C824 Nursing Leadership and Management

Chapter 1:  Introduction

Background

For many individuals, the emergency department (ED) is often the first point of contact with healthcare providers before admission to other units. Consequently, the problems of the patients vary from minor issues that do not require admission to complex or serious illnesses that require close and continuous monitoring. Because the ED is required to ensure proper management of all categories of patients, the environment can be fast-paced and sometimes chaotic. This reason explains why the emergency department is the busiest unit in any healthcare facility. Crowding in the ED is among the challenges brought about by the busy nature of this workplace environment. Implementing policies and designing strategies to improve patient flow can greatly help in the provision of safe and effective care to patients in the ED.

Emergency departments are not designed to care for patients for extended periods, but rather involve the transfer of patients to the wards or discharge upon treatment. When delays occur in the patient transfer process, there are often adverse effects on both the patient and healthcare worker. For instance, the quality of services provided can decrease due to the increasing demand for services by different patients brought about by overcrowding. Consequently, the nurses and other healthcare providers become overwhelmed due to the sluggish movement of patients and increasing demand for healthcare services. Providence St Peter Hospital provides emergency service care to numerous patients yearly and the problem of patient flow in the ED is prominent. This issue cannot be attributed to a specific group of healthcare professionals, but rather a combination of patient, healthcare provider, and system factors.

The problem of patient flow in the department exists due to a lack of proper strategies to manage the patient transfer to other units. For example, most departments require that a bedside report be provided during admission of the patient leaving the ED staff with a lot of tasks to complete before the transfer of patients. Additionally, the primary registered nurse (RN) has to make a call report before the transfer of patients to inpatient units leaving a gap in patient care in the ED. With the shortage of staffing and the increased census in the emergency center, this process of patient transfer puts more pressure on staff and increases waiting time before admission and discharge to the wards. Apart from the above factors, overcrowding in the ER as a result of increased patient flow makes it difficult to coordinate care for those requiring admission, immediate care, and discharge to home. To address this challenge, this project proposes a solution that will change the process of patient discharge to inpatient units.

Problem Statement

A patient’s visit to the healthcare facility is made up of a series of smaller events or services that make up the patient flow. These services can include triage, registration, assessment, consultation, or admission for inpatient care. A delay in one of these services contributes to decreased quality of care characterized by increased waiting time and even increased mortality rates that could otherwise be prevented. According to statistics, interference with the patient flow in the ED can compromise the quality of care, increase the length of stay, increase medication errors, and compromise organizational performance (Agency for Healthcare Research and Quality (AHRQ), 2020). Despite overcrowding in the ED being the leading cause of delayed patient flow, inefficiencies in service delivery can result in sluggish movement of patients from the ED to other units.

The problem in the emergency center in the organization is the lack of a standardized process for patient reporting to the inpatient units. The use of the traditional call report system before admission of the patient does not seem to address the challenge of overcrowding and decreased patient flow in the department. The registered nurses find it difficult to coordinate the transfer of patients to inpatient units because of staffing issues. For instance, utilizing the call report system means that the RN has to leave the patient room, make calls, and write reports to aid in the transfer of patients to other wards. This approach leaves a gap in patient care, delays care for other patients, and is tiresome. A practice change that will avoid the call report system while providing the inpatient units with adequate patient information can greatly streamline patient flow in the ED.

Practice Change, Quality Improvement, or Innovation

The proposed solution to the identified problem in the emergency department involves a practice change in the process of patient transfer to inpatient units. One of the commonly recommended practices to address patient flow issues is the use of hospital-wide coordinated strategies (Chang et al., 2018). For example, the ED inpatient units can develop a change strategy on how patients are transferred within the shortest time possible. Issues like unavailability of beds, cleanliness of patient rooms, and incomplete patient data should be solved to streamline the process of patient transfer. Additionally, with the increased use of technology today, a simple notification to the inpatient unit should prompt preparation for receiving a patient without the presence of the ED registered nurse or cal in reports. This project will utilize a ‘no call report’ system during the transfer of patients to inpatient units.

