ups, and hospital records” (Barker et. al, 2019, P. 2) was collected blindly.

Overall, this study found that providing a patient education program through

telecommunication based on a fall prevention program ultimately reduce the number of falls

presenting to the emergency department but had no effect on reduction of fall injuries. In other

words, the reduction of falls was statistically significant (p < 0.042), and the reduction of fall

injuries was not significant (p = 0.374). Limitations of this study included a high number of

patients dropping out and the possibility of inaccurate data reporting. Strengths include the study

using statistical analysis as well as randomization.

Fast-Tracks in the Emergency Room

The purpose of this next study was to evaluate the effectiveness of implementing a fast-

track within the emergency department on quality of patient care and length of stay (Chrusciel et.

al, 2019). This study was a before-after analysis design that took place in France within a larger

hospital with 127 surgical beds, 442 medical beds, and 63 obstetrics and gynecology beds. The

intervention included the extension of the emergency room to include a fast-track to treat patients

with minor injuries or non-urgent conditions. Within the fast-track, two emergency physicians

cared for adult and pediatric patients, and residents took their place when they were not there.

For patients to be triaged to the fast-track, a protocol was utilized to guide this decision. Length

of stay, this was defined as the time between patient registration and departure from the

emergency department. To analyze results, the hospital used the 111,733-emergency department

stays during the two-year study period and found that the average length of stay before the

intervention was 215 minutes vs. 186 minutes after the implementation of the intervention (p <

0.001). This study attributes the decrease in overcrowding to quick patient discharge through the
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fast-track. Limitations of this study include its lack of randomization and generalizability as it

took place in a single hospital. Further research would be necessary to determine if this

intervention would be an adequate addition to the emergency room to decrease overcrowding.

Although this study had its limitations, the study did have many patients participate over the two-

year study period (Chrusciel et. al, 2019).

Similar to the previous article, this next article aimed to address interventions to decrease

emergency room overcrowding, including the utilization of a fast-track in the emergency

department. This study is considered an umbrella review of systematic reviews and meta-

analyses assessing these different interventions (De Freitas et. al, 2018). Thirteen articles that

assessed 26 interventions to decrease emergency overcrowding were utilized for the purpose of

this study. Within these systematic reviews and meta-analyses, fourteen of the randomized

controlled trials provided statistical evidence. Of the interventions assessed, only the fast-track

intervention was supported by moderate evidence; however, the limitation to this evidence

included that clustering of observations or correlation was not considered in the randomized

controlled trials that covered this intervention (De Freitas et. al, 2018).

Emergency Room Triage Protocol

Regarding the triage protocol itself, this next research article presented the goal of

determining if the implementation of a triage method would improve wait times within the

emergency department (Yuzeng & Hui, 2020). The Plan, Do, Study, Act (PDSA) method was

implemented during four different cycles to test the chosen intervention and different variables

discovered during implementation. The intervention consisted of triaging patients according to

the severity and acuity of their presenting illness. Patients included within this study were those

who presented to the emergency department of Singapore General Hospital; thus, a convenience
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sampling method was used. For those that presented to the emergency room, they were triaged

into four levels with P1 patients being those who required immediate intervention and

resuscitation and P4 being those who presented to the emergency room with conditions that were

non-emergent. Throughout each of these cycles, this Patient Acuity Category system was utilized

(Yuzeng & Hui, 2020). After triage, patients were then sent to patient care areas where necessary

care tests were performed, such as electrocardiograms, urinalysis, and laboratory work. Within

the first PDSA cycle, less complex P1 and P2 patients were triaged to the ambulatory area of the

emergency department instead of the trolley area to compensate for the higher amounts of critical

patients. These patients were considered less acute P1 and P2 patients if they were experiencing

non-emergent cases but still needed to be seen as soon as possible, such as glaucoma, shortness

of breath, and chest pain (low risk). Researchers found a difference in triage levels between

nurses and their efficiency. To help counter this, researchers implemented a process in which the

senior nurses “eyeball-triaged” patients in the second PDSA cycle and took those that needed

trolley area care to the trolley area. However, with this intervention, congestion at the triage area

was still experienced, so a nurse clinician role was established to help facilitate patients to the

trolley area, maintain staffing, and assist less experienced triage nurses in the third PDSA cycle.

In the fourth PDSA cycle, an assessment of nursing activities and nursing manpower needed was

completed. Increased nursing power was introduced, and effective staffing occurred in the triage

area. The wait time to triage was considered the time it took to go through quick registration to

the beginning of triage. This is significant as reducing the wait time can help decrease congestion

within emergency departments (Yuzeng & Hui, 2020).

