Ensuring Compliance with Documentation Policy for Patients Waiting to Be Evaluated

Aim: : At our institution, patients are spending increased lengths of time in the Emergency Department waiting to be assigned to a treatment area and evaluated by a physician. During this time, patients do not have an assigned nurse, therefore vital signs and reassessments were not being performed every two hours as per department policy. This compromised patient safety and regulatory compliance. The aim of this project was to improve patient safety and satisfaction through implementation of a designated nurse to reassess, intervene when necessary and ensure documentation is completed every two hours on waiting room patients.

Framework:: LEAN Methodology was used for this quality improvement project.

Setting:: This project was implemented at an urban, level I trauma center located in the Western United States.

Stakeholder Team:: The deviation from documentation policy was identified by the department’s Executive Director who proposed that a designated q2hr reassessment nurse role be created within the existing department staffing pattern. Assistant nurse managers developed the role definition and staffing strategy using feedback from frontline clinical end users, including charge nurses and staff working in the assignment during a pilot period.

Methods: : Our department implemented a new nursing role to re-assess patients who are experiencing long holding times in the waiting room. Vital signs and a focused assessment are completed by a reassessment RN every two hours after the initial triage encounter with patients. Vital signs may be assisted by Emergency Trauma Technicians or Clinical Care Partners. The Electronic Medical Record displays a red flag indicating when the reassessment is past due. Periodic chart audits will be performed throughout the day by the charge nurse and administrative nurse to increase compliance.

Outcomes:: Implementation of a designated nurse to provide re-assessment documentation every two hours for waiting room patients occurred in October 2022 and data collection is ongoing. Preliminary data demonstrates a mean non-compliance rate of 17.77% (range 3.26%, 30.47%). Ongoing analysis will examine associated factors to rates of low and high compliance days, including ED volume and staffing.

Implications:: Emergency Departments are experiencing longer wait times to be evaluated and treated by providers. Due to the acute nature of patients’ presenting illnesses, it is imperative that patients are frequently monitored and reassessed in order to receive timely and appropriate care. Based on preliminary data collection, designating nursing staff to the role is a strategy that may effectively perform these assessments in the waiting room environment. Data also suggests that compliance is best achieved by having clear indicators on the Electronic Health Record (EHR) to notify staff of overdue documentation. Real-time chart audits by administrative nurses may additionally provide a positive effect in the implementation of the documentation and care standards. With a multi-faceted approach, the impact of various strategies will be analyzed to evaluate which demonstrated the most positive impact on nursing documentation and practice.