Bibliometric characteristics
As shown the Fig. 2, the distribution of papers over time highlighted that academic interest for the subject has developed in particular among 2017–2021 (34 papers published).
Most of the studies on risk, quality improvement and resilience topics in the emergency departments are articles (68%), literature reviews (30%) and just one conference paper (See Table 1).
Table 1
Number of articles for document type
Document type
|
Frequency
|
Percentage
|
Article
|
40
|
68%
|
Review
|
18
|
30%
|
Conference Paper
|
1
|
2%
|
Total
|
59
|
100%
|
From the analysis and as shown in Fig. 3, it emerged that the study approach most used are the empirical research (55%) and systematic literature review methodology (41%).
In particular, with regard to empirical research, most of the studies were conducted in the USA (44%), UK (18%), Italy (11%) and Australia (11%). (see Fig. 4).
As shown the Table 2, the research target major investigated in the empirical studies reviewed are: patients (10), medical staff (4), patients and medical staff (3).
Table 2
Frequency of research’ target investigated
Target
|
Frequency
|
Percentage
|
Patients
|
10
|
37%
|
Medical staff
|
4
|
15%
|
Patients and medical staff
|
3
|
10%
|
Clinical and administrative leaders
|
2
|
7%
|
Nurses
|
2
|
7%
|
Health care provider
|
1
|
4%
|
Interprofessional staff
|
1
|
4%
|
Medical staff and nurses
|
1
|
4%
|
Patients and nurses
|
1
|
4%
|
Patients, nurses and physicians
|
1
|
4%
|
Scribes, providers, clinic managers, quality improvement specialists, and scribe program managers
|
1
|
4%
|
Total
|
27
|
100%
|
Most of the reviewed papers were published in the following Journals: Annals of Emergency Medicine, Academic Emergency Medicine, Cochrane Database of Systematic Reviews and Emergency Medicine Journal. All papers were found in Journals and Conference on healthcare field. The Table below (Table 3) listed the source title of reviewed studies.
Table 3
Frequency of the source title
Source title
|
Frequency
|
Percentage
|
Annals of Emergency Medicine
|
6
|
10%
|
Academic Emergency Medicine
|
4
|
7%
|
Cochrane Database of Systematic Reviews
|
4
|
7%
|
Emergency Medicine Journal
|
3
|
5%
|
BMC Emergency Medicine
|
2
|
3%
|
BMJ Open
|
2
|
3%
|
International Journal for Quality in Health Care
|
2
|
3%
|
International Journal of Health Care Quality Assurance
|
2
|
3%
|
Journal of Emergency Medicine
|
2
|
3%
|
Systematic Reviews
|
2
|
3%
|
Advanced Emergency Nursing Journal
|
1
|
2%
|
American Journal of Medical Quality
|
1
|
2%
|
Annali di igiene: medicina preventiva e di comunità
|
1
|
2%
|
Australian Health Review
|
1
|
2%
|
BMC Family Practice
|
1
|
2%
|
BMJ (Online)
|
1
|
2%
|
Clinical Governance
|
1
|
2%
|
CMAJ
|
1
|
2%
|
Disaster Medicine and Public Health Preparedness
|
1
|
2%
|
EMA - Emergency Medicine Australasia
|
1
|
2%
|
European Journal of Emergency Medicine
|
1
|
2%
|
Health Affairs
|
1
|
2%
|
Internal and Emergency Medicine
|
1
|
2%
|
International Emergency Nursing
|
1
|
2%
|
International Journal of Healthcare Management
|
1
|
2%
|
International Journal of Nursing Practice
|
1
|
2%
|
JBI database of systematic reviews and implementation reports
|
1
|
2%
|
Journal of Emergency Nursing
|
1
|
2%
|
Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management
|
1
|
2%
|
Journal of Interprofessional Care
|
1
|
2%
|
Journal of Nursing Care Quality
|
1
|
2%
|
Journal of the American Board of Family Medicine
|
1
|
2%
|
Journal of the American Medical Informatics Association
|
1
|
2%
|
Journal of Trauma Nursing
|
1
|
2%
|
Pilot and Feasibility Studies
|
1
|
2%
|
Psychiatric Services
|
1
|
2%
|
Quality management in health care
|
1
|
2%
|
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
|
1
|
2%
|
Sustainability (Switzerland)
|
1
|
2%
|
The Kansas nurse
|
1
|
2%
|
Themes And Sub-themes On Quality And Risk Management Research
To extract, synthesize and analyze the results of studies, we used the content analysis in order to identify the main themes and sub-themes addressed in the reviewed papers. Indeed, through content analysis is possible to identify, analyze, and resume data in the form of themes within a text [42, 43, 44]. In particular, the title, abstract, author’s keywords context, aim and research gap of the 59 studies were reviewed and coded.
We summarized the results of the studies in order to identify the main results and further research for any theme identified in the emergency department context.
As shown Fig. 5, our systematic literature review reveals three main themes and four sub-themes: Quality improvement (17 papers) topic composed of Effectiveness of quality improvement strategies (9) and Medical scribes themes; (3) Risk management (12), including Handoff (3) and Crowding (6) issues; and Resilience (9) theme.
Below, we better explained the contents and key findings of each theme and sub-theme.
3.2.1 Quality improvement theme
As shown in Table 4, most articles focused on the quality improvement theme, analyzing several processes or indicators that aim to enhance healthcare needs and focus on patient-centered satisfaction and medical staff [45].