The results demonstrated that there was a 28% reduction in wait time for the weekly

average with implementation of this triage system in addition to the PDSA cycles to assist in
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improving the process of this triage as seen in the reduction from 18 minutes to 13 minutes. This

was significantly significant as p < 0.01. Limitations of this study include not being able to

determine if interfering factors, such as language barriers, physical disabilities, communication

disabilities, or demanding patients, influenced the results (Yuzeng & Hui, 2020).

Like the previous article, this systematic review with meta-analysis examined the

effectiveness of the utilization of advanced triage protocols on emergency department stays,

patient safety, and patient satisfaction. To locate the resources presented in this systematic

review, randomized clinical trials were found through Embase, PubMed, Cochrane Library,

CINAHL, and BVS (Soster et. al, 2022). The studies analyzed through this research were those

that used an advanced triage protocol in the emergency department in a controlled randomized

trial. This systematic review included ten articles that examined the use of advanced triage

protocols; of those that were used, there was a total of 25,795 subjects. Of these ten articles,

seven were included in the analysis for patient wait time in the emergency department. Within

these studies, it was found that a statistically significant (p = 0.002) 36-minute reduction in the

patient’s length of stay was identified with utilization of an advanced triage protocol in the

emergency department. Limitations included the lack of standardized data in presentation, low

certainty of evidence as p = 0.002, and possible implementation of result bias (Soster et. al,

2022).

Similar to the previous article, this next article examines and analyzes the use of a triage

system in order to deliver timely and effective care for emergency situations to prevent adverse

patient effects from occurring. The study type utilized in this case was a systematic review

involving nine studies that were determined for inclusion through the CINAHL Complete,

PsychINFO, Medline (with full text), and EBSCO Discovery Services electronic databases as
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well as keyword searches. Keywords utilized include “emergency nursing” and “triage

accuracy.” Studies that examined any type of disaster triage, special population triage, or specific

condition triage were not utilized within this review. The articles also had to be written in

English to qualify for inclusion. For five studies, the researchers implemented a written case

scenario to analyze the triage accuracy of the nurses. In two studies in particular, Emergency

Severity Index (ESI) triage system was implemented, and triage accuracy of the nurses was

evaluated. The ESI is a five-level triage system that ranks patients on an acuity scale of one to

five based on presentation and resources needed, with a level one being the most urgent

(Emergency severity index (ESI), n.d.). With evaluation of several triage systems, it was

determined in a study completed by Hinson et. al that the ESI system proved to have the most

accuracy when triaging (82.9%). The systematic review also determined that this method of

study may have had an impact on the results as data was collected cross-sectionally over two

years in which training to refresh triage skills was provided to the nurses. Other results included

that collaboration between different emergency rooms was necessary as well as monitoring the

triage systems continuously. Strengths of this research article include that it was a systematic

review in which evidence was pulled from many studies and that it applied quantified data in

terms of triage accuracy; however, limitations persist as there was only nine articles analyzed

which limits the generalization of the study.

To elaborate on the topic of the Emergency Severity Index (ESI) triage system, a research

study was completed regarding the accuracy of this specific method. Because overcrowding is a

significant problem within the emergency department, triage methods are often utilized to help

decrease wait times and identify emergent cases. Without proper triage, a longer wait time results

and can lead to complications during the patient’s ED/hospital stay. The Emergency Severity
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Index has already been recognized as a beneficial system; however, the purpose of this study was

to specifically test the effectiveness of this triage method as well as identify the strengths and

limitations of it. This quasi-experimental study took place in Imam Khomeini Hospital, north of

Iran and consists of eighteen wards and 328 approved beds. The effectiveness of the

implementation of this triage system was evaluated in accordance with time indicators in the

emergency department. The ESI system was compared to the hospital’s current spot check triage

system during two different four-month time periods that were chronologically close to each

other. Descriptive statistics as well as analyzation using t-test (independent samples) were

utilized to process the data of 770 patient records regarding triage. Compared to the utilization of

the spot check triage system, the results demonstrated that with the implementation of the ESI

system there was an increase in patient wait time (6.46 minutes vs. 8.92 minutes) for being

visited by a physician (P < 0.001) and an increase in time from physician appearance to receiving

nursing care (7.68 minutes vs. 15.89 minutes) with P <0.001; however, it also demonstrated a

decrease in waiting time for laboratory services (112.3 minutes vs. 84.1 minutes; P = 0.033). The

decrease in the average waiting time for sonographic services and length of stay in the

emergency department was not significant. Additionally, the ESI system demonstrated increased

effectiveness when compared to the spot check method. Although there was a statistically

significant increase in time between physician appearance and nursing care given with the ESI

system compared to the spot check system, these findings were inconsistent with other studies

regarding this. Because this system was new to these nurses, this may have contributed to the

increase in the time for patients to receive care, so future research should analyze how proper

triage training using this system effects emergency room service times (Maleki et. al, 2015).
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The next research article aimed to compare the effectiveness of the Emergency Severity