To begin with, the hospital Electronic Medical Record (EMR) system will be used to coordinate the process of patient transfer to the inpatient units. A SMART phrase added in the emergency center’s EMR charting will be filled out and sent to the respective ward when the patient is placed up for admission. Among the crucial components of the SMART phrase include whether the patient is ambulatory (how many assist/bedbound/walker), orientation (confused/combative/alert and oriented), and Covid testing status. The hospital EMR system will provide the patient’s history, vital signs, and any investigations or tests performed in the ED. According to the new strategy, it will be required that a new set of vital signs and blood sugar if the patient is diabetic be done before transport to the inpatient floor. Upon completion of these sets, the EC physician and patient placement navigator will confirm if the SMART phrase is filled and send a reminder to the RN when something is missing.

The utilization of technology will be evident in the new strategy of improving patient flow to the inpatient units. For example, the patient placement navigator will confirm the status of the SMART phrase and put the patient on the bedboard of the appropriate floor. The charge nurse on the appropriate floor will be informed to allocate the patient a room after receiving an admission request from the ED via the EMR system. In case a delay is present due to the cleanliness of the patient’s room, a STAT clean will be initiated and the EC informed to place a safe transport when the preparations are done. This process will surpass the call report system that is required to coordinate patient transfers to inpatient units. The project will exclude the pediatric unit and Cardiovascular ICU (CVICU) and Neuro/trauma ICU (NTICU) that always require a bedside report from the EC registered nurse to the unit nurse.

Rationale

The management of patient flow in the ED can help improve efficiency that leads to quality patient outcomes. According to evidence, reviewing workflow patterns in the ED and streamlining processes helps improve front-end and back-end processes such as triage, admission, and patient discharge (Chang et al., 2018). The new strategy will ensure the reduction of length of stay for patients waiting for admission to inpatient units. Additionally, it is well-known that mortality and morbidity in the ED are contributed by factors like delays in patient transfer and lack of close monitoring (Ko et al., 2019). The new strategy will help address these adverse patient outcomes because providers will have more time to look after other patients. Lastly, the new strategy offers the ED and inpatient units a simplified method of communicating patient care in a timely manner. The use of the EMR SMART phrase technology will ensure that two-way communication exists between ED and inpatient staff without physical contact. The strategy saves time by minimizing phone calls that could otherwise end in arguments and delays in patient transfer.

Chapter 2: Literature Review

Credible Sources

Unlike other departments in healthcare, the emergency department has limited control over patient input. The volume of patients seeking healthcare in the ED can be large depending on the healthcare facility, location of the institution, or the patient flow metrics in that particular organization. More often observed is overcrowding in the ED that contributes to poor patient outcomes. Numerous research has been conducted on the issue of overcrowding in the ED and strategies to address the problem. Other scholars have described the patient throughput process and patient flow in the ED including factors hindering these processes. Alongside these researches is the incorporation of technology into the improvement of patient flow and communication in the ED. Appendix A in this paper provides an evidence summary of 30 credible sources that address the issue of patient flow in the ED and strategies that can be used to improve the transfer of patients to inpatient units. The credible sources were obtained from various databases like Pro-Quest, Cochrane, EMBASE, PubMed, and CINAHL.

Best Practices

Digitization of patient care is the first best practice that is evident from the literature review. The use of electronic health records (EHRs) has become universal to influence the delivery of safe, and effective patient care. The EHR system is observed to have a huge impact on patient flow across hospital units, especially the emergency department. Atasoy et al (2019) explain that EHRs have improved communication between nurses and physicians across all departments leading to improved quality of care. Additionally, the use of EHRs in the ED has led to real-time availability of information to frontline care providers leading to improved care delivery (Salmasian et al., 2019).

Patient-centered care involves the delivery of care that is responsive and respective to the individual’s needs, values and preferences. This theme is observed in numerous pieces of literature that address the problem of patient flow in the ED. For instance, Ko et al (2019) describes how operational efficiency in the ED contributes to patient-centered care. The research demonstrates that improving the flow of patients in the ED reduces waiting time that enhances patient satisfaction scores. Additionally, operational efficiency that results from reduced waiting time is an experiential element of quality in the context of patient-centered care (Austin et al., 2020). Lastly, prioritizing on improving processes in the ED depicts the efforts of organizations towards meeting the demands of the patients.