Table 4
Quality improvement theme
Quality improvement
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[55]
|
To evaluate the impact of consultant-level doctors overnight.
|
Empirical
(Quantitative)
UK
|
Overnight ED waiting time performance issues are rooted in process problems occurring during the day and early evening. Night working had a negative impact on sleep patterns, performance and well-being. Did not emerge a clinically important impact of consultant night working on total time patients spend in the department.
|
To develop quantitative and qualitative studies for quality, safety and process considering measures of emergency admissions, benefits to trainee workforce and intrahospital rate-limiting effects such as delayed transfers of care or hospital occupancy.
|
[48]
|
To improve the quality management of ED during the Covid-19 pandemic.
|
Empirical
(Experiment)
USA
|
The feedback supported quality improvement initiatives in the emergency room by generating mental health support for staff. Programs (debriefing) that facilitate clinicians to communicate their concerns with team leaders reduce negative outcomes, improve processes, alleviate burnout and increase resilience.
|
/
|
[57]
|
To present a model Web-based system for reporting of errors that occur in patient care in the ED.
|
Empirical
(Experiment)
USA
|
A web-based error reporting creates more opportunities for system improvement through anonymity.
|
To propose system changes to reduce future errors in order to pursue continuous quality improvement.
|
[58]
|
To evaluate the effectiveness of an ED peer review process in promoting incident reporting.
|
Empirical
(Mixed method approach)
USA
|
A non-punitive peer review process provides feedback and is perceived as valuable for error identification and education can lead to increased incident reporting by HCPs optimizing health care quality and safety.
|
To identify opportunities in order to enhance peer review process in promoting incident reporting.
|
[53]
|
To explore the successes and challenges of implementing systems of quality assurance.
|
Empirical
(Qualitative)
USA
|
It's necessary the implement quality management to improve an underdeveloped quality culture, inadequate data collection, poor incentives for improvement and high external pressures, including staff shortages, departmental crowding and lack of public empowerment.
|
To provide and analyze opportunities and challenges in the area of quality management and clinical governance in the developing world.
|
[46]
|
To improve the quality and safety in ED.
|
Conceptual
|
Emergency personnel must be trained to provide prompt patient care. Crowding directly impacts patient quality of care, morbidity and mortality. Quality indicators should be pragmatic, measurable and prioritized as components of an improvement strategy. EDs improvement strategy include audits, incident monitoring, guidelines, morbidity and mortality review, Integration and communication with ambulance, hospital specialities and primary care.
|
To develop indicators that improve clinical outcomes, staff and patient experience in a cost-efficient manner.
|
[47]
|
To improve emergency department triage.
|
Empirical
(Random chart review)
USA
|
Continuous and systematic assessment and improvement are needed to streamline the triage process and improve accuracy and efficiency. Nurses need to be involved and trained to identify problems and solutions to improve the triage process.
|
/
|
[51]
|
To develop an integrated patient-focused framework to improve quality of care in accident and emergency unit.
|
Empirical
(Case study)
Malta
|
The main problems in the ED were overcrowding and a shortage of beds. The combined QFD and LFA methods are effective to improve the quality of care involving all stakeholders and adopting a process approach focused on patients. The implementation of the quality improvement program is fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A&E unit.
|
To develop empirical studies in other countries also to establish causal relationships among the constructs for healthcare quality improvement using structure equation modelling or other techniques such as the analytic hierarchy process, the analytic network process, fuzzy theory, etc.
|
[54]
|
To analyze the customer service in ED.
|
Systematic literature review
|
Patient satisfaction is related to the timeliness and quantity of care. the presentation of symptoms, the style of practice, the position and problems of the physician have a direct impact on satisfaction. It is necessary to consider the demographic profile, the presentation of symptoms and the interventions of the physician by creating an empathic relationship with the patient to improve the quality of care and patient satisfaction.
|
To define goals in patient care and service to improve the quality care and patients satisfaction.
|
[52]
|
To evaluate the Lean intervention to improve safety processes and outcomes on ED.
|
Empirical
(Lean)
UK
|
Lean improves compliance with a bundle of safety-related processes but it's crucial the senior management support to facilitate change across multiple departments.
|
To understand the lean applications and effects on quality improvement.
|
[49]
|
To summarise the effectiveness of deprescription interventions in primary care, and to describe the barriers and enablers of the process from the point of view of patients and healthcare professionals.
|
Systematic literature review
|
It's necessary to improve communication with patients as well as other colleagues involved in patient care. Amongst the identified barriers we found lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. The educational component of deprescription procedures is a key factor. Good communication between healthcare professionals is a key element for success in the deprescription process.
|
/
|
[60]
|
To increase the effectiveness of communication and reduce clinical risk.
|
Empirical
(Quantitative)
Australia
|
The rate of documentation of emergency department security interventions in clinical notes can be increased by encouraging clinicians and security staff to collaborate and share documentation responsibilities.
|
To evaluate the rate of documentation of security interventions in other countries.
|
[59]
|
To create a Continuous Quality Improvement program using a suggestion-based model to empower physicians.
|
Empirical
(Quantitative)
USA
|
Through Kaizen program, all ED stakeholders can propose initiatives or solutions for active initiatives in order to promote a continuous quality improvements process.
|
To test kaizen in other countries and departments adopting a multicenter prospective approach and considering its impact on patient outcomes.
|
[62]
|
To develop quality measurement for ED.
|
Conceptual
|
Quality measurement can play an important role in improving the quality and value of ED care, including measures of effective care for serious conditions, measures of efficient use of resources, such as high-cost imaging and hospital admission; and measures of diagnostic accuracy.
|
To support the development of measures of care coordination and regionalization and the episode cost of ED care.
|
[50]
|
To summarizes key current issue in ED safety in order to improve the patient safety.
|
Conceptual
|
To improving patient safety in the ED it's crucial to decrease the length of time at triage, assessment, intervention and disposition. To improve patient safety have to create specialized patient care units, strategic staffing, admission lounges, streamlining communication, and medical record delivery systems.
|
To delve how improve the patient safety analyzing the problem and to create solution for the continuous improvement in the ED.
|
[56]
|
To identify and appraise the evidence for the effectiveness of e-learning programmes on health care professional behaviour and patient outcomes.
|
Systematic literature review
|
E-learning was at least as effective as traditional learning approaches, and superior to no instruction at all in improving health care professional behaviour. There was variation in behavioural outcomes depending on the skill being taught, and the learning approach utilised.
|
To provide empirical research on the effectiveness of e-learning and on how it changes healthcare professional behaviour or patient outcomes.
|
[61]
|
To improving the capacity, cccessibility, and quality of mental health services.
|
Systematic literature review
|
Peer Support Workers can reduce hospital admissions and inpatient days and engaging severely ill patients. Most PSW programs have reported implementation challenges but these workers can improve access to and quality of care.
|
To investigate and describe how these approaches (PSWs) can be combined to expand a community’s capacity to provide care.
|
In particular, Hansen et al. [46] analyzed how to improve the quality and safety in ED and triage process [47] even during the Covid-19 pandemic [48].