Index (ESI) triage system to that of the Simple Triage and Rapid Treatment (START) triage

system with regard to the treatment and hospitalization of emergent patients. This cross-sectional

design took place in an inner-city hospital and the participants included patients participating in

the “state triage tag exercise” (Hong et. al, 2015) that were transported through Emergency

Medical Services. If the patients had three or more abnormal vital signs upon arrival to the

emergency department with need for two or more emergent interventions, they were categorized

as high acuity and severity. For comparison, the START categories were re-categorized as urgent

with the colors red and yellow and not urgent with the colors green and white, while ESI was re-

categorized with levels 1, 2, and 3 as urgent, and levels 4 and 5 as low acuity. The results

demonstrated a statistical significance as the emergency severity index was able to properly

identify 88% of patients with more than two abnormal vital signs, while START triage system

only identified 51% of patients with more than two abnormal vital signs. Out of 233 patients, the

ESI identified 95% of patients that needed emergent treatment, while the START triage only

identified 33% of patient that needed emergent treatment. Regarding the strength of this

research, it presented a large sample size of 233 participants so it may be generalized; however,

weaknesses present as there may have been variety of staff/nurse opinion about the two triage

systems and they may have been more familiar with ESI (Hong et. al, 2015).

With implementation of the Emergency Severity Triage Index, it is essential that triage is

being performed correctly and is providing a means of time efficiency. Within this next research

article, the utilization of a computerized Emergency Severity Index is implemented and

evaluated for its ability to decrease triage time and to identify high acuity patients. The

experimental design involves a “retrospective before-and-after quasi-experimental study” (Villa

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et. al, 2018, p.1) looking at all patients that presented to a tertiary urban hospital during a two-

year period. Pediatric patients and patients that were not assigned an acuity or missed triaged

were excluded from the study. Because of the population used, this can be considered a

convenience sample. The ESI was computerized through the charting system, Epic, with a “step-

wise algorithm” (Villa et. al, 2018, p.1) that took the triage nursing through the steps required to

assign a patient’s acuity correctly. Prior to the implementation of this intervention, the triage

interval was 5.9 minutes for each patient and decreased to 2.5 minutes after the implementation

of the intervention. This was statistically significant as P was < 0.001. It also increased the

amount of high acuity patients triaged within the first fifteen minutes upon arrival from 63.9% to

75.0%. Although this study was found to be statistically significant, it also had limitations, such

as use of a single institution which decreases the ability to generalize the data. It was also

challenging for the researchers to effectively eliminate the Hawthorne Effect related to quick

triage. This study may also be biased toward the null due to missing data, such as missing

timestamps that may have increased the amount of patient acuities recorded. Strengths of this

research article include the use of empirical data and proper methods for data analysis (Villa et.

al, 2018).

Conclusion

This literature review addressed research that supports evidence-informed and evidence-

based interventions that reduce emergency room overcrowding. Several studies have shown the

benefits of utilizing technology within the emergency room to increase the accuracy, efficiency,

and timeliness of patient care. This is seen with utilization of the electronic asynchronous patient

handoff as well as the implementation of telehealth communication to decrease congestion.

Additionally, patient education serves as a major area for improvement based on the research
 22

reviewed, in which many patients view the severity and urgency of their illness higher than its

actual severity. Implementation of patient education programs may be useful in diverting patients

from the emergency room to other places of treatment, such as local urgent cares. Lastly, there is

significant evidence to inform evidence-based recommendations regarding the use of the

Emergency Severity Index triage system in the emergency room. It proved to be accurate,

reliable, and timely as it significantly times for first physician appearance, laboratory results,

nursing care, and provision of treatment. With improvements in these areas, the patients’ wait

times were typically shortened, which resulted in an overall decrease in emergency room

congestion.
 23

Chapter 3

Evidence-Informed and Evidence-Based Best Practice Recommendations for

Emergency Room Overcrowding

The purpose of this thesis was to develop best practice recommendations related to the

issue of emergency room overcrowding. The evidence-informed and evidence-based research

will be presented in Table 1. Within the table, the recommendations will be presented along with

the rationale, reference, and level of evidence for each research study. Because there are several

interventions utilized to improve emergency department workflow, and improvement is a

continuous process, the stated recommendations are broad. Additionally, the recommendations to

decrease emergency room overcrowding should be utilized by professionals, such as nurses, to

improve the pace of the workflow in the emergency room while providing patients the highest

quality of care.

