Running head: CRITICAL APPRAISAL OF LITERATURE FOCUSED ON
Critical Appraisal of Literature Focused on Throughput in the Emergency Department
Cheryl Miller & Lori Majeske
Ferris State University
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CRITICAL APPRAISAL OF LITERATURE FOCUSED ON
Abstract
The following literature review provides current evidence of the challenges surrounding
overcrowding in the emergency department, and possible creative solutions designed to reduce
waiting times, improve patient care and satisfaction, and hospital throughput. It includes a
critical appraisal of current literature evidence, and a project proposal plan for further research.
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Critical Appraisal of Literature Focused on Throughput in the Emergency Department
In our observation as nurses, emergency room overcrowding and extended waiting times
can negatively affect patient care, and overall patient satisfaction results. Our research goal is to
implement best practice guidelines through development of a model for care that will support
efficient and optimal patient care in the hospital emergency department. The following literature
review supports our project proposal by providing timely and evidenced based examples of
proposed interventions focused on improving patient care in the emergency department setting.
Each literature source has individual merit and builds a body of evidence to support our research
proposal by outlining some of the interventions currently under consideration.
Impact of Rapid Entry and Accelerated Care at Triage on Reducing Emergency
Department Patient Wait Times, Lengths of Stay, and Rate of Left Without Being Seen
In their systematic review article Impact of Rapid Entry and Accelerated Care at Triage on
Reducing Emergency Department Patient Wait Times, Lengths of Stay, and Rate of Left Without
Being Seen (2005), Chan, Killeen, Kelly and Guss introduced a rapid entry and accelerated care
at triage (REACT) process aimed specifically at reducing the number of patients who leave the
emergency department prior to being evaluated by a physician.
Critical Appraisal
This is an example of a quantitative quasi-experimental research study. The title of the
report explains the purpose of the study and is consistently written. The purpose of the study is
prominently displayed and logical. The author’s qualifications are consistent with the study
proposal as they are all licensed medical professionals. The research study results and
conclusions are clearly documented, and prominently displayed on the title page of the study.
These authors report a significant decrease in leave before being seen frequency, patient wait
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times, and overall length of stay. These research findings directly support the proposed study
objectives.
Validity
Chan, Killeen, Kelly and Guss (2005) chose a quasi-experimental research study design
that seeks to determine the cause and effect relationship between the applied interventions
known as REACT upon ambulatory patients presenting to an urban hospital emergency
department. The interventions include patient identification tracking, integrated computer
interfaces, immediate placement of patients in open beds, and physician directed ancillary testing
and care when no beds were available. The sample size of 36,000 is large, and includes all
ambulatory patients presenting for care. As is typical with this type of study, there is no
randomization of research subjects. These researchers utilized a historical comparison group
within the same institutional setting, which they identified as an urban academic emergency
room setting. The major strengths of utilizing a quasi-experimental approach is that it is practical
to conduct, more likely to be acceptable to participants, and can be generalized to the general
population (Ross-Kerr & Wood, 2011). We agree that it is an appropriate choice, as it would be
difficult to randomize the applied interventions to assigned groups within this type of setting.
Major weaknesses include the passage of time, and the challenge of limiting all possible
extraneous variables that may affect study results (Ross-Kerr & Wood, 2011). It is important to
note that Chan, Killeen, Kelly and Guss (2005) include current research evidence within their
study that supports their claim that most patients leave prior to being seen by a physician due to
increased waiting times. This serves to strengthen the study results as it provides proof of
internal validity, a strong statistically relationship between the independent and dependent
variables, as well as, clear evidence of the true cause and effect relationship identified within the
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study (Polit & Tatano-Beck, 2008). The authors attempted to gain research control by recording
data six months prior to instituting the proposed changes, and re-measuring data again during a
similar six month period, one year later in order to reduce the Hawthorne Effect. Ross-Kerr and
Wood (2011) note that this important step may enhance interpretability of study findings, and
helps reduce the risk of sampling bias.