Olry De Labry Lima et al. [49] summarised the effectiveness of deprescription interventions in primary care and described the barriers and enablers of the process from the point of view of patients and healthcare professionals in order to analyze the key current issues in ED safety to improve the patient safety [50].
Buttigieg et al. [51] developed an integrated patient-focused framework to improve quality of care in accident and emergency units as Lean [52] exploring the implementing systems of quality assurance [53], the customer service [54] and evaluating the impact of consultant-level doctors overnight [55]. Sinclair et al. [56] identified and appraised the evidence for the effectiveness of e-learning programs on health care professional behaviour and patient outcomes.
Other studies [57] presented a model web-based system for reporting errors that occur in patient care in the ED. Reznek & Barton [58] evaluated the effectiveness of an ED peer review process in promoting incident reporting the effectiveness of e-learning programmes on health care professional behaviour and patient outcomes [56].
Jacobson et al. [59] highlighted that it is crucial to create a continuous quality improvement program using a suggestion-based model to empower physicians, increase communication effectiveness and reduce clinical risk [60, 61, 62].
Eighteen studies analyzed the Quality improvements theme: three conceptual research [46, 50, 62], four systematic literature reviews [49, 54, 56, 61] and eleven empirical studies, in particular, three quantitative research respectively conducted in the USA [59] in Australia [60] and UK [55]; one qualitative study carried out in the USA [53], one mixed method approach conducted in the USA [58], two experiments performed in USA [48, 57], one random chart review conducted in the USA [47], one case study on a Maltese emergency department [51] and finally one study that implemented the Lean in an ED in the UK [52].
The reviewed studies showed that the implement quality management must improve an underdeveloped quality culture, inadequate data collection, poor incentives for improvement and high external pressures, including staff shortages, departmental crowding, overcrowding of patients, a shortage of beds and lack of public empowerment [51, 53].
Quality measurement can play an essential role in improving the quality and value of ED care, including effective care measures for serious conditions and efficient use of resources, such as high-cost imaging and hospital admission [62].
The combined Quality Function Deployment (QFD) and Logical Framework Analysis (LFA) and also Lean [52, 59] methods are effective to improve the quality and safety of care involving all stakeholders and adopting a process approach focused on patients [51].
For instance, the feedback supported quality improvement initiatives [57] in the emergency room by generating mental health support for staff. Programs (debrifing) that facilitate clinicians to communicate their concerns with team leaders reduce negative outcomes, improve processes, alleviate burnout and increase resilience [48]. In addition, Reznek & Barton [58] showed that a non-punitive peer review process provides feedback and is perceived as valuable for error identification and education can lead to increased incident reporting by health care providers (HCPs) optimizing health care quality and safety.
To improving patient safety in the ED it is crucial to decrease the length of time at triage, assessment, intervention and disposition. To improve patient safety, have to create specialized patient care units, strategic staffing, admission lounges, streamlining communication, and medical record delivery systems [50].
Overnight ED waiting time performance issues are rooted in process problems occurring during the day and early evening. Night working harmed sleep patterns, performance, and well-being but did not significantly impacts on the total time patients spend in the department by the consultant night working [55].
Nurses need to be involved and trained to identify problems and solutions to improve the triage process [47]. Indeed, emergency personnel should be trained to provide prompt patient care in order to reduce the overcrowding. EDs improvement strategy include audits, incident monitoring, guidelines, morbidity and mortality review, integration and communication with an ambulance, hospital specialties and primary care [46].
Patient satisfaction is related to the timeliness and quantity of care. Medical staff must consider the demographic profile, the presentation of symptoms, and the physician's interventions by creating an empathic relationship with the patient to improve the quality of care and patient satisfaction [54].
It is necessary to improve communication with patients as well as other colleagues involved in inpatient care. The study conducted by Olry De Labry Lima et al. [49] showed that the identified barriers in ED were lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. Indeed, healthcare professionals must cooperate, communicate, and share documentation responsibilities [60].
Effectiveness of quality improvement strategies sub-theme
The effectiveness of quality improvement strategies theme evaluates several interventions in ED to enhance the service quality provided and medical staff and patients’ satisfaction (see Table 5).
Table 5
Effectiveness of quality improvement strategies sub-theme
Effectiveness of quality improvement strategies
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[68]
|
To evaluate the results of emergency telehealth and assess their effectiveness and cost-effectiveness.
|
Systematic literature review
|
Emerged the effectiveness of emergency telehealth services, evidence on their effectiveness and cost-effectiveness in rural and remote.
|
To analize the effectiveness and cost-effectiveness of emergency telehealth services in several contexts.
|
[69]
|
To explore the impact and content of early assessment and/or intervention carried out by health professionals in the ED on the quality, safety and cost-effectiveness of care.
|
Systematic literature review
|
Interdisciplinary teams can enhance the quality of care provided in healthcare settings thanks to a more collaborative and comprehensive approach to the patient.
|
/
|
[65]
|
To evaluate the effectiveness of interventions to reduce the number of ED visits by frequent users.
|
Systematic literature review
|
Interventions targeting frequent users may reduce ED use. Case management, the most frequently described intervention, reduced ED costs and seemed to improve social and clinical outcomes.
|
/
|
[70]
|
To evaluate effectiveness of interventions targeting adult frequent ED users in reducing visit frequency and improving patient outcomes.