As the evidence has demonstrated, many hospitals within the United States, as well as

worldwide, experience overcrowding within their emergency room. Reasons this may exist

include lack of proper staffing and a high influx of patients presenting to the emergency room

with non-emergent conditions (Tasi et. al, 2021). This research remains relevant as the functional

capacity of the emergency room is impaired if overcrowding exists. In the previous chapter, the

literature review addresses interventions involving the utilization of technology, patient

education, and triage protocols to assist in improving workflow in the emergency room.

Interventions and programs found in this literature were used to develop the following

recommendations.
 24

Table 1

Recommendations for Decreasing Emergency Department Overcrowding

Level
Recommendati of
Rationale References
on Eviden
ce
Within the
emergency
department, an
electronic
asynchronous
Tasi, M. C., Baymon, D. M. E., Temin, E. S.,
handoff
Zheng, H., Lehman, K. M., Baccari, B.,
demonstrated to
… Yun, B. J. (2021). Evaluation of
be quicker than
process IMPROVEMENT interventions
a verbal handoff
on Handoff times between the emergency
when
department and Observation Unit. The Level
transferring
Journal of Emergency Medicine, 60(2), III
patients to the
237–244.
emergency
https://doi.org/10.1016/j.jemermed.2020.1
department to
0.002
the observation
Implementatio
unit. This will
n of modern
decrease patient
technology into
congestion
processes
within the
within the
emergency
emergency
department.
department.
Integrating McHugh, C., Krinsky, R., & Sharma, R. (2018). Level
telehealth Innovations in emergency nursing: III
communication transforming emergency care through a
to consult with novel nurse-driven ED telehealth express
nonacute care service. Journal of Emergency
patients in the Nursing, 44(5), 472–477.
emergency https://doi.org/10.1016/j.jen.2018.03.001
department
decreases
overcrowding
and increases
patient
satisfaction due
to decrease
length of stay.
 25

Andrews, H., & Kass, L. (2018). Non-urgent

Patients in the
use of emergency departments:
emergency
populations most likely to overestimate
department rate
illness severity. Internal and Emergency
their illness Level
Medicine, 13(6), 893–900.
severity higher IV
https://doi.org/10.1007/s11739-018-
Patient than physicians’
1792-3
education score of their
programs are illness severity.
necessary in
the emergency Barker, A., Cameron, P., Flicker, L., Arendts,
room to
The use of a G., Brand, C., Etherton-Beer, C., Forbes, A.,
prevent
telecommunicati Haines, T., Hill, A. M., Hunter, P.,
presentation of
on for a fall Lowthian, J., Nyman, S. R., Redfern, J.,
non-emergent
prevention Smit, V., Waldron, N., Boyle, E.,
conditions and
education MacDonald, E., Ayton, D., Morello, R., &
recurrent
program reduces Hill, K. (2019). Evaluation of RESPOND, a Level II
health
the amount of patient-centered program to prevent falls in
problems.
fall cases older people presenting to the emergency
presenting to the department with a fall: A randomised
emergency controlled trial. PLoS Medicine, 16(5),
room. e1002807.
https://doi.org/10.1371/journal.pmed.10028
07
Implementing Level
fast-tracks in the Chrusciel, J., Fontaine, X., Devillard, A., III
emergency Cordonnier, A., Kanagaratnam, L.,
department can Laplanche, D., & Sanchez, S. (2019).
decrease patient Impact of the implementation of a fast-track
length of stay. on emergency department length of stay and
quality of care indicators in the Champagne-
Utilization of Ardenne region: a before-after study. BMJ
fast-tracks in Open, 9(6), e026200.
the emergency https://doi.org/10.1136/bmjopen-2018-
department. 026200

Implementing De Freitas, L., Goodacre, S., O'Hara, R., Level 1

fast-tracks in the Thokala, P., & Hariharan, S. (2018).
emergency Interventions to improve patient flow in
department can emergency departments: an umbrella
decrease review. Emergency Medicine Journal:
overcrowding. EMJ, 35(10), 626–637.
https://doi.org/10.1136/emermed-2017-
207263
 26

Soster, C. B., Anschau, F., Rodrigues, N.