Core measures include average wait times, emergency room length of stay, emergency
department census, and overall admission data. Outcome measures and primary data analysis
was obtained by utilizing the hospital medical records database which provided time stamps
measurements for overall census, patients who leave before being seen, length of stay, and wait
times. Descriptive statistics were performed using a computerized statistical software package,
and included use of the central tendency of the sample, and confidence intervals. These
descriptive statistics further validate the results of this study. In addition, because this data is
applicable and transferable to emergency practice settings, we find that it meets the criteria
defined by Polit and Tatano-Beck (2008) for external validity. In addition, Chan, Killeen, Kelly,
and Guss (2005) reported a significant decrease in leave before being seen frequency after
application of the proposed interventions. Documentation of the research study results and
conclusions are clearly, directly supporting the study objectives.
One weakness of this study, as identified by the research authors, is that some results may
not be transferrable to all emergency departments. However, they note that overall improvements
in registration delays and computer integration in the emergency department, could serve as a
model for other emergency rooms settings. We agree. Additional strengths include a strong
presentation of findings including the use of tables and graphs, use of evidence based literature
that supports the overall purpose of this study and is cited appropriately throughout their review.
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Usefulness in Clinical Practice
The research study results reported by Chan, Killeen, Kelly, and Guss (2005) are based
upon a variety of interventions that utilize upgrades of information technology, bar coding,
software integration, and changes in staff culture, and specific processes changes. As previously
stated, although these results may not be transferrable to all emergency departments, overall
improvements in registration delays and computer integration in the emergency department,
could serve as a model for other emergency rooms settings. Adoption of these proposed changes
in other health care institutions could positively affect patient safety, overall patient satisfaction,
and improved access to care by allowing for better coordination of patient care services. The end
result of this coordination, are partly dependent upon an effective triage system for emergency
room patients, as illustrated in the following study.
Telephone consultation and triage: effects on health care use and patient satisfaction
In the systematic review by Bunn, Byrne and Kendall (2009), the use of telephone
consultation as a means of determining the need for further treatment by either a General
Practitioner (GP) or Emergency Department (ED) visit is studied. The review considers safety,
service usage and patient satisfaction, adverse events and compared consultations by different
healthcare workers.
Critical Appraisal
This study utilizes a quasi-experimental research design as described by Polit and Beck
(2008). This systematic review uses several types of studies, including controlled random trials
and interrupted studies. The resulting review is lengthy and describes intervention summaries as
determined through the various studies. This type of review although useful, is difficult to
summarize the entire content.
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Validity
In order to accurately analyze data qualities in quantitative studies, several factors are
involved (Polit & Tatano-Beck, 2008). The reviewers did not use a meta-analysis to present the
findings, but rather a narrative summary. This is due to the heterogeneity of the study methods.
The variables of this study are congruent between the introduction and methodology section of
this paper. There is noted analysis error reported by the authors in at least one study. The data
extraction and quality assessment was well documented. Data quality was assessed using a
modified version of the EPOC checklist. Overall scores of each study were not given. Reliability
methods discussions are tabulated using appropriate methods for each type of study. These
include P values; slope regression lines were used for interrupted time studies. The reviewers’
document specific information regarding each study concluding the study may have had
inappropriate techniques. Cautious interpretation of the findings is recommended due to the
variability in interventions and lack of power of some studies. The possibility exists that not all
studies could be identified, due in part to the vast terminology used. An adverse effect of
validity may occur because not one study met all of the methodological criteria on the EPOC
checklist. In addition, selection biases may threaten validity. Sensitivity and specificity are not
specifically discussed, only that this review supports previous estimates of calls able to be
handled at least fifty percent of the time.