 Evidence Summary

The Challenge of Patient Flow in the ED

Although ED throughput is viewed as a singular issue in the department, many factors outside the ED can contribute to the problem. Factors such as poor reception of patients in the wards, housekeeping delays, and inpatient discharge times can have a significant impact on ED throughput (Tasi et al., 2021). Another study by Austin et al (2020) explains that the crowding and sluggish flow of events in the emergency department is a consequence of input, throughput, and output factors. Emphasis is put on the volume of patients arriving in the ED and the availability of beds in the hospital wards. Additionally, it is observed that to identify the solutions to patient flow issues in the ED, an understanding of the input, throughput, and output factors should be made (Ko et al., 2019). These findings are consistent with Norman et al (2018) who suggests that an evaluation of available checklists for patient transfer and review of ED processes can greatly help to solve the challenge of patient flow in the department.

Electronic Health Record Use in the ED

The widespread adoption of electronic health records (EHRs) has increased the availability of real-time information for frontline healthcare providers. The emergency department is among the hospital units that have greatly benefited from the adoption of the technology. For instance, the availability of push notifications has helped physicians make informed choices including immediate transfer of patients to the wards (Salmasian et al., 2018)). The utilization of this technology has reduced the length of stay of patients awaiting discharge to the inpatient units and those discharged home (Atasoy et al., 2019). The incorporation of the EHR technology is also observed to have an impact on the communication of patient care. The system demonstrates strengths in timely communication between departments, clarity of complex orders, and notification of care when needed by the patient. Incorporation of this technology can help streamline services in the ED leading to improved patient flow.

Strategies to Reduce ED Overcrowding and Improve Patient Flow

The use of hospital-wide coordinated strategies is identified to be effective in enhancing the patient flow and reducing overcrowding in the ED (Chang et al., 2018). Strategies such as electronic tracking and dashboard, changing staffing patterns, and addressing transport can help in alleviating the problem. The AHRQ (2020) recommends the use of well-designed checklists to improve processes within the ED as a remedy to patient flow issues. Additionally, the agency recommends changes in nursing protocols and the use of flow coordinators to control patient flow in and out of the ED. These recommendations are consistent with another research that analyzed perceptions of nurses towards overcrowding in the ED (Eriksson et al., 2018). The study recommends that emergency departments should review their procedures to avoid both deviations from normal practice and moral stress among registered nurses.

Recommendation

The increased number of admissions to hospital emergency departments has resulted in overcrowding due to patient flow-related issues. Lack of clear guidelines and standardized method of discharge of patients to inpatient units is among the causes of inefficiencies at Providence St Peter Hospital. The literature review above provides guidelines for the implementation of processes that can improve patient flow in the unit. For example, AHRQ(2020) identifies a change in nursing protocols and standardizing communication to be among the best strategies to reduce delays in the ER. Other studies recommend a review of procedures and processes that deviate from normal practice in the ED to address the challenge of patient flow (Eriksson et al., 2018, Chang et al., 2018). The recommended strategy in this project will involve the incorporation of a SMART phrase in the ED EMR system to act as a standardized tool of patient transfer to inpatient units. A ‘no call report’ strategy will be utilized to minimize time spent by the ED RN to communicate patient transfer to other units since all information will be available through the EMR system.

 