This H., Alves da Silva, L.G., Klafke, A.
recommendation (2022). Advanced triage protocols in
Implementation
reduces overall the emergency department: a
of an advanced
wait-time which systematic review and meta-analysis.
triage protocol in Level I
decreases Rev Lat Am Enfermagem.
the emergency
congestion in https://doi.org/10.1590/1518-
department.
the emergency 8345.5479.3511
department.

Utilization of the Proper use Yuzeng, S., & Hui, L. L. (2020). Improving Level III
Emergency of the ESI the wait time to triage at the emergency
Severity Index triage system department. BMJ Open Quality, 9(1),
(ESI) is significantly e000708. https://doi.org/10.1136/bmjoq-
necessary to decreases 2019-000708
effectively triage patient wait
patients and time for care
decrease in the
overcrowding in emergency
the emergency department.
department. Villa, S., Weber, E. J., Polevoi, S., Fee, C., Level III
A Maruoka, A., & Quon, T. (2018).
computerized Decreasing triage time: effects of
step-wise implementing a step-wise ESI algorithm
ESI system in an EHR. International journal for
that is quality in health care: journal of the
implemented International Society for Quality in
decreases Health Care, 30(5), 375–381.
time from https://doi.org/10.1093/intqhc/mzy056
patient
arrival to the
ED to triage
and identifies
higher acuity
patients
within the
first fifteen
minutes upon
arrival.
 27

The ESI
Maleki, M., Fallah, R., Riahi, L., Delavari, S.,
decrease the
& Rezaei, S. (2015). Effectiveness of
time it takes
Five-Level Emergency Severity Index
for patients
Triage System Compared With Three-
to receive
Level Spot Check: An Iranian
laboratory Level III
Experience. Archives of Trauma
work in the
Research, 4(4), e29214.
ED.
https://doi.org/10.5812/atr.29214

Maleki, M., Fallah, R., Riahi, L., Delavari, S.,

The ESI tool
& Rezaei, S. (2015). Effectiveness of Five-
has
Level Emergency Severity Index Triage
significant
System Compared With Three-Level Spot
accuracy in Level III
Check: An Iranian Experience. Archives of
determining
Trauma Research, 4(4), e29214.
patient
https://doi.org/10.5812/atr.29214
acuity.
Hong, R., Sexton, R., Sweet, B., Carroll, G.,
The ESI is Tambussi, C., & Baumann, B. M.
accurate in (2015). Comparison of START triage
determining categories to emergency department
two or more triage levels to determine need for
abnormal urgent care and to predict Level III
patient vital hospitalization. American Journal of
signs for Disaster Medicine, 10(1), 13–21.
emergency https://doi.org/10.5055/ajdm.2015.018
cases. 4
 28

Summary of Best Practice Recommendations

In the profession of nursing, patient health and well-being is held to the highest standard,

so the quality of care provided is expected to follow evidence-based and evidence-informed

recommendations. Although the health of our patients is of utmost importance in this profession,

hospital processes and policies can impede the nurse’s ability to provide the quality-of-care

patients deserve. The healthcare system is in a state of ever-evolving improvements to make this

possible, so continued research is necessary to determine how to enhance our patient processes

and improve quality of care. Emergency department overcrowding exists as a continuously

occurring problem that ultimately affects the nurses’ ability to care for the chronically and

acutely ill patients in need of urgent medical assistance. This thesis has set forth research that is

applicable to addressing this specific issue to improve patient care and satisfaction.

As demonstrated in this chapter, Table 1 displays evidence-informed and evidence-based

recommendations. The strength and amount of the available evidence determines whether it is

evidence-based or evidence-informed. The first three recommendations within this table are
 29

evidence-informed because of the lower strength of evidence and lack of adequate research.

More rigorous research is necessary to for these recommendations to qualify as evidence based.

Research for the third recommendation is evidence-based due to the amount of supporting

articles and the higher strength of evidence. Within Table 1, interventions such as the

implementation of modern technology into emergency room protocols and processes, patient

education programs and fast-tracks were addressed. In terms of modern technology, telehealth

programs may be utilized to see non-emergent cases that have presented to the emergency room

to rotate patients in and out of the emergency room faster. In addition to technology, patient

education programs are necessary as patients are often unaware of the severity of their illness,

while patient education programs may also decrease the number of patients presenting to the

emergency department for non-urgent matters. Patient education programs can teach patients

about the severity of illnesses as well as prevention methods for readmission into the hospital.