|
Systematic literature review
|
The interventions targeted toward adult frequent ED users effectively decrease ED visit frequency overall. Cost is important when determining interventions’ sustainability. The overall cost of an intervention inclides costs of the intervention itself (physician time, paramedical staff, infrastructure, services), savings from decreased healthcare utilization (ED visits, hospitalizations), costs of increased service use (e.g., community or outpatient services), and savings from improved productivity of more medically and socially stable patients (gains in employment, stable housing).
|
To evaluate interventions’ cost-effectiveness and should employ standardized definitions and high methodological rigor to allow comparable research.
|
[63]
|
To improve the coordination of care to reduce health care utilization.
|
Systematic literature review
|
The interventions targeted to frequent users should consider specific strategies, such as team changes, case management and promotion of self-management, because these approaches are more effective than other quality improvement strategies in reducing health care utilization.
|
To determine how to optimize care coordination strategies for specific patient subgroups and settings.
|
[71]
|
To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce hospital admissions, emergency department visits, and mortality in adults.
|
Systematic literature review
|
Interventions in primary care for reducing preventable medication errors probably make little or no difference to the number of people admitted to hospital or the number of hospitalizations, emergency department visits, or mortality.
|
To explore which interventions involving healthcare professionals (nurse, physician or pharmacist) are beneficial in preventing errors in primary care should also be addressed, improving the study' quality and defining the 'usual care'.
|
[74]
|
To reduce utilization by uninsured frequent users of the ED.
|
Empirical
(Mixed method approach)
USA
|
Coordinated, team-based drop-in group medical appointments DIGMAs integrating medical and behavioral health care and care management services is a cost-effective model to reduce ED visits and charges.
|
/
|
[72]
|
To evaluate the effectiveness of visit reduction programs in ED.
|
Systematic literature review
|
Case management for high-risk individuals can be effective in reducing ED visits; its effectiveness may in part be related to the size of the copayment. The data on the costs of ED visit reduction programs are insufficient to determine whether any of these programs are cost-effective.
|
To provide high-quality studies on effectiveness of visit reduction programs in ED.
|
[73]
|
To examine the effectiveness of strategies that lead to improvements in communication and the factors that mitigate or improve transitions in care specifically from Emercengy Medical Services practitioners to ED nurses.
|
Systematic literature review
|
A standardized approach to transitions in care ensures that patient expectations and needs are communicated, thereby making ED care more responsive to patient needs.
|
To identify the existing evidence on transitions in care between EMS and ED nurses.
|
Several studies evaluated the effectiveness of quality improvement strategies, which translates into improving the coordination and organization of health care [63, 64]. Team changes and multidisciplinary teams were likely to reduce emergency department visits and admission [65, 66]. Patient education and self-management were quality improvement strategies targeting patients that reduce hospital resource usage [67].
This theme is described by nine articles: eight systematic literature reviews [63, 65, 68, 69, 70, 71, 72] and one empirical research conducted in the USA using mixed-method approach [73].
The study conducted by Tsou et al. [68] highlighted the effectiveness of telemedicine services for their economy especially in emergencies such as the Covid-19 health pandemic.
Interdisciplinary teams can improve healthcare quality provided through a more collaborative and global approach to the patient [69]. The studies reviewed confirmed that interventions targeting and case management to frequent users reduce emergency room visits and costs [65]. Targeted interventions must include implementing team changes, case management, and the promotion of self-management to reduce the use of healthcare [63, 71, 72].
Cost is important when determining the sustainability of interventions. The total cost of intervention includes the costs of the intervention itself (medical time, paramedical staff, infrastructure, services), savings deriving from lower use of health care (emergency room visits, hospitalizations), costs of greater use of the service (e.g. community or outpatient services), and savings from the increased productivity of more medically and socially stable patients (employment gain, stable housing) [65, 70].
In addition, coordinated, team-based drop-in group medical appointments DIGMAs integrating medical and behavioural health care and care management services is a cost-effective model to reduce ED visits and charges [74].
Reay et al. [73] found that a standardized approach to healthcare ensures the creation of a dialogue between doctor and patient while meeting the needs of patients.
Medical scribes sub-theme
Medical scribes theme is a sub-category of the Quality improvement theme. A scribe assists medical staff with primary documentation and nonclinical functions. In fact, through the medical scribes, it is possible to implement and pursue the continuous improvement process in the Emergency Departments to enhance patient-provider interaction (i.e. productivity, efficiency, patient and provider experience) and patient satisfaction [75].
The studies included in the literature review aimed to assess the effect of scribes on throughput, revenue, provider satisfaction, and patient satisfaction and safety in the emergency department.
The theme is composed of three articles, two of which are a systematic literature review [76, 77], and an empirical study [78] that shows the results of a mixed method approach with interviews and observations in the USA (Table 6).
Table 6
Medical scribes sub-theme
Scribes
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[76]
|
to assess the effect of scribes on throughput, revenue, provider satisfaction, and patient satisfaction.
|
Systematic Literature Review
|
Scribes enhanced relative value units (RVUs) per hour, RVUs per encounter, patients per hour, provider satisfaction, and patient satisfaction but not an improvement in ED length of stay.
|
To determine the cost-benefit effect of scribes and the effect on satisfaction, physician stress and burnout also in other countries.
|
[78]
|
to investigate the effect of scribes on patient safety.
|
Empirical
(Mixed method approach)
USA
|
Scribes reduce perceived risks in the emergency room. It is necessary that suppliers and scribes receive training to improve safety.
|
To identify national oversight needs and new roles and investigate the potentiality of scribes.
|
[77]
|
to evaluate the effects of medical scribes in ED.
|
Systematic Literature Review
|
Scribes increase patients seen per day and decrease the length of stay improving emergency department efficiency. Scribes may increase financial productivity but costs associated with developing, implementing, and maintaining scribe programs must be thorough. No studies examined the effects of scribes based on compensation structure, qualifications or duties.
|
More information is needed on the effectiveness and clinical findings, harms, patient or clinician satisfaction, financial productivity in EDs and costs before widespread implementation of scribes. There are no data on the use of virtual scribes, and no published data on the cost of developing, implementing, or maintaining a scribe program.
|
The empirical study showed that medical scribes reduce perceived risks in the emergency room, but suppliers and scribes must receive training to improve safety [78].