Credible Sources

Author(s) (Formatted as in-text citation)	Database (CINAHL, EBSCO, Cochrane, Pro-Quest)	Peer-Reviewed (Yes/No)	Applicability   (Yes/No)	Evidence Grade (Strength/ Hierarchy)	Appraisal (Brief summary of findings; how findings inform your project?)	Inclusion   (Yes/No)
Walker et al., 2016	PubMed	Yes	Yes	Level I/Systematic review	There is need to identify a standardized process or methodology to improve patient throughput. Additionally, evidence-based research is needed to guide hospitals in implementing patient throughput strategies. My research focuses on improving the transfer process of patients from the EC to inpatient units.	Yes
Stankiewicz et al., 2018	Pro-Quest	Yes	Yes	Level IV/retrospective study	Implementation of a patient transfer protocol reduced time of patient transfer from the emergency department to the surgical intensive care unit. My project implements a no call report strategy to improve patient transfer to inpatient units.	No
Atasoy et al., 2019	CINAHL	Yes	Yes	Level V/Meta-synthesis	The adoption of EHRs has reduced fragmentation across disparate providers and care settings. EHRs are crucial for coordinating activities across hospital departments. My research uses EMR to improve communication and transfer of patients to the inpatient units.	Yes
Yarmohammadian et al., 2017	Cochrane	Yes	No	Level I/Integrative review	The most comprehensive strategy to reduce overcrowding in the emergency departments is the use of ideal patient journey models. My research focuses on a strategy to transfer patients from EC to inpatient unit using a no call report model.	No
Hemesath et al., 2019	EMBASE	Yes	Yes	Level IV/cross-sectional study	The implementation of standardized communication process using a summary form greatly contributed to the transfer of patients through facilitation of communication. My research utilizes a similar strategy of SMART phrase charting to improve transfer of patients.	No
Bittencourt et al., 2020	PubMed	Yes	Yes	Level V/Meta-synthesis	Interventions involving change in ED’s work processes, strengthening of ED teams, strengthening of triage services and creation of new care zones improved patient throughput in the emergency departments. My research implements a strategy that changes ED work processes to improve patient throughput to inpatient units.	No
Probus & Smith, 2020	PubMed	Yes	No	Level IV/Retrospective study	Significant decrease in mean length of stay (LOS) for patients in the ED were observed after interventions focusing on nursing-centric activities were made. My research’s intervention is on call report system used by nurses that is part of the nursing-centric activities during the transfer of patients.	No
Chang et al., 2018	EBSCO	Yes	Yes	Level IV/Comparative study	Across all hospitals, ED crowding was recognized as an issue. Organizational performance strategies like coordinated activities and leadership involvement were proposed to solve the problem. My research’s intervention focuses on organizational performance using a no call report system during patient transfer.	Yes
Salmasian et al., 2019	Pro-Quest	Yes	Yes	Level IV/Retrospective study	Event-based notification systems using the EHR were effective in improving patient flow in the emergency department. My research incorporates the use of SMART phrase technology in the EMR to improve transfer of patients to the inpatient units.	Yes
Ko et al., 2019	EBSCO	Yes	Yes	Level V/Meta-synthesis	Operational efficiency is crucial factor in achieving patient satisfaction. Length of stay longer than 17 minutes reduces the odds of getting better satisfaction scores. My project aims at improving transfer of patients from EC to reduce length of stay in the emergency department.	Yes
Sanchez et al., 2017	CINAHL	Yes	No	Level IV/Retrospective study	Implementation of an electronic handoff between ED and inpatient units maximized opportunities for patient signout. My research utilizes the EMR to improve transfer of patients to the inpatient units.	No
Patton et al., 2017	EMBASE	Yes	No	Level VII/Quality improvement project	The use of standardized handoff was crucial fro safe transfer of pediatric patients to inpatient units alongside improving patient satisfaction scores. My research focuses on the use of a no call report strategy fro patient transfer except for transfers to the pediatric and intensive care units.	No
Morley et al., 2018	Cochrane	Yes	Yes	Level I/Systematic review	Overcrowding in the ED was related to number of patients attending the ED, timely discharge from the ED and the patient flow processes. My research addressing the issue of patient flow to inpatient units by utilizing a no-call report strategy.	No
Austin et al., 2020	CINAHL	Yes	Yes	Level I/Systematic review	Interventions to improve emergency department performance included the domains of time, proportion, cost, clinical outcomes and process.My research addresses the process domain of improving patient transfer to inpatient units.	Yes
