uu.seUppsala University Publications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Patient Safety in the Emergency Department: Culture, Waiting, and Outcomes of Efficiency and Quality
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables.

I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements.

II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up.

III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. The median length of stay was 158 minutes for physician-led team triage compared with 243 and 197 minutes for nurse–emergency physician and nurse–junior physician triage, respectively. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage.

IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate.

In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. , 100 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1009
Keyword [en]
Emergency department, physician, triage, teamwork, HSOPS, grounded theory, waiting, patient safety, culture
National Category
Other Medical Sciences not elsewhere specified
Research subject
Health Care Research
Identifiers
URN: urn:nbn:se:uu:diva-223987ISBN: 978-91-554-8971-7 (print)OAI: oai:DiVA.org:uu-223987DiVA: diva2:714718
Public defence
2014-08-29, Aulan, Ingång 21, Västmanlands sjukhus, Västerås, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2014-05-28 Created: 2014-04-29 Last updated: 2014-06-30Bibliographically approved
List of papers
1. The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles: a repeated cross-sectional study
Open this publication in new window or tab >>The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles: a repeated cross-sectional study
Show others...
2014 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, 296- p.Article in journal (Refereed) Published
Abstract [en]

Background: Patient safety is of the utmost importance in health care. The patient safety culture in an institution has great impact on patient safety. To enhance patient safety and to design strategies to reduce medical injuries, there is a current focus on measuring the patient safety culture. The aim of the present study was to describe the patient safety culture in an ED at two different hospitals before and after a Quality improvement (QI) project that was aimed to enhance patient safety. Methods: A repeated cross-sectional design, using the Hospital Survey On Patient Safety Culture questionnaire before and after a quality improvement project in two emergency departments at a county hospital and a university hospital. The questionnaire was developed to obtain a better understanding of the patient safety culture of an entire hospital or of specific departments. The Swedish version has 51 questions and 15 dimensions. Results: At the county hospital, a difference between baseline and follow-up was observed in three dimensions. For two of these dimensions, Team-work within hospital and Communication openness, a higher score was measured at the follow-up. At the university hospital, a higher score was measured at follow-up for the two dimensions Team-work across hospital units and Team-work within hospital. Conclusion: The result showed changes in the self-estimated patient safety culture, mainly regarding team-work and communication openness. Most of the improvements at follow-up were seen by physicians, and mainly at the county hospital.

Keyword
Patient safety, Patient safety culture, Patient safety climate, Quality improvement, Team-work
National Category
Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:uu:diva-223979 (URN)10.1186/1472-6963-14-296 (DOI)000339219600001 ()
Available from: 2014-04-28 Created: 2014-04-28 Last updated: 2017-12-05Bibliographically approved
2. Waiting management at the emergency department - a grounded theory study
Open this publication in new window or tab >>Waiting management at the emergency department - a grounded theory study
2013 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, 95- p.Article in journal (Refereed) Published
Abstract [en]

Background: An emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED. Methods: Qualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data. Results: The main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up. Conclusion: To manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.

Keyword
Waiting, Management, Emergency department, Grounded theory, Focus group, Participant observation
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-200118 (URN)10.1186/1472-6963-13-95 (DOI)000317462000002 ()
Available from: 2013-05-21 Created: 2013-05-20 Last updated: 2017-12-06Bibliographically approved
3. Physician-led team triage based on lean principles may be superior for efficiency and quality?: A comparison of three emergency departments with different triage models
Open this publication in new window or tab >>Physician-led team triage based on lean principles may be superior for efficiency and quality?: A comparison of three emergency departments with different triage models
Show others...
2012 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 20, no 1, 57- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

The management of emergency departments (EDs) principally involves maintaining effective patient flow and care. Different triage models are used today to achieve these two goals. The aim of this study was to compare the performance of different triage models used in three Swedish EDs. Using efficiency and quality indicators, we compared the following triage models: physician-led team triage, nurse first/emergency physician second, and nurse first/junior physician second.

METHODS:

All data of patients arriving at the three EDs between 08:00- and 21:00 throughout 2008 were collected and merged into a database. The following efficiency indicators were measured: length of stay (LOS) including time to physician, time from physician to discharge, and 4-hour turnover rate. The following quality indicators were measured: rate of patients left before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days.

RESULTS:

Data from 160,684 patients were analysed. The median length of stay was 158 minutes for physician-led team triage, compared with 243 and 197 minutes for nurse/emergency physician and nurse/junior physician triage, respectively (p < 0.001). The rate of patients left before treatment was completed was 3.1 % for physician-led team triage, 5.3 % for nurse/emergency physician, and 9.6 % for nurse/junior physician triage (p < 0.001). Further, the rates of unscheduled return within 24 hours were significantly lower for physician-led team triage, 1.0 %, compared with 2.1 %, and 2.5 % for nurse/emergency physician, and nurse/junior physician, respectively (p < 0.001). The mortality rate within 7 days was 0.8 % for physician-led team triage and 1.0 % for the two other triage models (p < 0.001).

CONCLUSIONS:

Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators, compared with the two other models.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-181961 (URN)10.1186/1757-7241-20-57 (DOI)000310207200001 ()22905993 (PubMedID)
Available from: 2012-10-02 Created: 2012-10-02 Last updated: 2017-12-07Bibliographically approved
4. Change of triage model to physician-led team triage explains better quality and efficiency at one emergency department.
Open this publication in new window or tab >>Change of triage model to physician-led team triage explains better quality and efficiency at one emergency department.
Show others...
(English)Article in journal (Refereed) Submitted
National Category
Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:uu:diva-223980 (URN)
Available from: 2014-04-28 Created: 2014-04-28 Last updated: 2014-06-30

Open Access in DiVA

fulltext(4938 kB)1514 downloads
File information
File name FULLTEXT01.pdfFile size 4938 kBChecksum SHA-512
492618bb0341de88f8a020fe4df77d1b0ccada18c3cf9e2dcf01104a9354cf7be5cdb225b78a5b5e218c0a125d60244eff60bca53c4e8282a969642e3f118be5
Type fulltextMimetype application/pdf
Buy this publication >>

By organisation
Department of Surgical Sciences
Other Medical Sciences not elsewhere specified

Search outside of DiVA

GoogleGoogle Scholar
Total: 1514 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 2422 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf