Hospitalists and an innovative emergency department admission process

Systematic Improvement in the Patient Transfer Process to a Tertiary Care Children's Hospital

OBJECTIVE

Interfacility transfer of pediatric patients to a children's hospital is a complex process that can be time consuming and dissatisfying for referring providers. We aimed to improve the efficiency of communication and acceptance for interfacility transfers to our hospital.

METHODS

We implemented iterative improvements to the process in 2 phases from 2013 to 2016 (pediatric medicine) and 2019 to 2022 (pediatric critical care and surgery). Key interventions included creation of a hospitalist position to manage transfers with broad ability to accept patients and transition to direct phone access for transfer requests to streamline connection. Effective initiatives from Phase 1 were adapted and spread to the other services in Phase 2. Data were manually extracted monthly from call transcripts and monitored by using statistical process control (SPC) charts. Primary outcome measures were time from call to connection to a provider and number of providers added to the call before making a disposition decision.

RESULTS

Average time from call initiation to provider connection for pediatric medicine calls decreased from 11 minutes to 5 minutes. The average number of internal physicians on each call before acceptance decreased from 2.1 to 1.3. In Phase 2, time to provider connection decreased from 11 to 4 minutes for pediatric critical care calls and 16 to 5 minutes for pediatric surgery calls.

CONCLUSIONS

We streamlined the process of accepting incoming transfer requests throughout our children's hospital. Prioritizing direct communication led to efficient disposition decisions and progression toward transfer and was effective for multiple service lines.

Outcomes of a Neurohospitalist Program at an Academic Medical Center

Background and Purpose

The purpose is to determine the impact of an academic neurohospitalist service on clinical outcomes.

Methods

We performed a retrospective, quasi-experimental study of patients discharged from the general neurology service before (August 2010–July 2014) and after implementation of a full-time neurohospitalist service (August 2016–July 2018) compared to a control group of stroke patients. Primary outcomes were length of stay and 30-day readmission. Using the difference-in-difference approach, the impact of introducing a neurohospitalist service compared to controls was assessed with adjustment of patients’ characteristics. Secondary outcomes included mortality, in-hospital complications, and cost.

Results

There were 2706 neurology admissions (1648 general; 1058 stroke) over the study period. The neurohospitalist service was associated with a trend in reduced 30-day readmissions (ratio of ORs: .52 [.27, .98], P = .088), while length of stay was not incrementally changed in the difference-in-difference model (-.3 [-.7, .1], P = .18). However, descriptive results demonstrated a significant reduction in mean adjusted LOS of .7 days (4.5 to 3.8 days, P < .001) and a trend toward reduced readmissions (8.9% to 7.6%, P = .42) in the post-neurohospitalist cohort despite a significant increase in patient complexity, shift to higher acuity diagnoses, more emergent admissions, and near quadrupling of observation status patients. Mortality and in-hospital complications remained low, patient satisfaction was stable, and cost was not incrementally changed in the post-neurohospitalist cohort.

Conclusions

Implementation of a neurohospitalist service at an academic medical center is feasible and associated with a significant increase in patient complexity and acuity and a trend toward reduced readmissions.

Impact on Length of Stay of a Hospital Medicine Emergency Department Boarder Service

BACKGROUND

It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS).

OBJECTIVE

To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder.

INTERVENTION

The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed.

PRIMARY OUTCOME AND MEASURES

The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate.

RESULTS

There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates.

CONCLUSION

Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.

Admission Decisions Made by Emergency Physicians Can Reduce the Emergency Department Length of Stay for Medical Patients

Background

Emergency department (ED) overcrowding is a worldwide problem that poses a threat to patient safety by causing treatment delays and increasing mortality. Consultations are common and important in the emergency medicine profession and are associated with longer ED length of stay (LOS). The purpose of this study was to evaluate the impact of admission decisions by emergency physicians without consultations on the ED LOS and other quality indicators.