Usefulness in Clinical Practice
Using additional resources, including advanced practice roles, to decrease patient wait
times may be beneficial. The need for a communication system to aid in the determination of
additional treatment can reduce ED wait times as well as increase the qualitative measure of
patient satisfaction. Further research would be needed to ascertain the need for follow up
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treatment or a resulting decrease in quality of care if the treatment advice is not accepted. The
following study outlines the impact of efficient coordination of patient care services and its
impact upon providing safe and efficient patient care.
The Role and Impact of the Physician Assistant
The review by Doan, Sabhaney, Kissoon, Sheps, & Singer (2011) examines the role and
impact of the Physician Assistant (PA) in relation to department efficiency and patient
satisfaction. This review was not intended to determine the use of the nurse practitioner (NP), in
fact, studies using NPs alone, were excluded from the study.
Critical Appraisal
This study used non randomized studies and is considered a quantitative methodology
demonstrating before and after results of implementing the use of PAs to increase patient
satisfaction and reduce wait times resulting in efficiency in the emergency department. The
authors of this review are medical professionals, and consulted experts if disagreements were
found in the data. The review is clearly explained in the title and is consistent throughout the
review. Results are clearly documented and evident in the abstract. According to the findings of
this review, there is limited evidence as to whether PAs improve the workflow or are cost
effective.
Validity
Congruence of variables associated with this study are found consistently throughout the
review. The studies do not delineate any specific type of measurement used for operational
definitions. The review does address a level of agreement using Kappa statistic and Quality
Assessment Tool for Quantitative Studies Method. The Kappa score is 0.83, with 1.00 being the
highest, differing opinions exist but some concensus to 0.60 minimally with 0.75 and above as
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excellent (Polit & Tatano-Beck, 2008, p. 456). The factor analysis used in this study attempts to
deduce the variables of prevalence, guideline and policies, roles and task assignments, quality of
care, use, ED flow and costs, and physician attitudes. The last variable includes a crosssectional survey of senior ED residents acting as patients. These patients determined their level
of satisfaction based on the severity of their supposed illness and willingness to be treated by a
PA. The methodological quality of these studies is rated as weak with low responses. Two tables
are included in the study succinctly displaying study methods and outcomes measures with
results. These tables compare the factors of clinical decision and patient management and
procedure performance between physicians and PAs. The generalizability of the data is limited.
The methodological quality is reported as weak to moderate, with specific qualities listed. These
include small number of participants studies, and comparison baselines not adequately adjusted.
Usefulness in Clinical Practice
The use of advanced practice professionals in an emergency department setting can
increase patient throughput, thereby increasing patient satisfaction scores and lead to a positive
budgetary outcome by decreasing overhead expenses of physician or resident salaries and
increasing volume of visits annually. If current trends continue with associated indigent care on
the rise, patients may still be able to receive treatment in a timely manner while reducing
associated issues seen with co-morbidities in this patient population. The role of nursing in
emergency care settings also impacts overall efficiency and throughput, as illustrated in the
following research study.
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Fast Track to Efficiency
In her journal article Fast Track to Efficiency (2011), Handley summarizes how a new
nursing role, an acute medicine assessment nurse, was created to improve patient care and reduce
the amount of time that patients spend in the emergency department.
Critical Appraisal
The title is clearly written and explains the general nature of the topic to be discussed. The
author is a freelance writer who interviewed nursing staff and physicians regarding their role in
conducting this research and their results. A list was compiled of the top sixteen medical
conditions requiring treatment, and nurses developed new pathways designed to improve patient
triage and throughput. Unstable patients were directed to the emergency department, while stable
patients were directed to the medical assessment unit. Because of these nursing initiatives,
patient wait times are reported as being reduced from two hours to twenty minutes.
Validity
This journal article is a secondary source document, as described by Polit and Tatano-Beck
(2008). It is interesting to read, and current. The overall study results sound promising, and may
offer some insight into the benefits of early triaging of patients. However, it does not provide
information regarding methodology utilized or concrete use of data collection. The use of this
information is therefore limited.