Scribes strengthened the patient-provider relationship and improved provider experience, for instance, enhanced relative value units (RVUs) per hour, RVUs per encounter, patients per hour, and enhanced patient satisfaction but not an improvement in ED length of stay. Medical staff are more engaging with patients increasing the interaction during the visit face-to-face and reducing, through the scribes work, the interaction with a computer [76].
Furthermore, spending more time visiting the patient enhance the patient care experience and patient satisfaction. Indeed, scribes increase patients seen per day and decrease the length of stay, improving emergency department efficiency. However, despite scribes increasing financial productivity, costs associated with developing, implementing, and maintaining scribe programs must be evaluated and investigated. A lack of studies emerged that examined the effects of scribes based on compensation structure, qualifications or duties [77].
Following the quality improvement lens, integrating medical scribes with medical providers improves access, quality of care, enhances patient/medical staff satisfaction, and increases revenue productivity.
Risk management theme
Risk management theme analyzes how improves the effectiveness and safety of test-result management by establishing transparent governance processes of communication, responsibility and accountability harnessing health information technology [79]; for instance, to enhance a triage process [80, 81].
The studies evaluate telephone follow-up systems and their effect on patient care and satisfaction [82], considering causes of patient safety incidents in emergency departments [83, 84].
Welch & Jensen [85] showed the differences in culture between emergency medicine and other high-risk organizations and pointed to the qualities that promote reliability.
Recent studies have instead investigated benefits and risks generated from Covid-19 [86, 87] in particular investigates the hospital risk analysis and management (the indoor air quality and determination of microbial load, surface management and strategies in cleaning activities, ventilation and air conditioning systems’ management and filters’ efficiency) [88] and assesses the effectiveness of screening for Covid-19 infection compared with no screening [89]. Furthermore, during the health crisis, the number of nurses had to be optimized [90].
As shown in Table 7, twelve studies analyze risk management topic: four conceptual research [85, 86, 87, 88], two systematic literature reviews [84, 89] and six empirical studies that adopted a qualitative approach in the USA [82] and Australia [83], a quantitative approach in Iran [90] and in Canada [80], a mixed-method approach in Australia and a study has implemented in an Italian ED the root cause analysis.
Table 7
Risk management
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[87]
|
To analyze and implement a crisis standard of cure.
|
Conceptual
|
There is a relatively scarcity of critical resources, such as intensive care units beds, emergency department beds, ventilators, personal protective equipment, and medications. A crisis standard of care can act as a guidepost for rationing supplies and care.
|
/
|
[82]
|
To evaluate telephone follow-up systems and its effect on patient care and satisfaction.
|
Empirical
(Qualitative)
USA
|
A follow-up call system for selected patients is an effective method for demonstrating patient concern, improving quality assurance, and providing useful feedback to the emergency staff.
|
To develop a quality assurance program.
|
[83]
|
To examine reported incidents affecting ED episodes of care.
|
Empirical
(Qualitative)
Australia
|
The most common incidents were related to patient behaviour, patient management and medications. Differences in personal and clinical characteristics of patients whose ED care involved reported incident(s) highlights the need for better understanding of incidents occurring in the ED in order to improve systems for high-risk patients.
|
To investigate perceptions of a reportable incident, attitudes to incident reporting, and comparison of ‘reported’ and ‘reportable’ incidents to improve the systems and accurate reporting of incidents in emergency care.
|
[81]
|
To improve a triage process.
|
Empirical
(Root cause analysis)
Italy
|
The ‘‘root cause’’ simplest to solve was the absence of nurse training. training program aim to acquire technical, scientific and interpersonal competencies; discuss real-life case studies and simulate cases which might occur.
|
/
|
[84]
|
To understand what causes patient safety incidents in emergency departments.
|
Systematic literature review
|
Participation in efforts to diminish risk and improve patient safety through appropriate incident reporting, communication and collaboration is critical for removing barriers to safe care.
|
To investigate the causes of practice errors and formulate safety improvement strategies.
|
[85]
|
To illustrate the differences in culture between emergency medicine and other high-risk organizations and points to the qualities that promote reliability.
|
Conceptual
|
A reliability model for emergency medicine designing for the masses instead of the individual will effectively aims the safety, effectiveness, patient centeredness, timeliness, efficacy and equity.
|
/
|
[79]
|
To improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability harnessing health information technology to monitor test-result management.
|
Empirical
(Mixed method approach)
Australia
|
Mixed method approach capture the experiences and opinions of trained health consumer representatives and patients to improve communication and resource management.
|
/
|
[86]
|
To analyze benefits and risks generated from Covid-19.
|
Conceptual
|
Improved use of tiered ED telemedicine with teletriage and then an ED physician virtual visit could improve the ED quality service.
|
/
|
[90]
|
To analyze the specialized human force in ED during pandemic to optimize the number of nurses.
|
Empirical
(Quantitative)
Iran
|
The pressure in addition to nurses’ accuracy reduction and raising the error probability in the cares lead to stress for the nurses. Due to nurses’ shortage in the ED for keeping the nursing service quality, some programming is done for creating motivation, and enthusiasm in medical employees. The regulation of 9 h shift for some of the nursing personnel, approaches like using the part-time nurses, and rotating the nurses among the various departments of hospital can be useful.
|
To investigate, in other countries, how ED managed the allocation of human resources to manage the flow of patients during the pandemic.
|
[88]
|
To investigate the hospital risk analysis and management (the indoor air quality and determination of microbial load, surface management and strategies in cleaning activities, ventilation and air conditioning systems’ management and filters’ efficiency).
|
Conceptual
|
Enhanced ventilation may be a key element in limiting the spread of the SARSCoV- 2 virus. If the ventilation system is properly designed and kept clean to preserve the correct pressure among the functional units, it can be effective in removing airborne infectious agents.
|
/
|
[80]
|
To explore if, and how, triage affected their treatment outcomes.