Methods

The study was a retrospective observational study comparing the ED LOS of patients admitted to the internal medicine (IM) department before and after the policy change regarding admission decisions that was implemented in October 2016. During and after the policy change, emergency physicians decided how to arrange for and treat medical patients by processing their admission and providing follow-up care without consultations. The ED LOS and other indicators of patients admitted to the IM department were compared between the study period (January to June 2017) and the control period (January to June 2016).

Results

The median ED LOS of patients admitted to the IM department decreased from 673 (IQR: 347-1,369) minutes in the control period to 237 (IQR: 166-364) minutes in the study period. There were no significant differences in the interdepartmental transfer rate or in-hospital mortality between the two periods.

Conclusions

The admission decisions regarding medical patients made by emergency physicians without specialty consultations reduced the ED LOS without a significant negative effect on mortality or hospital LOS.

Hospitalists as Triagists: Description of the Triagist Role across Academic Medical Centers

From the hospitalist perspective, triaging involves the evaluation of a patient for potential admission to an inpatient service. Although traditionally done by residents, many academic hospitalist groups have assumed the responsibility for triaging. We conducted a cross-sectional survey of 235 adult hospitalists at 10 academic medical centers (AMCs) to describe the similarities and differences in the triagist role and assess the activities and skills associated with the role. Eight AMCs have a defined triagist role; at the others, hospitalists supervise residents/advanced practice providers. The triagist role is generally filled by a faculty physician and shared by all hospitalists.We found significant variability in verbal communication practices (P = .02) and electronic communication practices (P < .0001) between the triagist and the current provider (eg, emergency department, clinic provider), and in the percentage of patients evaluated in person (P < .0001). Communication skills, personal efficiency, and systems knowledge are dominant themes of attributes of an effective triagist.

Multicentre, prospective observational study of the correlation between the Glasgow Admission Prediction Score and adverse outcomes

OBJECTIVES

To assess whether the Glasgow Admission Prediction Score (GAPS) is correlated with hospital length of stay, 6-month hospital readmission and 6-month all-cause mortality. This study represents a 6-month follow-up of patients who were included in an external validation of the GAPS' ability to predict admission at the point of triage.

SETTING

Sampling was conducted between February and May 2016 at two separate emergency departments (EDs) in Sheffield and Glasgow.

PARTICIPANTS

Data were collected prospectively at triage for consecutive adult patients who presented to the ED within sampling times. Any patients who avoided formal triage were excluded from the study. In total, 1420 patients were recruited.

PRIMARY OUTCOMES

GAPS was calculated following triage and did not influence patient management. Length of hospital stay, hospital readmission and mortality against GAPS were modelled using survival analysis at 6 months.

RESULTS

Of the 1420 patients recruited, 39.6% of these patients were initially admitted to hospital. At 6 months, 30.6% of patients had been readmitted and 5.6% of patients had died. For those admitted at first presentation, the chance of being discharged fell by 4.3% (95% CI 3.2% to 5.3%) per GAPS point increase. Cox regression indicated a 9.2% (95% CI 7.3% to 11.1%) increase in the chance of 6-month hospital readmission per point increase in GAPS. An association between GAPS and 6-month mortality was demonstrated, with a hazard increase of 9.0% (95% CI 6.9% to 11.2%) for every point increase in GAPS.

CONCLUSION

A higher GAPS is associated with increased hospital length of stay, 6-month hospital readmission and 6-month all-cause mortality. While GAPS's primary application may be to predict admission and support clinical decision making, GAPS may provide valuable insight into inpatient resource allocation and bed planning.

Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea

BACKGROUND

The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists.

METHODS

A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI).

RESULTS

HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points.

CONCLUSION

Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.

Emergency Department Holding Orders

BACKGROUND

Holding orders help transition admitted emergency department (ED) patients to hospital beds.

OBJECTIVE

To describe the effect of ED holding orders.

METHODS

We conducted a single-site retrospective study of ward admissions from the ED to the hospital internal medicine (HIM) service over 2 years. Patients were classified based on whether the ED did (group 1) or did not (group 2) write holding orders; group 1 was subdivided into patients sent to the floor with only ED holding orders (group 1A) vs. with subsequent HIM admission orders (group 1B). Outcomes were ED length of stay (LOS), time from decision to admit to ED departure (D→D), transfer to a higher level of care within 6 h (potential undertriage), and discharge from admission ward within 12 h (potential overtriage).