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Usefulness in Clinical Practice
This study may offer insight for health care professionals who are engaged in process
improvement initiates by offering potential creative options for triaging emergency room
patients, and serve as an impetus for encouraging further research in this area. Engaging
emergency room staff in this process can be beneficial as presented in the following study
focused on throughput efficiency.
Rapid Assessment and Disposition; Applying LEAN in the Emergency Department
In the journal article Rapid Assessment and Disposition: Applying LEAN in the
Emergency Department (2009), Eller explains how they instituted LEAN principles within their
metropolitan adult acute care hospital emergency department utilizing a quantitative quasiexperimental study design.
Critical Appraisal
The title is clearly written, describes the major goals of rapid assessment and disposition,
and is prominently displayed. The research question proposed by Eller (2009) is clear written,
logical, and aligned with their final research study results. The purpose of the study is explained
in the abstract, which outlines the main goals as reducing emergency department length of stay,
reducing diversion, and reducing the number of patients who leave before being evaluated by a
physician. This author’s qualifications support and enhance this research study, as she is a
bachelor’s prepared licensed registered nurse, clinical educator, and project lead for LEAN
implementation in the emergency department. Study results appear in the abstract portion of this
journal article using appropriate statistical data. Eller (2009) reports that application of the
LEAN principles had a substantial impact on reducing average length of stay, diversion, and
overall number of patients who left prior to being treated.
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Validity
The identified research design utilized by Eller (2009) is a quasi-experimental
research approach, which seeks to determine what relationship applying LEAN principles will
have upon average length of stay, diversion, and patients who leave prior to being evaluated by a
physician. The interventions utilized include education, workplace organization, and
standardization to reduce process variances in registration, triage, patient placement, physician
assessment, and testing results. The sample size is large consisting of all patients presenting for
care in the emergency department averaging a reported 32,000 annually. This is adequate.
Randomization was not utilized in this research study, which is consistent, and appropriate for
this type of setting. Baseline historical data was compiled in 2007 utilizing internal hospital
metrics that included emergency department length of stay, diversion time, and the number of
patients who left before receiving treatment. Data collection and measurement results are
presented in graphic form, and in paragraph form utilizing percentages. Eller (2009) ranked
baseline results by comparing the data to a study by the Centers for Disease Control (CDC),
which adds internal validity, and supports the goals for this study. In addition, the use an
emergency severity index (ESI) was used in the data collection process. This is an international
standardized measurement, which provides additional credibility to the study data. The following
outcome data was monitored and reported on a daily and monthly basis: emergency department
length of stay, percentage of patients who left prior to being treated, total hospital diversion,
number of radiology patients, length of stay, and emergency department volume. Eller (2009)
reported sustained reductions in three of the above measurements at six months, one year, and
two years, which further validates the study results. Study results are presented in table form,
and adequately discussed. The data methods are described sufficiently, and a thorough analysis
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was done through comparison of baseline data and post intervention data results. Research
results are suggestive of a positive correlation between LEAN initiatives and a reduction in
emergency department length of stay, percentage of patients who left prior to being treated, and
total hospital diversions. However, there are no study limitations identified by the author, which
clearly weakens the study results. Polit and Tatano-Beck (2008) state that researchers need to
understand possible study limitations, take precautions to either counteract them, or consider
them when interpreting the data. Limitations common to this type of study includes the
Hawthorne Effect and the passage of time (Polit & Tatano-Beck, 2008). Eller (2009) cites all
relevant sources appropriately in the research study.
Usefulness in Clinical Practice
The research study results reported by Eller (2009) are current, evidence based, well
written and appear to be applicable to other emergency department settings. The LEAN
initiatives discussed appear to offer value to understanding the issues associated with
overcrowding in the emergency department, and possible solutions for consideration. These
results may serve as a guideline for future research studies focused on reducing overcrowding in
the hospital emergency department. Overall treatment time and measures of emergency room
overcrowding are further reviewed in the following study.