Norman et al., 2018	Cochrane	Yes	Yes	Level VII/Quality improvement project	The use of a locally validated checklist improved the transfer and care of patients from the ED to medical and surgical wards. My research integrates a SMART phrase checklist in the EMR to improve transfer of patients to the inpatient units.
Potts et al., 2018	Pro-Quest	Yes	Yes	Level IV/Case controlled study	Implementation of a ready to move (RTM)- to- occupied time strategy using EHR improved waiting time from 83 minutes to 49 minutes. My research implements an EHR strategy to improve transfer of patients and potentially reduce waiting time in the EC.	No
van der Linden et al., 2019	EMBASE	Yes	No	Level IV/Cross-sectional study	Implementation of a multimodal intervention in the ED reduced the overall turnaround times, length of stay and patient admission processes. My research aims at improving the process of patient transfer to inpatient units.	No
Purushothaman, 2020	CINAHL	Yes	No	Level I/Narrative review	Solutions to improve patient flow for psychiatric patients from the ED department all focused on coordinated approaches.My research strategy involves coordination of patient transfer to inpatient units using a multidisciplinary approach.	No
Agency for Healthcare Research and Quality (AHRQ), 2020	AHRQ website	No	Yes	Level VII/Case study	The study recommends the use of nursing protocols, flow coordinators and communication strategies to minimize overcrowding in the ED. My research addresses this issue by improving patient transfer to inpatient units.	Yes
Kreindler, 2017	EBSCO	Yes	No	Level V/Qualitative study	Smooth flow of patients in the ED is dependent on efficiency of processes and capacity building for populations. My research focuses on improving process especially timely transfer of patients to inpatient units using a no call report strategy.	No
Shen & Lee, 2019	PubMed	Yes	Yes	Level VII/Quality improvement study	Interventions to reduce congestion in the ED showed marked reduction in waiting times, and efficiency in patient transfer from the ED. My research aims at improving the patient transfer process to inpatient units.	No
Jarvis, 2016	PubMed	Yes	Yes	Level V/Meta-synthesis	The study indicates that the use of new technologies such as point of care testing can help improve patient flow in the ED. My research uses the EMR technology to improve patient transfer to inpatient units.	No
Eriksson et al., 2018	Cochrane	Yes	Yes	Level IV/Descriptive study	Nurses are challenged in their professional responsibilities due to workload in the ED. Extended length of stay reduces the level of performance for nurses in the ED. My research addresses this challenge by implementing a no call report during patient transfer to the inpatient units.	Yes
Lee et al., 2017	PubMed	Yes	Yes	Level IV/Cross-sectional study	The handoff process in the ED in many institutions is not standardized. Most providers preferred bedside handoffs to telephone handoffs. My research uses a no call report to address the challenge of patient transfer in the ED.	No
Walker et al., 2016	PubMed	Yes	Yes	Level I/Systematic review	The findings indicate a lack of a standardized patient throughput strategies across all hospital departments. My research implements a standardized No call report strategy using a SMART phrase checklist in the ED to improve transfer of patients.	No
Tasi et al., 2021	Pro-Quest	Yes	No	Level IV/Retrospective study	The utilization of emergency department observational units (EDOUs) and the use of synchronous electronic handoffs increased the transfer of patients from the ED. My research utilizes the EMR technology to create a transfer protocol that can reduce waiting times in the ED.	No
Hendrickson et al., 2019	Cochrane	Yes	No	Level VI/Qualitative study	An innovative approach utilizing conference call during admission to pediatric unit supported safe patient care. My research uses an innovative strategy (SMART phrase using EMR technology) to address the challenge of patient transfer from the ED to inpatient units.	No
Smith et al., 2018	Cochrane	Yes	Yes	Level IV/cross-sectional study	Implementation of SBAR-DR structured communication strategy in the ED improved handoff efficiency and patient transfer to other units. My research implements a new throughput strategy to streamline patient transfer from the EC.	No
Department of Health, 2016	Queensland Health website	No	Yes	Level I/Practice guidelines	The guidelines recommend the use of standardized documents to check for the patient status to ease transfer from the ED department. My research uses the SMART phrase checklist incorporated into the hospital EMR to improve patient transfer.	No
Singleton et al., 2018	Pro-Quest	Yes	No	Level IV/Retrospective study	The use of an electronic signout strategy to improve ED-to-inpatient transfer and patient safety yielded minimal results to support the effectiveness of the intervention. My research tries to use a no call report strategy with EMR technology to improve transfer of patients from ED to inpatient units.	No