RESULTS

There were 9501 admissions: 6642 in group 1 (2369 in group 1A and 4273 in group 1B) and 2859 in group 2. Reductions in mean LOS between groups (with 95% confidence intervals [CIs] of the differences) were as follows: group 1 vs. 2: 44 min (39-49 min); group 1A vs. 1B, 48 min (43-53 min); group 1B vs. 2: 27 min (22-32 min); group 1A vs. 2: 75 min (69-81 min). Mean D→D was shorter in group 1A than 1B by 43 min (40-45 min). Holding orders were not associated with increases in potential undertriage or overtriage.

CONCLUSIONS

ED holding orders were associated with improved ED throughput, without evidence of undertriage or overtriage. This work supports the use of holding orders as a safe and effective means to improve ED patient flow.

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay

OBJECTIVE

The objective was to evaluate the effect of an emergency clinician-initiated "ED admission holding order set" on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients.

METHODS

We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a "non-value-added" activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior.

RESULTS

The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention.

CONCLUSIONS

We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change.

Resident and hospitalist perspectives on the "great teaching case": Correlation with actual patient assignment decisions

BACKGROUND

With the advent of limits to resident duty hours and the size of teaching services, many academic institutions have introduced nonteaching services, often triaging perceived better teaching cases to the resident services.

OBJECTIVE

To compare resident versus faculty perceptions of ideal cases for teaching services and compare these perceptions with actual triage decisions made by faculty who assigned patients to either teaching or nonteaching services.

DESIGN

Residents and hospitalist faculty were surveyed about their perceptions of ideal and actual teaching admissions, first with qualitative, open-ended questions and then with quantitative, specific questions generated from responses to the first survey. Characteristics of patients admitted to teaching and nonteaching services were analyzed retrospectively and compared with resident and faculty perceptions.

RESULTS

Residents and faculty agreed that rare cases, patients with unique physical findings, and a variety of pathology were ideal for teaching services and that social admissions, benefactors, and patients with chronic or functional pain were not. Residents believed that traditional ("bread and butter") medicine cases were under-represented on the teaching services. Although residents perceived that they received a disproportionate number of older patients, outside transfers, patients with chronic pain, and patients with cancer, the only statistically significant difference was in patient age, with the teaching service actually receiving younger patients (66.7 vs 69.3 years; P=0.008).

CONCLUSIONS

Residents and faculty have similar views about ideal teaching cases, but a triage system based on perceived educational merit creates the possibility of resident misperceptions about their case mix, even if patients are distributed relatively equitably.

Patient flow in the emergency department: a classification and analysis of admission process policies

STUDY OBJECTIVE

We investigate the effect of admission process policies on patient flow in the emergency department (ED).

METHODS

We surveyed an advisory panel group to determine approaches to admission process policies and classified them as admission decision is made by the team of providers (attending physicians, residents, physician extenders) (type 1) or attending physicians (type 2) on the admitting service, team of providers (type 3), or attending physicians (type 4) in the ED. We developed discrete-event simulation models of patient flow to evaluate the potential effect of the 4 basic policy types and 2 hybrid types, referred to as triage attending physician consultation and remote collaborative consultation on key performance measures.

RESULTS

Compared with the current admission process policy (type 1), the alternatives were all effective in reducing the length of stay of admitted patients by 14% to 26%. In other words, patients may spend 1.4 to 2.5 hours fewer on average in the ED before being admitted to internal medicine under a new admission process policy. The improved flow of admitted patients decreased both the ED length of stay of discharged patients and the overall length of stay by up to 5% and 6.4%, respectively. These results are framed in context of teaching mission and physician experience.

CONCLUSION

An efficient admission process can reduce waiting times for both admitted and discharged ED patients. This study contributed to demonstrating the potential value of leveraging admission process policies and developing a framework for pursuing these policies.