|
Empirical
(Quantitative)
Canada
|
The ED triage is one of the innovations to the delivery of the current emergency services to regulate the flow and trajectory of patients’ care within the ED setting.
|
To examine the occurrence of severe adverse health outcomes such as sepsis, septic shock, and death.
|
[89]
|
To assess the effectiveness of screening for Covid-19 infection compared with no screening.
|
Systematic literature review
|
It's necessary greater emphasis on other ways to prevent transmission, such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers.
|
To test different screening strategies considering more comprehensive symptom and risk assessment, rapid laboratory tests, and combinations of approaches.
|
The main critical issues that emerged from the studies highlighted a lack of resources such as intensive care unit beds, emergency room beds, ventilators, personal protective equipment and, medications. A crisis standard of care can serve as a guide for rationing supplies and care [87]. ED triage is one of the innovations in the provision of current emergency services to regulate the flow and trajectory of patient care within the emergency room [80]. Facial covers, physical distance, quarantine and appropriate personal protective equipment for frontline workers are required to prevent transmission. In high prevalence settings such as congregated housing facilities, universal testing with RTPCT (Reverse Transcription-Polymerase Chain Reaction) may be a preferred strategy for screening [88, 89]. Multilevel telemedicine with teletriage and therefore a virtual visit of the ED doctor could improve the quality of the service provided to patients [86].
The most common incidents were related to patient behavior, patient management, and medications. The mixed method approach captures the experiences and opinions of patients and doctors to improve communication and resource management [79]. Differences in the personal and clinical characteristics of patients whose emergency room care involved reported incidents highlight the need for a better understanding of incidents occurring in the emergency room to improve systems for high-risk patients [83].
The pressure, in addition to reducing the accuracy of nurses and increasing the likelihood of error in care, leads to stress for nurses. Due to the shortage of nurses in the emergency room to maintain the quality of the nursing service, some programming is done to create motivation and enthusiasm in the staff. The regulation of the 9-hour shift for part of the nursing staff, approaches such as the use of part-time nurses and the rotation of nurses between the hospital's various departments may be useful [90]. However, it is crucial to provide nursing education. the training program aims to acquire technical, scientific and interpersonal skills [81].Participation in efforts to reduce risk and improve patient safety through adequate incident reporting, communication and collaboration is critical to removing barriers to care safety [84].
A follow-up call system for selected patients effectively demonstrates patient concern, improves quality assurance, and provides helpful feedback to emergency personnel [82]. A reliability model for designing emergency medicine for the masses rather than the individual aims at safety, efficacy, patient-centeredness, timeliness, efficacy and equity [85].
Crowding sub-theme
Among the risks that affected access and quality of care in emergency departments context, crowding emerged. Crowding harms patients and medical staff [91], involving the healthcare delivery process and outcomes. Crowding generates delays or no visits for patients or to the abandonment of patients due to the long perceived length of stay [92]. Indeed, the existing literature has shown excess mortality in crowded emergency departments [93, 94]. This issue generated a lack of privacy and dignity [95] for the patients. The most affected by the harms of crowding are the elderly, the critically ill, the mentally ill and the vulnerable [96].
Delayed patient assessment and delivery of care can generate medical errors as well as negatively impact the cost of treatment and patient satisfaction [97] and an increase in bed occupancy rate [98].
The increased flow of patients generates a delay in the provision of health care. It increases the pressure and stress of the medical staff that negatively affect the quality of emergency healthcare.
As shown in Table 8, this theme evaluates the effectiveness and efficiency of interventions on reducing emergency room crowding also considering the effects of locating primary care professionals in the emergency room to provide care to patients with non-urgent health problems [99, 100, 101]. In particular, some studies analyze the crowding within EDs, the most appropriate access target, the clinical effects of the 4-h rule, and delve the evidence on the effectiveness and safety of short-stay units, compared with usual care [102, 103]. While, the study conducted by Aacharya et al. [104] provide an ethical analysis of emergency department triage considering the biomedical ethics principles (i.e. respect for autonomy, beneficence, nonmaleficence and justice).
Table 8
Crowding
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[104]
|
To provide an ethical analysis of emergency department triage considering the four principles of biomedical ethics (respect for autonomy, beneficence, nonmaleficence and justice).
|
Conceptual
|
To provide support on educational (communication, stress and aggression management), psychological (feedback) and ethical level, is essential for realizing a clinical-ethical based process of triage planning.
|
/
|
[102]
|
To analyze the crowding within EDs, the most appropriate access target, the clinical effects of the 4-h rule and differential effects on different patient populations.
|
Conceptual
|
Factors preventing timely transfers of emergency patients to in-patient beds is major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific specialty units.
|
/
|
[103]
|
To update the evidence on the effectiveness and safety of short-stay units, compared with usual care, on hospital and patient outcomes.
|
Systematic literature review
|
A short-stay unit is a cost-savings option highlighting the effectiveness and safety of short-stay units, compared with inpatient care.
|
Further economic studies of short-stay units are required to justify whether the costs of implementation are worth the outcomes compared to usual care.
|
[99]
|
To assess the effectiveness of interventions on reducing ED crowding by older patients.
|
Systematic literature review
|
The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff lead to a decrease in ED length of stay but poor methodological quality hinder drawing firm conclusions on the intervention’s effectiveness in reducing ED crowding by older adults.
|
To conduct experimental research on reducing ED crowding by older adults, using uniform and valid effect measures to evaluate the effectiveness of interventions.
|
[100]
|
To assess the effects of locating primary care professionals in EDs to provide care for patients with non-urgent health problems.
|
Systematic literature review
|
The study showed weak evidence that the primary care professionals to the ED do not modify patients' subsequent use of primary care or the ED. There is very weak evidence to suggest that general practitioners and nurse practitioners may use fewer resources to treat non-urgent patients in the ED than emergency physicians, and thus that employing sessional primary care providers may introduce cost-savings to EDs.
|
To investigate whether providing primary care in EDs generates more demand and increases the use of EDs for non-urgent problems and analyze how to maximise the number of practitioners. The effect on wait times, adverse effects, mortality, and patient outcomes must be thorough.
|
[101]
|
To detect critical process steps in the ED with respect to time and efficiency.
|
Empirical
(Mixed method approach)
Germany
|
Modelling with Event-Process-Chain is a useful tool to understand the complexity of emergency medical care and to identify key performance indicators for effective quality management, reducing crowding and improving patient safety and satisfaction.
|
To implement the Event Process Chain methodology and relatively KPI in other countries, to evaluate the effect of these interventions to reduce crowding and to monitor the effectiveness of processes.
|
The Crowding theme includes six papers, two of these conceptual [102, 104], three systematic literature reviews [99, 100, 103] and one empirical study conducted in Germany [101].