Fast-tracks have can be used to see patients with non-urgent medical conditions and provide

rapid patient treatment and discharge to decrease overcrowding. The evidence-based

recommendations set forth in Table 1 include the use of advanced triage protocols, such as the

Emergency Severity Index. Proper use of these tools has the ability to identify the most acute

patient cases and decrease patient time in the emergency room by improving the workflow.
 30

Chapter 4

Within the previous chapters, current evidence on practices to prevent emergency

department overcrowding were discussed. Through analysis of this evidence, best practice

recommendations were synthesized to address overcrowding. In Chapter Four of this thesis, the

focus will be on the implementation of these best practice recommendations into the clinical

setting. For implementation and evaluation of these recommendations, the Plan-Do-Study-Act

(PDSA) model will be utilized (Institute for Healthcare Improvement, 2022).

The Plan-Do-Study-Act is a comprehensive tool that is commonly used within hospital

settings, including the emergency department, to execute changes (Institute for Healthcare

Improvement, 2022). Planning is the first step within this cycle and involves the development of

a plan to implement and test a change. After this step, the plan is carried out within the setting

(Do), and the results are observed and analyzed (Study). Lastly, necessary modifications to the

plan are made (Act) and carried out through other PDSA cycles (Institution for Healthcare
 31

Improvement, 2022). The PDSA method is effective within many settings and will be used for

implementation and evaluation of the best practice recommendations specific to this thesis.

Plan

Based on the best-practice recommendations developed, planning will be centered around

the implementation of the Emergency Severity Index Triage protocol. For the purpose of this

thesis, the recommendations will not be implemented; however, an Urban Hospital Emergency

Department will be the setting for the hypothetical implementation of this plan. For the first step

of implementation, it would be necessary to determine the correct stakeholders, including the

emergency department managers, educators, directors, and registered nurses. The feasibility of

this recommendation would be discussed through a compensated meeting with the stakeholders

regarding approval for implementation, cost, the necessary resources for implementation,

education, staff time for education, and the need for IT assistance for revisions to the electronic

health record.

According to the Emergency Nurses Association, it is necessary for emergency nurses to

have a well-developed and comprehensive background to properly triage patients (Emergency

Nurses Association, 2022). The Emergency Nurses Association offers the ENA Triage

Curriculum which incorporates courses specific to the ESI triage method. To implement this

curriculum and develop a budget, it would be necessary to work with the emergency

department’s manager and educator. In addition to the ENA curriculum, an alternative education

method could be developed through collaboration with the ED educational department due to the

high expense of the ENA curriculum. This educational method would be based on

recommendations from the ESI manual and virtual for registered nurses to complete. To

participate in the ENA curriculum for the ESI or the alternative educational method, the
 32

registered nurses would have to meet criteria, including amount of experience in the emergency

department. This specific curriculum and alternative educational method would be offered online

and can be completed by emergency nurses virtually within a sixty-day time frame from the

meeting. After nurses have qualified and passed the ESI triage curriculum, this specific triage

method would be implemented into the emergency department.

For effective implementation, coordination with the informatics team would need to

occur to ensure the electronic health record reflected what is necessary for implementation, such

as the embedment of the ESI into each patient chart and the ability to assign acuity to each

patient. Next, a compensated general staff meeting would be held to present the evidence and

best practice recommendations discovered and developed in this thesis and the changes that they

can expect with implementation of this recommendation.

To determine the results of the implementation process, evaluation would be necessary to

determine the effectiveness of these interventions. ED occupancy, volume, and patient length of

stay are effective indicators of emergency room overcrowding (Badr et. al, 2022). Before

implementation of these interventions, these indicators would be evaluated for a six-month

period. After one year of implementation, these indicators would be evaluated again to determine

the effectiveness of the plan. To effectively evaluate these indicators, it would be essential for

the informatics team to allow the tracking of each patient’s length of stay and the daily ED

volume and occupancy in the electronic health record.

Do

After the previous step is completed to plan for the implementation of best practice

recommendations, the next step in this cycle would involve carrying out the plan. This would

incorporate the meeting with the unit manager and educator about the application of the ENA
 33

triage curriculum or alternative educational method for implementation of the ESI triage

protocol. The ESI will then be implemented for each patient and its effectiveness in decreasing

emergency room overcrowding will be tested. The ESI will be embedded in the electronic health

record for each patient’s chart for the triage nurse to complete. The indicators used for

overcrowding, including patient length of stay, ED occupancy, and ED volume, will be evaluated

to test the effectiveness of the intervention and its planning. To keep track of these indicators, the

electronic health record will collect data on each patient’s length of stay during the

implementation period. The electronic health record will also track ED occupancy and volume

each day based on bed occupancy and availability as well as the number of patients in the

waiting room. As well as this data, feedback and observations from the emergency department

staff will be documented during the implementation period. Feedback from staff will also be

collected through an anonymous survey via email at six months of the implementation period.