References

Agency for Healthcare Research and Quality. (2020). Some patients can’t wait: Improving timeliness of emergency department care. https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care

Atasoy, H., Greenwood, B. N., & McCullough, J. S. (2019). The digitization of patient care: A review of the effects of electronic health records on health care quality and utilization. Annual Review of Public Health, 40, 487-500. https://doi.org/10.1146/annurev-publhealth-040218-044206

Austin, E. E., Blakely, B., Tufanaru, C., Selwood, A., Braithwaite, J., & Clay-Williams, R. (2020). Strategies to measure and improve emergency department performance: A scoping review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 28(1), 55. https://doi.org/10.1186/s13049-020-00749-2

Bittencourt, R. J., Stevanato, A. M., Bragança, C., Gottems, L., & O’Dwyer, G. (2020). Interventions in overcrowding of emergency departments: An overview of systematic reviews. Revista de Saude Publica, 54, 66. https://doi.org/10.11606/s1518-8787.2020054002342

Chang, A. M., Cohen, D. J., Lin, A., Augustine, J., Handel, D. A., Howell, E., Kim, H., Pines, J. M., Schuur, J. D., McConnell, K. J., & Sun, B. C. (2018). Hospital strategies for reducing emergency department crowding: A mixed-methods study. Annals of Emergency Medicine, 71(4), 497–505.e4. https://doi.org/10.1016/j.annemergmed.2017.07.022

Department of Health. (2016). Guidelines for inpatient admission facilitation. https://www.health.qld.gov.au/__data/assets/pdf_file/0032/377771/qh-hsdgdl-025-3.pdf

Eriksson, J., Gellerstedt, L., Hillerås, P., & Craftman, Å. G. (2018). Registered nurses’ perceptions of safe care in overcrowded emergency departments. Journal of Clinical Nursing, 27(5-6), e1061–e1067. https://doi.org/10.1111/jocn.14143

Hemesath, M. P., Kovalski, A., Echer, I. C., Lucena, A. D. F., & Rosa, N. G. D. (2019). Effective communication on temporary transfers of inpatient care. Revista Gaucha de Enfermagem, 40(spe), e20180325-e20180325. https://doi.org/10.1590/1983-1447.2019.20180325

Hendrickson, M. A., Schempf, E. N., Furnival, R. A., Marmet, J., Lunos, S. A., & Jacob, A. K. (2019). The admission conference call: A novel approach to optimizing pediatric emergency department to admitting floor communication. Joint Commission Journal on Quality and Patient Safety, 45(6), 431–439. https://doi.org/10.1016/j.jcjq.2019.02.008

Jarvis P. R. (2016). Improving emergency department patient flow. Clinical and Experimental Emergency Medicine, 3(2), 63–68. https://doi.org/10.15441/ceem.16.127

Ko, D. G., Mai, F., Shan, Z., & Zhang, D. (2019). Operational efficiency and patient‐centered health care: A view from online physician reviews. Journal of Operations Management, 65(4), 353-379. DOI:10.1002/joom.1028

Kreindler S. A. (2017). Six ways not to improve patient flow: A qualitative study. BMJ Quality & Safety, 26(5), 388–394. https://doi.org/10.1136/bmjqs-2016-005438

Lee, S., Jordan, J., Hern, H. G., Kessler, C., Promes, S., Krzyzaniak, S., Gallahue, F., Stettner, T., & Druck, J. (2017). Transition of care practices from emergency department to inpatient: Survey data and development of algorithm. The western Journal of Emergency medicine, 18(1), 86–92. https://doi.org/10.5811/westjem.2016.9.31004

Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: A systematic review of causes, consequences and solutions. PloS One, 13(8), e0203316. https://doi.org/10.1371/journal.pone.0203316

Norman, S., DeCicco, F., Sampson, J., & Fraser, I. M. (2018). Emergency room safer transfer of patients (ER-STOP): A quality improvement initiative at a community-based hospital to improve the safety of emergency room patient handovers. BMJ Open, 8(12), e019553. http://dx.doi.org/10.1136/bmjopen-2017-019553

