Administration of Emergency Medicine
The Effects of Emergency Department Staff Rounding on Patient Safety and Satisfaction

https://doi.org/10.1016/j.jemermed.2008.03.042Get rights and content

Abstract

Background: Two recent inpatient studies documented that regular nursing staff rounding increased patient safety and satisfaction. However, the effect of systematic emergency department (ED) staff rounding on patient safety and satisfaction has not been adequately tested. Study Objective: The objective of this study was to test the effectiveness of three different rounding techniques. Methods: An 8-week study using a quasi-experimental, non-equivalent group, time-sampling design was conducted in 28 EDs. The three rounding protocols were: 1) rounds every 30 min; 2) rounds every hour; 3) rounds every hour with an Individualized Patient Care tactic (IPC; patients were asked to name their most important expectation for the ED visit). Baseline data were collected the first 4 weeks; rounding was done the second 4 weeks. Outcome measures compared the baseline to the rounding period data for patients who left without being seen (LWBS), those leaving against medical advice (AMA), patient satisfaction, call light use, and nursing station encounters. Results: The three rounding protocols combined reduced LWBS by 23.4%, leaving AMA by 22.6%, falls by 58.8%, call light use by 34.7%, and approaches to the nursing station by 39.5%. Patient satisfaction ratings for overall care and pain management increased significantly. The protocol using the IPC tactic produced the most significantly improved outcomes. Conclusions: Rounding in the ED reception and treatment areas is effective and improves outcomes. Further research should determine the optimal design for rounding considering the mixed shifts in EDs, seek ways to increase communicating delays to patients, and investigate how to integrate rounding with physician activities.

Introduction

Emergency departments (EDs) generate 42% of all hospital admissions nationally (1, 2). Besides being an important revenue source for the inpatient side, patients' experiences in an ED affect them personally, can influence future hospital choice, and generate either positive or negative word-of-mouth comments among family and friends. Unfortunately, EDs nationally receive the lowest satisfaction ratings from patients when compared to all other hospital departments, and additional analyses reveal that inpatients admitted from EDs give lower overall satisfaction ratings for their inpatient hospital experiences when compared to inpatients admitted through the normal admissions process (3). Because negative experiences are long-lasting, it is important to improve patients' experiences in the ED to ensure optimal patient care, continued ED usage, and increased patient satisfaction. This study evolved as a result of many calls and questions from ED managers about the most effective rounding techniques to use in an ED after publication of an article by one of the authors on the outcomes from hourly inpatient rounding as well as knowledge of the authors' beliefs that specific rounding techniques can improve the ED patient experience (4).

Before 2006, empirical research on the benefits of systematic nursing staff rounding with either inpatients or outpatients was not being performed. Within the last year, two empirically based studies with inpatients demonstrated that hourly rounds by nursing staff can drastically reduce the number of patient call lights and falls while increasing patient and nursing staff satisfaction, and twice daily rounds by Early Nursing Intervention Teams can prevent avoidable adverse events and reduce codes on a general care-medical intensive care unit (4, 5). Research on the effects of interdisciplinary rounding tactics (i.e., periodic rounding usually done twice a week using different clinical members including physicians, physical therapists, dietitians, social workers, nurses) performed with varied patient types and hospital units has also shown positive effects. Various studies found that communication and shared decision-making with patients and family members improve, pain management is more effective, and patient satisfaction levels improve when nurses engage in specific behaviors during semi-weekly pain management assessment rounds among cancer patients (6, 7). Other studies found that there is increased staff satisfaction and a reduced incidence of decubiti ulcers for a surgical intensive care unit (ICU) population and for patients staying in the ICU for more than 72 h when rounds are conducted (8, 9). Thus, prior research suggests that both systematic nurse rounding and periodic interdisciplinary rounding can positively impact patient care and satisfaction.

The ED research to date has shown that lengthy waits and overcrowding cause patients to leave without being seen (LWBS) and that increasing communication with patients in the waiting area can be an effective strategy to reduce LWBS (10, 11, 12). Other studies have documented that staff explanations of health status and treatment, information provided to patients, prompt pain control methods, and the attitudes and interpersonal skills (including caring) of health care providers all significantly impact ED patient satisfaction (13, 14, 15, 16, 17, 18). Data from the largest ED satisfaction vendor in the United States reveal that the factors most important to patients in an ED are being kept informed about delays, the degree to which the staff care about patients as people, pain control, and nurses keeping patients and family informed about their treatment (19). Although total time spent in the ED does have a strong impact on overall satisfaction, how well patients are informed about delays has an even greater impact. The largest number of complaints about ED care center around patient treatment, communication, poor staff attitudes, and delay in treatments, and other data reveal that in addition to providing optimal patient care, the number one priority for America's EDs is to improve communication with patients about delays (20).