The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment
Time
The journal article in the February 2011 volume of the Annals of Emergency Medicine
discuss a retrospective nested cohort study of patients receiving treatment at an academic
emergency department between January 2007 and August 2009 (Retezar, Bessman, Ding, Zeger,
& McCarthy, 2011). This study attempts to determine if initiating standing orders for four
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common diagnosis decreases the length of stay. The study concludes a substantial reduction in
length of stay while further evaluation is warranted to include additional diagnoses.
Critical Appraisal
This nested cohort study analyzing data retrospectively ascertains the answer to the
proposed question “Do triage standing orders decrease patient length of stay defined as room
placement through disposition?” The study question was clearly explained in the abstract of the
article and presented clearly throughout. The study authors are colleagues in an academic based
emergency department and are all medical professionals. The conclusions are clearly
documented with pertinent summary clearly accessible. The emergency department described in
the study had an annual volume of approximately 57,000 visits with 33 acute care rooms and 8
urgent care rooms.
Validity
There is congruence in the variables assessed throughout the review. The data extracted
was both from an electronic source and from the retrospective review of charts revealing data
that was scanned after disposition. A limited amount of data was retrieved using manual
methods. To ascertain the validity of the elements, a random sample was compared. The results
show a high reliability of the factor. The study participants were categorized into three groups, a
propensity score calculating a likelihood score was noted. This score assisted the researchers to
retain variables if the regression coefficient was less than .05. This measurement describes the
specificity and sensitivity (Polit & Tatano-Beck, 2008, p. 471). Analysis comparisons using
quintiles are described. A succinct table displaying the distribution of variables according to
placement within the three participant groups is beneficial to readers. Limitations of the research
are presented. These limitations include patients not randomized to treatment assignments, the
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triage nurse determined discretion of order usage, and the groups could not be balanced on
unmeasured confounders such as presence of co-morbidities. The volume of compliance of use
of orders was done by volume not individually. The magnitude of the effect may be reduced.
The generalizability of the study is also limited, since it was used at only one facility. An
appropriateness of order sets was not evaluated, nor was the effect on further orders needed.
Morbidity and mortality were not determined based on effect of standing orders used.
Usefulness in Clinical Practice
This research could assist in increasing efficiencies in an emergency department setting
because of their time saving ability. In addition, determining which standing orders to initiate can
control factors associated with overall patient satisfaction. However, cost assessments will still
be a crucial element, as will the effect of unnecessary testing. Efficient order entry has the ability
to positively impact emergency room throughput, as illustrated in the following study.
Impact of computerized physician order entry on ED patient length of stay
Length of stay in an emergency department setting can assist in the measurement of
practice efficiency and patient satisfaction. Computerized Patient Order Entry (CPOE) as
studied by Retezar, Bessman, Ding, Zeger, and McCarthy, (2011) attempts to determine a
favorable association with this additional factor, as it has shown much promise in similar critical
care settings.
Critical Appraisal
The study is current, being published this year. The researchers could not determine a
similar study involving the factors of emergency departments and CPOE. Similar studies were
found associating treatment for patients receiving thrombolysis. The hypothesis was clearly
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written and discussed thorughout the review. The design uses written order entry as a pretest
variable, with computerized orders as post test.
Validity
The research method chosen for the study was a before and after design. This is
considered a quantitative design study, more commonly referred to as pre-test/post-test design
(Polit & Tatano-Beck, 2008, p. 261). The incongruence between variables conceptualized and
operationalized is noted. Nurse staffing hours were not taken into consideration. Other
unmeasured covariates are likely to affect patient length of stay. The onset of computerized
order entry took place between the time frames of pre and post test. This may assist in assuring
any validity concerns with user education are not applicable. Student t test compared variables
with multiariable linear regression analysis testing for association between the variables.
