Incorporating Hourly Rounding to Increase Emergency Department Patient Satisfaction: A Quality Improvement Approach.

PROBLEM: Patient satisfaction is an important factor that influences the perceived quality of care delivered. In an effort to meet patient expectations, a process improvement initiative involving hourly rounding was implemented to improve low patient satisfaction scores. METHODS: This project took place over 23 months and consisted of 4 phases (baseline, intervention I, break, and intervention II). During the intervention phases, self-reported hourly rounding was tracked on a daily basis. Compliance with rounding and patient satisfaction results were provided to staff during unit meetings and were displayed on a visual tracker board. Weekly 5-minute customer service training was provided to all staff. During the baseline and break phases, hourly rounding was not tracked. However, patient satisfaction data were still collected through the Interactive Customer Evaluation system. Three variables were measured using a 5-point Likert scale: overall patient satisfaction, patient perception of staff attitude, and whether the health care team answered all patient questions/concerns. RESULTS: Hourly rounding compliance was 39% during intervention I and 51% during intervention II. Approximately 0.01% of patients submitted satisfaction data. From baseline to conclusion of intervention II, overall patient satisfaction increased from 52% to 73%; perception of staff attitude increased from 70% to 84%; and whether the health care team answered all patient questions/concerns increased from 63% to 81%. DISCUSSION: There is a positive relationship between hourly rounding and patient satisfaction scores. Despite low compliance with hourly rounding, patient satisfaction increased for all 3 variables measured. To achieve a change in culture with hourly rounding compliance, nurse managers must consistently monitor staff compliance with hourly rounding.

Comparison of Temporal Artery Versus Rectal Temperature in Emergency Department Patients Who Are Unable to Participate in Oral Temperature Assessment.

INTRODUCTION: In the emergency department, pediatric and geriatric patients who present with illnesses and are unable to participate in oral evaluation of temperature must undergo a rectal temperature (RT) assessment. This study asks if a temporal artery temperature (TAT) measure can supplant the RT measure. METHODS: A convenience sample, using a within-subject design, was used to evaluate the efficacy of TAT compared with RT in patients ≤ 3 and ≥ 65 years of age, who were unable to participate in oral temperature assessments. RESULTS: Instrument reliability of the TAT is adequate for both the pediatric and geriatric populations. An unadjusted TAT did not provide acceptable temperature measurements. We also found that adjusting a TAT reading by adding -17.22°C (1° F) rendered the TAT average (either mean or median) adequately similar to RT averages for research purposes for both pediatric and geriatric groups. DISCUSSION: No influence was detected on the differences between RT and TAT due to age, sex, or emergency severity index (ESI) score in patients or due to profession, years of education, or years of experience in caregivers for either the pediatric or geriatric groups. Furthermore, the adjusted TAT reading could detect fever in individual patients adequately in both the pediatric and geriatric groups. However, the adjusted TAT readings were too frequently divergent from RT readings to be used to measure temperature in individual patients for both pediatric and geriatric groups.

Improving Triage Accuracy: A Staff Development Approach.

PURPOSE: The purpose of the process improvement initiative was to improve the percentage of undertriaged patients to less than 10% (benchmark) using the Emergency Severity Index tool. Undertriaged patients have an increased potential for poor outcomes due to a lengthier waiting room stay, which results in delay of care. DESCRIPTION OF THE PROJECT: An evidence-based project designed for staff development was conducted for a 7-month period. Project procedures consisted of triage chart reviews for a 3-month period during pre- and post-Emergency Severity Index training. Emergency Severity Index refresher training for nurses triaging in the emergency department was conducted for a 1-month period. OUTCOME: Chart reviews revealed that 102 of 388 patients (26.3%) were undertriaged before Emergency Severity Index training. After Emergency Severity Index training, chart reviews depicted that 41 of 440 patients (9.3%) were undertriaged. This difference was statically significant (P < .001), when tested using a 1-sided t test at the 95% confidence level and achieving at least 80% power. IMPLICATIONS: Regardless of previous training or years of emergency department nursing experience, triage refresher training has been shown to increase accuracy of triage categorization, thus leading to a decreased risk of poor patient outcomes.

Implementing diagnostic reasoning to differentiate Todd's paralysis from acute ischemic stroke.

Emergency department clinicians with limited resources are relied upon to deliver safe and timely patient care. Clinicians rely on cognitive biases such as anchoring, availability, and premature closure based on experience and quick mental algorithms to streamline medical data and arrive at a diagnosis. Although this is a time-saving and efficient method in the management of uncomplicated illnesses, it can result in a wrong diagnosis when managing patients with complicated presentations such as a stroke or a stroke mimic. Two conditions that present similarly, making it difficult to differentiate between them, are Todd's paralysis (a stroke mimic seen in selected patients with epilepsy) and acute ischemic stroke. However, by clinical reasoning, clinicians can formulate an accurate diagnosis while avoiding diagnostic biases. Incorporating clinical reasoning into the diagnostic process consists of gathering pertinent data, performing a diagnostic time-out, and arriving at a diagnosis reflective of data findings.