Finally, an important theme in the literature since the introduction of SERVQUAL is that service quality—as consumers perceive it—is a function of: 1) what consumers expect and 2) how well the organization performs in providing the service (21). Patients' expectations for care can be defined as anticipation that given events are desired or likely to occur during a health care encounter, and these expectations form the basis of their evaluations of the care and service received (22). Patients who receive the care they hoped for (i.e., their idealized expectations were met) are more likely to be satisfied than those who do not (23). Conversely, when there is a disparity between the expectation and experience for an encounter, dissatisfaction increases (24, 25, 26). Understanding and meeting patients' expectations and requests are central to most theories of patient satisfaction, the assessment of quality care, and achieving satisfaction in a service encounter. Because patients' expectations are varied, it is suggested that patients be asked about their expectations. The increased patient satisfaction from meeting expectations is in turn related to greater adherence to medical advice and a lower propensity to sue for malpractice (27, 28, 29, 30, 31). In pediatric encounters, physician knowledge of parental expectations about a child's pain management increases satisfaction (32, 33). Unfortunately, not meeting expectations is quite common in health care settings (14).

The literature has documented the positive effects of various types of inpatient rounding, the reasons patients are not satisfied with ED care, and what they like about emergency care, as well as the impact of meeting patient expectations. However, an important research question that has yet to be answered is whether or not a systematic, non-interdisciplinary, proactive rounding protocol that anticipates and meets patients' needs in an ED setting can result in improved patient care management and satisfaction.

For this study it was hypothesized that systematic rounding using three different well-defined rounding protocols that addressed the issues causing the greatest amount of patient dissatisfaction with ED care would result in improved outcomes, including: 1) reduced LWBS; 2) reduced leaving against medical advice (AMA); 3) reduced patient falls; 4) reduced patient call lights; 5) reduced patient or family member visits to the nursing station to check on the patient's treatment status, inquire about waits and delays, ask for things for the patient; and 6) increased patient satisfaction. A key objective was to determine the most effective rounding technique of the three types tested.

Section snippets

Materials and Methods

A total of 28 hospital EDs participated from October 1–November 30, 2006. An e-mail communication along with a detailed research protocol was sent to a random sample of ED directors throughout the United States using the American Hospital Association's bed size categories to ensure a representative sample (Table 1). The departments self-selected to participate after reviewing the protocol and agreeing to the time frame and rigor necessary to complete the study. Each hospital's Institutional

Results

Of the 28 EDs in the study, a total of 10 performed 30-min rounds (36%), nine performed 1-h rounds (32%), and nine performed 1-h rounds with IPC (32%). Collectively, after the study there were declines in all five measures, which represent positive changes for these EDs. Patients LWBS declined by 23.4% (from 1999 to 1532 patients; p = 0.001); patients leaving AMA declined by 22.6% (from 717 to 555 patients; p = 0.002); patient falls declined by 58.8% (from 17 to 7 patients; p = 0.01); patients'

Discussion

Consistent with what we know from previous inpatient studies, rounding can increase patient safety and both patient and staff satisfaction. We also know a major problem with ED care throughout the United States is a lack of communication about delays. Furthermore, we know that what increases patient satisfaction is meeting patient expectations; staff explaining health status, treatment plans and delays; prompt pain control; and the attitudes of the staff. Just as inpatient rounding resulted in

Conclusions

In summary, rounding in the ED is an effective behavioral method to increase patient safety and patient satisfaction, and improve hospital financial performance by reducing the numbers of patients LWBS and leaving AMA. Staff and physicians were also pleased with the outcomes. The most effective method was hourly rounding with IPC (i.e., asking patients what is most important to them while they are in the ED). However, this study fell short on significantly increasing patient satisfaction with

Acknowledgment

We gratefully acknowledge the following hospitals, their Institutional Review Boards, their Emergency Departments, managers, and staff for participating in this study: Altoona Regional Medical Center, Altoona, PA; Baylor Medical Center at Garland, Garland, TX; Baylor Plano Specialty Hospital, Plano, TX; Baylor Regional Medical Center at Grapevine, Grapevine, TX; Central Carolina Hospital, Sanford, NC; Children's Healthcare of Atlanta–Egleston Campus, Atlanta, GA; Children's Healthcare of

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