The main cause for crowding in ED is the slow transfer of emergency patients to in-patient beds. Several remedial strategies parallel the processing of probable admissions, direct-to-ward admissions, and single-point medical registrars for receiving and processing all referrals directed at specific speciality units [102]. Furthermore, to reduce the negative consequences on hospital costs and patient satisfaction, the study conducted by Galipeau et al. [103] highlighted that a short-stay unit is a cost-savings option for the effectiveness and safety of short-stay units, compared with inpatient care.
The rapid evaluation of care for the elderly based on time efficiency objectives by dedicated staff reduces the length of stay in the emergency department, but quality methodological approaches are needed to highlight the effectiveness of the intervention in reducing crowding [99].
The Event-Process-Chain is a useful tool for understanding the complexity of emergency medical care and identifying key performance indicators for effective quality management, reducing crowding and improving patient safety and satisfaction. This tool supports hospital managerial leaders to identify critical process steps in the ED [101]. The studies conducted in Ireland, the UK, and Australia have not shown the effectiveness and safety of care provided to non-urgent patients by general practitioners and nurse practitioners versus emergency physicians in the ED to mitigate overcrowding, wait times, and patient flow [100].
It is crucial to give a clinical-ethical-based triage planning process to support educational (communication, stress and aggression management), psychological (feedback), and ethical level. The triage planning phase is crucial for the hospital context to reduce risks such as crowding, adopting a comprehensive ethics perspective [104].
Handoff sub-theme
The Handoff theme evaluates the effectiveness and safety of this phase between physicians in the ED, analyzing a novel model attending physician staffing to decrease patient handoffs through the standardized procedure in providing diagnostic and follow up care [105, 106, 107]. The literature review emerged that the handoffs topic is connected to the risk management theme, as it represents a criticality to be overcome within the healthcare field.
Patient handoffs are a crucial step in improving emergency department care. During handoffs, nurses play a crucial role in providing all information about the patient. This phase identifies predictive actions or interventions on patient care [108, 109].
Three papers focused on the handoff theme: two empirical studies conducted in the USA, using quantitative [106] and mixed method approach [105] and one conceptual paper [107]. The papers are summarized in Table 9.
Table 9
Handoff
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[107]
|
to analyze the process and safety of handoffs between physicians in the ED.
|
Conceptual
|
To reduce the number of unnecessary handoffs it's necessary to provide a clear summary of the patient’s visit, communicating outstanding tasks, anticipating changes, and making information readily available for direct review.
|
To evaluate how technology supports handoffs and modifies behavior in order to monitor the performance. In addition, to derive the best timing and location of handoffs, define the optimal order of presentation within handoffs and among patients and characterize the integration and influence of medical records.
|
[109]
|
to evaluate the effectiveness of the standardizing handoff in providing diagnostic and follow up care.
|
Empirical
(quantitative)
USA
|
To standardize handoff communication from ED to Primary Care Providers improves the quality of patient care by ensuring timely diagnostic and follow-up care.
|
To validate the use of this tool (an electronic Emergency Provider Written Plan of Discharge) to standardized handoff communication.
|
[105]
|
to evaluate a novel attending physician staffing model to decrease patient handoffs.
|
Empirical
(mixed method approach)
USA
|
An overlapping staffing model improved perceptions of patient safety, ED flow, and job satisfaction reducing the proportion of patient handoffs.
|
To deepen how this novel staffing model affects patient safety and analyze the effects in other care settings.
|
The study conducted by Cheung et al. [107] showed that handoff aims to provide a clear summary of the patient’s visit. Indeed, the medical staff must receive a complete overview of all information on the patient's health status to reduce handoffs by communicating outstanding activities, anticipating changes and making information readily available for direct review.
From empirical studies, it showed that standardizing handoff communication from the Emergency Department to Primary Care Providers improves the quality of patient care by ensuring timely diagnostic and follow-up care. Using the electronic Emergency Provider Written Plan of Discharge (eEPWPD) template, medical staff provides immediate diagnostic and follow-up care reducing waiting times for the patient and improving the service provided [106]. In addition, in a Pediatric Emergency Department in the USA, a multidisciplinary team has redesigned an attending physician staffing model in which there are two zones with overlapping “waterfall” shifts to reduce patients handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. This overlapping staffing model improved perceptions of patient safety, emergency department flow, and job satisfaction, reducing the proportion of patient handoffs [105].
Resilience theme
Resilience is defined as the ability to react to complex and emergency situations to strengthen ED’s staff integrity [110, 111, 112].
Several strategies support establishing a culture of resilience: training courses [113], increasing social support and personal reflection, coping skills, dialogue between staff and health professionals experts to share their resilience experiences in the form of coaching. It is crucial to create professional relationships that create a positive context that motivates you to improve your work mood.
Medical staff, through resilient strategies, reduce moral distress, increase workplace engagement, reduce turnover and improve patient satisfaction [114].
Nine studies analyzed the resilience theme (Table 10): two conceptual papers [115, 116], one systematic literature review [117] and six empirical researches: qualitative studies conducted in Italy [118] and UK [119] two mixed method approach in the UK [120, 121], one experiment conducted in USA [122] and one study that implemented discrete event simulation and system dynamics methodology in Italian emergency department.
