The impact of an Emergency Department ambulance offload nurse role: A retrospective comparative study
Introduction
Emergency Department (ED) overcrowding is a common issue noted internationally [1], [2], [3] that can impact on the ability to deliver safe, timely, quality care. ED overcrowding has been described as a situation where patient care is hindered due to large numbers of patients exceeding the department’s ability to provide adequate physical space and provision of sufficient staff to meet patients’ needs [4]. Negative outcomes such as increased length of stay (LOS) in EDs and hospital [5], [6], [7], [8], and increased risk of in-hospital mortality [1], [2], [3] have been linked to ED overcrowding.
An emerging issue that has been linked to ED crowding (and reflective of a broader system’s issue) is ambulance offload time (AOT) delay, also known as ambulance ramping. AOT delay refers to the extended time (usually >15 min or 30 min) [9], [10] from ambulance arrival at the ED to the time the patient is transferred onto an ED bed/chair. Of the 7.2 million ED presentations in Australia, around one in four arrived by ambulance in 2013–14 [11]. Previous research has indicated that approximately 16% of ambulance arrivals experience AOT delay of >30 min [12]. Some patient outcomes (including ED LOS) are better for those with an AOT less than 15 min [13] or 30 min [12] with an AOT of more than 30 min identified as a predictor of an extended ED LOS of more than 4 h [12]. Other reports indicate patient safety [14], patient privacy [15] and the ability for ambulances to return to the field [16] may be compromised when AOT delays occur. The economic impact to the health and ambulance services of AOT delays have been noted [10], however formal economic analyses have not, as far as we are aware, emerged.
Recommendations to minimise ED crowding, plan for times of increased ED workload and reduce AOT delays have emerged and include the introduction of a nursing role to assist waiting patients [17], [10], ensuring triage occurs on arrival to the ED, that no patient returns to an ambulance after triage, the establishment of a high-level Emergency Services Management Committee to provide policy advice to the Minister and the nomination of an accountable person at the Executive Director level (or higher) to be responsible for ED access issues [10]. Little formal research evaluating the impact and effect of these recommendations exist. The temporary implementation of one of these recommendations (a triage competent registered ED nurse designated to rapidly assess and commence treatment for patients arriving to the ED by ambulance) provided an opportunity to investigate the impact of this initiative. The aim of this study was to identify if patient and service delivery improvements (particularly time to be seen by a clinician) occurred with the implementation of the Emergency Department Ambulance Offload Nurse (EDAOLN) role.
The EDAOLN role was introduced in one Australian ED in 2012 and operated 24 h a day, seven days a week for a 39-day trial period. The role was performed by triage competent ED nurses; that is, senior nurses trained in the assignment of Australian Triage Scale (ATS) categories. These ATS categories are an indicator of the degree of urgency for treatment where the allocated category number corresponds to a timeframe in which patients should be seen by a doctor [18]. The EDAOLN role was dedicated to ambulance arriving patients. Another nurse/s would triage patients arriving by other means of transport allowing the EDAOLN to focus on ambulance arriving patients.
Following initial assessment by the EDAOLN, patients who arrived by ambulance and were triaged as Category 1 or 2 were promptly offloaded onto an ED stretcher as they should be seen immediately (ATS 1) or within 10 min (ATS 2) by a doctor or nurse working under the clinical supervision of a doctor [18]. Those triaged as Category 3 (should be seen within 30 min of arrival), 4 (should be seen within 60 min of arrival), or 5 (should be seen within 120 min of arrival), [18] were either offloaded onto an ED chair (if available and able) or remained on the ambulance stretcher and treatment commenced if required. Treatments and tests provided or ordered by the EDAOLN (in collaboration with ED doctors as required) included pain relief, X-rays, intravenous cannulation and laboratory/pathology collection.
Prior to the introduction of the EDAOLN there was one main triage nurse who was responsible for all arriving patients – those that walked into the ED and those who arrived by ambulance or police vehicle. The main triage nurse was assisted, on an ad hoc basis, by other nurses. Once triaged, patients were either seated on a chair in the waiting room, allocated to an ED bed if one was available, or they may have needed to remain on the ambulance trolley. The main difference during the trial was that a designated senior nurse was allocated to assess and manage patients arriving by ambulance.
Section snippets
Design
A retrospective study was undertaken to compare demographic and ED patient outcomes before, during and after the implementation of the EDAOLN role.
Setting
The study site was a 570 bed, regional teaching hospital in Queensland, Australia that provided care to approximately 65,000 adults and children from a surrounding population of over 500,000 inhabitants during the study year [19].
Sample
Included in this study were all patient presentations made to one Queensland ED in 2012 during the study periods.
Outcomes
The
Results
After data cleaning, the final sample consisted of 21,454 of the 21,560 patient presentations made to the ED over the study time period: 7191 during Time 1 (T1); 7104 during Time 2 (T2) and 7159 during Time 3 (T3).
Discussion
The aim of this study was to evaluate patient outcomes before, during and after the period when the EDAOLN role was trialled. During this time period (T2) small but statistically significant differences were identified in important clinical outcomes including time to be seen, admission rate, proportion of DNWs, and the proportion of those who left after treatment commenced. Outcomes that did not improve with the EDAOLN role were NEAT (i.e. ED LOS < 4 h), overall ED LOS and access block (i.e. ED LOS
Limitations
There were several limitations to this study. First, as this was a retrospective study it is susceptible to bias in data collection and analysis. We recommend undertaking further advanced level analysis that includes matching, within group analyses and times series analysis [22]. Second, the EDAOLN role was implemented at only one site and thus results may not be generalisable to other EDs. Third, our data source, EDIS, was mainly designed for clinical use, and was therefore limited in the
Conclusion
The illness group that appeared to benefit most during the time when the EDAOLN role was operational was those who were diagnosed with a gastrointestinal illness. From an overall departmental functioning point of view, an important aspect of the patient journey (time to see a clinician) improved marginally during the time when the EDAOLN was operational but was not sustained once the role was removed. Given improvements in other output outcomes were not realised, proactive interventions
Funding
We wish to acknowledge Queensland Emergency Medicine Research Foundation for funding awarded to undertake part of this study.
Conflicts of interest
Tanya Greaves has no conflicts of interest to report.
Associate Professor Marion Mitchell has no conflicts of interest to report.
Associate Professor Julia Crilly works at the Emergency Department (in Dept. Research) that this study was set in.
References (34)
- et al.
The effects of ambulance ramping on Emergency Department length of stay and in-patient mortality
Austral Emerg Nurs J
(2010) - et al.
Ambulance ramping in regional Australian emergency department: patient specific antecedents and the lived experience
Austr Emerg Nurs J
(2015) - et al.
The effect of emergency department crowding on paramedic ambulance availability
Ann Emer Med
(2004) - et al.
Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions
Ann Emerg Med
(2002) - et al.
Predictive outcomes for older people who present to the Emergency Department
Austr Emerg Nurs J
(2008) - et al.
Patient characteristics and institutional factors associated with those who “did not wait” at a South East Queensland Emergency Department: who are those who “did not wait” in ED?
Austr Emerg Nurs J
(2014) - et al.
Analysis of three advanced practice roles in emergency nursing
Austr Emerg Nurs J
(2012) - et al.
The clinical initiative nurse: extending the role of the emergency nurse, who benefits?
Austr Emerg Nurs J
(2005) - et al.
Revision and evaluation of an ‘advanced’ nursing role in an Australian emergency department
Austr Emerg Nurs J
(2011) - et al.
Clinical initiative nurses and nurse practitioners in the emergency department: what's in a name?
Austr Emerg Nurs J
(2007)