Patton, L. J., Tidwell, J. D., Falder-Saeed, K. L., Young, V. B., Lewis, B. D., & Binder, J. F. (2017). Ensuring safe transfer of pediatric patients: A quality improvement project to standardize handoff communication. Journal of Pediatric Nursing, 34, 44-52. https://doi.org/10.1016/j.pedn.2017.01.004

Potts, L., Ryan, C., Diegel-Vacek, L., & Murchek, A. (2018). Improving patient flow from the emergency department utilizing a standardized electronic nursing handoff process. The Journal of Nursing Administration, 48(9), 432–436. https://doi.org/10.1097/NNA.000000000000064

Probus, K. A., & Smith, T. B. (2020). Improving quality with emergency department throughput in a critical access hospital. The Journal of Nursing Administration, 50(6), 363–368. https://doi.org/10.1097/NNA.0000000000000898

Purushothaman, S. (2020). Patient flow from emergency department to inpatient psychiatric unit–A narrative review. Australasian Psychiatry, 1039856220936629. https://doi.org/10.1177/1039856220936629

Salmasian, H., Landman, A. B., & Morris, C. (2019). An electronic notification system for improving patient flow in the emergency department. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science, 2019, 242–247. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6568086/

Sanchez, L. D., Chiu, D. T., Nathanson, L., Horng, S., Wolfe, R. E., Zeidel, M. L., Boyd, K., Tibbles, C., Calder, S., Dufresne, J., & Yang, J. J. (2017). A model for electronic handoff between the emergency department and inpatient units. The Journal of Emergency Medicine, 53(1), 142–150. https://doi.org/10.1016/j.jemermed.2017.03.027

Shen, Y., & Lee, L. H. (2019). Improving the wait time to admission by reducing bed rejections. BMJ Open Quality, 8(3), e000710. https://doi.org/10.1136/bmjoq-2019-000710

Singleton, J. M., Sanchez, L. D., Masser, B. A., & Reich, B. (2018). Efficiency of electronic signout for ED-to-inpatient admission at a non-teaching hospital. Internal and Emergency Medicine, 13(7), 1105–1110. https://doi.org/10.1007/s11739-018-1816-z

Smith, C. J., Buzalko, R. J., Anderson, N., Michalski, J., Warchol, J., Ducey, S., & Branecki, C. E. (2018). Evaluation of a novel handoff communication strategy for patients admitted from the emergency department. The Western Journal of Emergency Medicine, 19(2), 372–379. https://doi.org/10.5811/westjem.2017.9.35121

Stankiewicz, S., Larsen, C., Sullivan, F., Zullo, C., Pugh, S. C., & Kopp, M. (2019). Evaluation of a practice improvement protocol for patient transfer from the emergency department to the surgical intensive care unit after a level I trauma activation. Journal of Emergency Nursing, 45(2), 144–148. https://doi.org/10.1016/j.jen.2018.10.006

Tasi, M. C., Baymon, D. E., Temin, E. S., Zheng, H., Lehman, K. M., Baccari, B., Tubridy, A., Conly, B., & Yun, B. J. (2021). Evaluation of process improvement interventions on handoff times between the emergency department and observation unit. The Journal of Emergency Medicine, 60(2), 237–244. https://doi.org/10.1016/j.jemermed.2020.10.002

van der Linden, M., van Ufford., & van der Linden, N. N. (2019). The impact of a multimodal intervention on emergency department crowding and patient flow. International Journal of Emergency Medicine, 12(1), 1-11. https://doi.org/10.1186/s12245-019-0238-7

Walker, C., Kappus, K., & Hall, N. (2016). Strategies for improving patient throughput in an acute care setting resulting in improved outcomes: A systematic review. Nursing Economics, 34(6), 277–288. https://pubmed.ncbi.nlm.nih.gov/29975490/

Yarmohammadian, M. H., Rezaei, F., Haghshenas, A., & Tavakoli, N. (2017). Overcrowding in emergency departments: A review of strategies to decrease future challenges. Journal of research in medical sciences : The Official Journal of Isfahan University of Medical Sciences, 22, 23. https://doi.org/10.4103/1735-1995.200277