Adjustments for variables were noted. A table succinctly describes the affect of pre and post test
results by patient demographic and clinical covariates. The independent inverse association is
shown between the variable of discharged and patient admitted. This association confirms the
reliability of the data (Polit & Tatano-Beck, 2008, p. 196). The limitations of this study are
revealed. The generalizability may be limited as this study took place at only one facility. The
baseline length of stay was comparatively long. The data set as previously stated, did not include
nurse staffing hours, but physician hours were considered. There are system-, patient- and
provider-related variables not measured including patient acuity, seasonal factors and test
processing times. Average daily census was lower in post test than in pretest, which may
confound relationships. Many other factors affecting emergency department efficiencies were
not measured such as quality of care or error rates.
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Usefulness in Clinical Practice
Interventions designed to decrease length of stay in an emergency department setting can
attribute to other favorable affects. Increasing patient satisfaction, decreasing the number of
patients leaving without being seen and decreasing ambulance diversion are concluded. Multiple
methods can be utilized for research analsysis as demonstrated by the following study.
Emptying the Corridors of Shame:Organizational Lessions From England’s 4-Hour
Emergency Throughput Target
England’s National Health Service mandated patients need to be treated or discharged
home within four hours of arrival in 2005 (Weber, Mason, Carter, & Hew, 2011). This target has
been gradually instituted at hospitals, receiving financial rewards for meeting thresholds. The
meeting of these targets is the responsibility of the administration of the facility. The
improvement of clinical outcomes is also a benefit, but some are concerned with the
unintentional consequence of facilities reporting false information. It is noted that change is
difficult and the qualitative study attempts to provide insight to facilities meeting the imposed
target.
Validity
A mixed methods study over a three month period was employed. The participants
were categorized into three groups, low, mid and high level performers as determined by
published results from the third quarter in the previous year. Sample size was determined by
saturation, that is samples are obtained until no new information emerged from data analysis
(Polit & Tatano-Beck, 2008, p. 357). Methods using both face-to-face and telephone interviews
were conducted. The questions were open-ended and semistructured, the use of open-ended
questions can result in a richer understanding of the topic of interest (Polit & Tatano-Beck, 2008,
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p. 415). The data was categorized into themese by the researchers, this use of data collection can
then quantify the qualitative information (Polit & Tatano-Beck, 2008, p. 374). After
interviewing coding by two investigators, interrater reliability improved after discussion between
the two investigators. Further concurrence of the findings were reached by using consultants
who were not part of the study and viewed blinded identity information. A table is presented
demonstrating results between the variables using themes. Validity may be decreased as this
study took place at only one point in time. Further validity may be biased due to the response
bias of interviewees only being pooled from the respondents of the quantitative portion that
occurred prior to this study. The investigators also discuss other qualitative studies exploring
similar variables and enhance their analysis by comparing effects. This can assist with validating
findings objectively (Polit & Tatano-Beck, 2008, p. 133)
Uefulness in Clincal Practice
The overall result of the study concludes that achieving a target is largely impacted on the
implementation of the change. This information is essential to researchers as it can assist in
developing hypotheses and determining types of research needed.
Conclusion and Plan
Based upon our review of these research studies, the interventions of rapid and efficient
triage of patients, phone consultation, nursing and provider roles, streamlining of information
technology, standing orders, and computerized order entry may have a positive impact upon
overcrowding and patient throughput in the emergency department. In addition, as these studies
illustrate, the identified problem of overcrowding in the emergency department is complex, and
requires an in-depth analysis. Therefore, further research investigation of other possible
interventions is warranted, so that solutions can be forthcoming.
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Our research proposal and plan includes developing a patient care model to reduce
emergency department length of stay and increase overall patient satisfaction. The use of several
methods will need to be diligently researched, with considerations for value added processes and
economic strategies. Senior administration will be consulted to determine the extent of our
proposal. Knowledge gained from this study will be evaluated for both short and long-term
impact upon patient throughput, reduced length of stay, and overall patient satisfaction measures.
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