Study

In the third step of the PDSA cycle, the data and feedback from the staff with

implementation of the intervention will be analyzed and studied. The difference between the ED

volume, occupancy, and patient length of stay, prior to and after the intervention will be

compared to determine if the ESI triage method helped improved overcrowding in the

emergency department. This data will be collected daily through the electronic health record for

analysis. A decrease in ED volume, occupancy, and patient length of stay would indicate that this

intervention was effective as there was an improvement with overcrowding in the emergency

department. As well as the emergency department indicators, feedback from the staff on issues

with implementation of the ESI triage protocol will be studied to identify common themes that

presented throughout this process. The indicators, verbal feedback from the staff, and survey
 34

feedback from the staff could guide future improvements in the implementation and evaluation

process.

Act

Lastly, the intervention for future implementation will be modified based on the data and

feedback provided throughout the PDSA cycle. These factors would determine the effectiveness

of the intervention and implementation process and what elements require refinement. For

example, if the nurses performing triage with the ESI protocol found that there needed to be a

workflow improvement to effectively implement this intervention, then this improvement would

be considered in future planning. On the contrary, the positive aspects and feedback from the

staff would provide insight on what part of the intervention implementation would stay the same

within the next round of the PDSA cycle.

Summary

It is essential that nurses are implementing best practice recommendations that are up to

date and supported by evidence. For the specific topic of emergency room overcrowding, the ESI

triage protocol is considered an effective method to correctly triage patients and reduce ED

overcrowding based on evidence. For implementation and evaluation of this intervention, the

PDSA cycle is a productive method to test effectiveness of the ESI in an ED and allows for

continuous improvement of the intervention. The ESI is an essential aspect in terms of patient

treatment and decreasing overcrowding in the emergency room; however, this is not the only

intervention that may improve emergency room overcrowding. To elaborate, other improvements

within the workflow of the emergency department as well as patient education are separate

factors to consider about decreasing emergency department overcrowding. In conclusion, nurses

should continue to seek best practice recommendations in the emergency department, such as
 35

implementing the ESI triage method, with the goal of increasing patient care quality and safety

by decreasing emergency department overcrowding.

References

American College of Emergency Medicine. (2021, January). Definition of emergency medicine.

ACEP. Retrieved October 20, 2022, from https://www.acep.org/patient-care/policy-

statements/definition-of-emergency-medicine/#:~:text=Emergency%20medicine%20is

%20the%20medical,of%20unforeseen%20illness%20or%20injury.

Andrews, H., & Kass, L. (2018). Non-urgent use of emergency departments: populations most

likely to overestimate illness severity. Internal and Emergency Medicine, 13(6), 893–900.

https://doi.org/10.1007/s11739-018-1792-3

Badr, S., Nyce, A., Awan, T., Cortes, D., Mowdawalla, C., & Rachoin, J. S. (2022). Measures of

emergency department crowding, a systematic review. How to make sense of a long

list. Open Access Emergency Medicine: OAEM, 14, 5–14.

https://doi.org/10.2147/OAEM.S338079
 36

Barker, A., Cameron, P., Flicker, L., Arendts, G., Brand, C., Etherton-Beer, C., Forbes, A.,

Haines, T., Hill, A. M., Hunter, P., Lowthian, J., Nyman, S. R., Redfern, J., Smit, V.,

Waldron, N., Boyle, E., MacDonald, E., Ayton, D., Morello, R., & Hill, K. (2019).

Evaluation of RESPOND, a patient-centered program to prevent falls in older people

presenting to the emergency department with a fall: A randomised controlled trial. PLoS

Medicine, 16(5), e1002807. https://doi.org/10.1371/journal.pmed.1002807

Chrusciel, J., Fontaine, X., Devillard, A., Cordonnier, A., Kanagaratnam, L., Laplanche, D., &

Sanchez, S. (2019). Impact of the implementation of a fast-track on emergency department

length of stay and quality of care indicators in the Champagne-Ardenne region: a before-

after study. BMJ Open, 9(6), e026200. https://doi.org/10.1136/bmjopen-2018-026200

De Freitas, L., Goodacre, S., O'Hara, R., Thokala, P., & Hariharan, S. (2018). Interventions to

improve patient flow in emergency departments: an umbrella review. Emergency Medicine

Journal: EMJ, 35(10), 626–637. https://doi.org/10.1136/emermed-2017-207263

Emergency Nurses Association (2022). ENA’s Triage Offering.

https://www.ena.org/enau/educational-offerings/triage

Emergency severity index (ESI): A triage tool for emergency department. AHRQ. (n.d.).

