Emergency Department, Fribourg Hospitals, Fribourg, Switzerland
Emergency Department, Fribourg Hospitals, Fribourg, Switzerland.
BMJ Open Qual. 2023 Aug;12(3). doi: 10.1136/bmjoq-2023-002431.
Overcrowding in the emergency department (ED) is a global problem and a source of morbidity and mortality and exhaustion for the teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. We initiated a quality improvement project with the objective of zero patients lying in bed awaiting care/referral outside a care area.
Several plan-do-study-act (PDSA) cycles were tested and implemented to achieve and especially maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: (1) no patients lying down outside of a care unit; (2) forward movement; (3) examination room always available; (4) team huddle and (5) an organisation overcrowding plan.
Adaptation of ED organisation in the form of PDSA cycles allowed to obtain a collective team dimension to patient flow management. Since December 2021, despite an increase in activity, no patient is placed in a lying-in waiting area outside a care zone, irrespective of their care level. Vital distress and fragile patients who need to be kept in a supine position are treated immediately. In 2022, waiting time before medical contact was <2 hours for 90% of all patients combined.
The PDSA strategy based on these five measures allowed to remove in-house obstacles to the internal flow of patients and to fight against their installation outside the care area. These measures are easily replicable by other management teams. Quality indicators of EDs are often heterogeneous, but we propose that the absence of patients lying on a stretcher outside a care area could be part of these indicators, and thus contribute to the improvement and safety of care provided to all patients.
急诊部门（ED）过度拥挤是一个全球性问题，也是导致发病率和死亡率上升以及医护人员精疲力竭的一个原因。尽管已经提出了多种策略来解决过度拥挤的问题，但等待治疗或住院的患者躺在病床上堆积的情况往往是不可避免的，这也是医疗质量的主要障碍。我们启动了一个质量改进项目，目标是实现零名患者躺在 ED 护理区外等待护理/转介。
进行了多个计划-执行-研究-行动（PDSA）循环测试和实施，以实现并特别维持 ED 护理区外无患者等待护理的目标。项目团队在这些循环中引入并调整了五项规则：（1）护理单元外无患者躺下；（2）向前推进；（3）检查室始终可用；（4）团队围坐讨论；（5）组织过度拥挤计划。
通过 PDSA 循环调整 ED 组织形式，使团队能够获得对患者流程管理的集体维度。自 2021 年 12 月以来，尽管活动增加，但无论患者的护理级别如何，都没有患者被安置在护理区外的等候区。需要保持仰卧位的危急和脆弱患者会立即得到治疗。2022 年，90%的患者在接受医疗接触前的等待时间都<2 小时。
基于这五项措施的 PDSA 策略，消除了患者内部流动的内部障碍，并防止他们在护理区外安置。这些措施很容易被其他管理团队复制。ED 的质量指标通常是异构的，但我们建议，没有患者躺在护理区外的担架上，这可能是这些指标的一部分，从而有助于改善和保障所有患者的护理安全。