Table 10
Resilience
|
Authors
|
Purpose
|
Method and context
|
Key findings
|
Further research
|
[118]
|
To present a mental health first aid service for people vulnerable to mental health problems, health-care professionals, people in isolation, and general citizenship.
|
Empirical
(Qualitative)
Italy
|
Anxiety, loneliness, depressive symptoms and fear of contagion were the main motivations prompting population and health-care professionals to ask for a psychological help highlighting the detrimental role of COVID-19 on both physical and mental health.
|
To consider different professionals and methods in order to provide psychological support.
|
[119]
|
To develop a method based on resilient healthcare principles to identify system vulnerabilities and quality improvement interventions.
|
Empirical
(Qualitative)
UK
|
Monitoring patients and workflow in the ED was identified as a priority for supporting staff to manage the complexity of the work. It's crucial the need to visualize the load on the system so that experts could detect and solve problems efficiently using resilient healthcare principles to address quality improvement.
|
To test resilient healthcare principles in different settings and organizations, including dental primary care, residential nursing homes and mental healthcare.
|
[115]
|
To explore social reality and rethink resilience among health professionals.
|
Conceptual
|
Staff who are resilient, engaged, happy and enjoy their work provide better quality care to patients and their families.
|
To delve into alternatives to maintaining staff resilience and well-being and analyze social constructionism and social constructivism.
|
[121]
|
To describe compassion fatigue and to present the process of Personal Reflective Debrief as an intervention to prevent compassion fatigue in ED nurses.
|
Empirical
(Experiment)
USA
|
Personal Reflective Debrief alleviates the stress of nurses promoting their resilience. Increasing nurses' resilience to workplace stress can counter compassion fatigue by providing planned, proactive resources to positively improve resiliency.
|
To evaluate the components of compassion fatigue over time evaluating the appropriate time frame needed for the intervention, large sample sizes, matching pre and post-test compassion fatigue evaluation scores, and evaluation over long periods of time.
|
[119]
|
To examine escalation policies to analyze the increase in demand of patients or a reduction in the capacity of beds.
|
Empirical
(Mixed method approach)
UK
|
Monitoring escalation is essential in understanding how to manage workload, analyzing the barriers and facilitators to improvement.
|
To test these actions of escalation policies in other contexts in order to generalize the findings.
|
[116]
|
To assess the effects of interventions aimed at supporting the resilience and mental health of frontline health professionals identifying barriers and facilitators of the resiliente interventions.
|
Systematic literature review
|
To conduct quantitative and qualitative evidence during or after epidemics that can generate interventions of resilience for the mental health frontline workers highlighting organizational, social, personal, and psychological factors.
|
To investigate barriers and facilitators to implementation of resilience interventions.
|
[115]
|
to understand how resilience can improve the ED context.
|
Conceptual
|
Learning through systematic training and simulation can be an important tool for identifying factors that have an impact on adaptive capacity.
|
To conduct empirical research to build and support resilient systems and processes in ED, identifying factors that promote resilience, both on individual-, team- and system- levels.
|
[122]
|
To assess and compare different hospital’s adaptive resource allocation strategies in responding to a Mass Casualty Incident.
|
Empirical
(Discrete event simulation, system dynamics)
Italy
|
In the daytime scenario, during the recovery phase of the emergency, a gradual disengagement of resources from the ED to restart ordinary activities in operating rooms and wards, returned the best performance. In the night scenario, the absorption capacity of the ED was evaluated by identifying the current bottleneck and assessment of the benefit of different resource mobilization strategies.
|
To analyze also additional resilience capacities, such as operational coordination mechanisms, in different countries.
|
[120]
|
To test the feasibility of translating Resilience Engineering concepts into practicalì methods to improve quality in ED.
|
Empirical
(Mixed method approach)
UK
|
Clinicians find the philosophy and principles of RE attractive because it accurately portrays the constant variability of clinical work, the need for adjustment and the important role of flexible adaptation in producing outcomes. Workshops and symposia for clinical practitioners may also be used to transfer skills.
|
To investigate the interaction of varying contextual factors to produce resilience and suggest different ways in which it can be strengthened and to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organizational contexts and different interventions.
|
The reviewed studies analyze social reality and rethink resilience among health professionals identifying system vulnerabilities and quality improvement interventions [115, 119]. The studies describe some models/processes to prevent fatigue in ED nurses and the mental health problems of healthcare professionals, people in isolation, and general citizenship [118, 122]. The resilience theme examines the effects of interventions aimed at supporting the resilience and mental health of medical staff, identifying barriers and facilitators of these, also analyzing the increase in demand of patients or a reduction in the capacity of beds and the different hospital’s adaptive resource allocation strategies in emergencies [116, 117, 120, 121, 123].
Anxiety, loneliness, depressive symptoms and fear of contagion were the main motivations prompting population and health-care professionals to ask for a psychological help highlighting the detrimental role of Covid-19 on both physical and mental health [118].
Monitoring patients and workflow in the ED was identified as a priority for supporting staff to manage the complexity of the work. It's crucial to visualize the load on the system so that experts can detect and solve problems efficiently using resilient healthcare principles to address quality improvement. Staff who are resilient, engaged, happy and enjoy their work provide better quality care to patients and their families [115, 119].
The Personal Reflective Debrief process alleviates the stress of nurses promoting their resilience. Increasing nurses' resilience to workplace stress can counter compassion fatigue by positively providing planned, proactive resources to improve resiliency [122]. Also, monitoring escalation is essential in understanding how to manage workload, analyzing the barriers and facilitators to improvement [120].
The management of emergencies like the health pandemic Covid-19 can generate resilience interventions for the mental health frontline workers, highlighting organizational, social, personal, and psychological factors. In the daytime scenario, during the recovery phase of the emergency, a gradual disengagement of resources from the emergency department (ED) to restart ordinary activities in operating rooms and wards, returned the best performance. In the night scenario, the absorption capacity of the ED was evaluated by identifying the current bottleneck and assessment of the benefit of different resource mobilization strategies [117, 123].