Retrieved October 31, 2022, from https://www.ahrq.gov/patient-safety/settings/emergency-

dept/esi.html

HealthCare. (n.d.). Emergency medical condition - glossary. Glossary | HealthCare.gov.

Retrieved October 20, 2022, from https://www.healthcare.gov/glossary/emergency-

 37

medical-condition/#:~:text=An%20illness%2C%20injury%2C%20symptom%20or,away

%20to%20avoid%20severe%20harm.

Holman H. R. (2020). The relation of the chronic disease epidemic to the health care crisis. ACR

open rheumatology, 2(3), 167–173. https://doi.org/10.1002/acr2.11114

Hong, R., Sexton, R., Sweet, B., Carroll, G., Tambussi, C., & Baumann, B. M. (2015).

Comparison of START triage categories to emergency department triage levels to

determine need for urgent care and to predict hospitalization. American Journal of

Disaster Medicine, 10(1), 13–21. https://doi.org/10.5055/ajdm.2015.0184

Institute for Healthcare Improvement (2022). PDSA Worksheet.

https://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

Maleki, M., Fallah, R., Riahi, L., Delavari, S., & Rezaei, S. (2015). Effectiveness of five-level

emergency severity index triage system compared with three-level spot check: an Iranian

experience. Archives of Trauma Research, 4(4), e29214. https://doi.org/10.5812/atr.29214

McHugh, C., Krinsky, R., & Sharma, R. (2018). Innovations in Emergency Nursing:

Transforming Emergency Care Through a Novel Nurse-Driven ED Telehealth Express

Care Service. Journal of Emergency Nursing, 44(5), 472–477.

https://doi.org/10.1016/j.jen.2018.03.001

Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency

department crowding: A systematic review of causes, consequences and solutions. PloS

One, 13(8), e0203316. https://doi.org/10.1371/journal.pone.0203316

 38

Rezaei, F., Yarmohammadian, M. H., Haghshenas, A., & Tavakoli, N. (2017). Overcrowding in

emergency departments: A review of strategies to decrease future challenges. Journal of

Research in Medical Sciences, 22(1), 23. https://doi.org/10.4103/1735-1995.200277

Sandhu, P., Shah, A. B., Ahmad, F. B., Kerr, J., Demeke, H. B., Graeden, E., Marks, S., Clark,

H., Bombard, J. M., Bolduc, M., Hatfield-Timajchy, K., Tindall, E., Neri, A., Smith, K.,

Owens, C., Martin, T., & Strona, F. V. (2022). Emergency department and intensive care

unit overcrowding and ventilator shortages in US hospitals during the COVID-19

pandemic, 2020-2021. Public health reports (Washington, D.C.: 1974), 137(4), 796–802.

https://doi.org/10.1177/00333549221091781

Soster, C. B., Anschau, F., Rodrigues, N. H., Alves da Silva, L.G., Klafke, A. (2022). Advanced

triage protocols in the emergency department: a systematic review and meta-analysis. Rev

Lat Am Enfermagem. https://doi.org/10.1590/1518-8345.5479.3511

Tasi, M. C., Baymon, D. M. E., Temin, E. S., Zheng, H., Lehman, K. M., Baccari, B., … Yun, B.

J. (2021). Evaluation of process IMPROVEMENT interventions on Handoff times between

the emergency department and Observation Unit. The Journal of Emergency Medicine,

60(2), 237–244. https://doi.org/10.1016/ja.jemermed.2020.10.002

Turale, S., & Nantsupawat, A. (2021). Clinician mental health, nursing shortages and the

COVID-19 pandemic: crises within crises. International Nursing Review, 68(1), 12–14.

https://doi.org/10.1111/inr.12674

Villa, S., Weber, E. J., Polevoi, S., Fee, C., Maruoka, A., & Quon, T. (2018). Decreasing triage

time: effects of implementing a step-wise ESI algorithm in an EHR. International journal

 39

for quality in health care: journal of the International Society for Quality in Health

Care, 30(5), 375–381. https://doi.org/10.1093/intqhc/mzy056

Young, C., & Horton, J. (2021). Treat and Release for Patients Requiring Emergency Medical

Services. Canadian Agency for Drugs and Technologies in Health.

 Yuzeng, S., & Hui, L. L. (2020). Improving the wait time to triage at the emergency

department. BMJ Open Quality, 9(1), e000708. https://doi.org/10.1136/bmjoq-2019-

000708