Reduction of admit wait times: the effect of a leadership-based program

OBJECTIVES

Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED.

METHODS

This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured.

RESULTS

After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001).

CONCLUSIONS

A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction.

A simple tool to predict admission at the time of triage

Aim

To create and validate a simple clinical score to estimate the probability of admission at the time of triage.

Methods

This was a multicentre, retrospective, cross-sectional study of triage records for all unscheduled adult attendances in North Glasgow over 2 years. Clinical variables that had significant associations with admission on logistic regression were entered into a mixed-effects multiple logistic model. This provided weightings for the score, which was then simplified and tested on a separate validation group by receiving operator characteristic (ROC) analysis and goodness-of-fit tests.

Results

215 231 presentations were used for model derivation and 107 615 for validation. Variables in the final model showing clinically and statistically significant associations with admission were: triage category, age, National Early Warning Score (NEWS), arrival by ambulance, referral source and admission within the last year. The resulting 6-variable score showed excellent admission/discharge discrimination (area under ROC curve 0.8774, 95% CI 0.8752 to 0.8796). Higher scores also predicted early returns for those who were discharged: the odds of subsequent admission within 28 days doubled for every 7-point increase (log odds=+0.0933 per point, p<0.0001).

Conclusions

This simple, 6-variable score accurately estimates the probability of admission purely from triage information. Most patients could accurately be assigned to ‘admission likely’, ‘admission unlikely’, ‘admission very unlikely’ etc., by setting appropriate cut-offs. This could have uses in patient streaming, bed management and decision support. It also has the potential to control for demographics when comparing performance over time or between departments.

Models for improving patient throughput and waiting at hospital emergency departments

BACKGROUND

Overcrowding diminishes Emergency Department (ED) care delivery capabilities.

OBJECTIVES

We developed a generic methodology to investigate the causes of overcrowding and to identify strategies to resolve them, and applied it in the ED of a hospital participating in the study.

METHODS

We utilized Discrete Event Simulation (DES) to capture the complex ED operations. Using DES results, we developed parametric models for checking the effectiveness and quantifying the potential gains from various improvement alternatives. We performed a follow-up study to compare the outcomes before and after the model recommendations were put into effect at the hospital participating in the study.

RESULTS

Insufficient physicians during peak hours, the slow process of admitting patients to inpatient floors, and laboratory and radiology test turnaround times were identified as the causes of reduced ED throughput. Addition of a physician resulted in an almost 18% reduction in the ED Main discharged patient length of stay.

CONCLUSION

The case study results demonstrated the effectiveness of the generic methodology. The research contributions were validated through statistically significant improvements seen in patient throughput and waiting time at the hospital participating in the study.

Modelling coordination in hospital emergency departments through social network analysis

Coordination theory provides a theoretical framework for analysing complex processes of project groups working towards a common goal. In this study, we explore the relationship between coordination and social networks for the development of a network-based coordination model. This model is applied to measure the performance and quality of complex and dynamic project coordination such as in hospital emergency departments. The dataset used for the study was collected by the 2004 National Hospital Ambulatory Medical Care Survey--a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay and general hospitals in the United States. Using social network analysis, this study allows us to understand the possible causes of inefficient coordination performance and coordination quality resulting in access blocks.

Patient satisfaction with hospitalists: facility-level analyses

Despite concerns and disagreements about the impact of hospitalist models on health care, hospitalists are becoming the dominant means of providing inpatient care, and models continue to diversify. Understanding their impact and the factors that influence their adoption is essential. This study examined hospitalists' impact on patient satisfaction, considering a host of characteristics. Cross-sectional data received in calendar year 2008, aggregated to the facility level, represent 1777 hospitals (41% of which employed hospitalists) and 2 648 275 patients. Press Ganey's psychometrically sound inpatient satisfaction survey consists of 38 items (10 sections) rated on a 5-point Likert-type scale. Findings suggest that facilities with hospitalists may have an advantage regarding satisfaction with nursing and personal issues (eg, privacy, emotional needs, response to complaints), both of which may be related to broader communication issues. Moreover, teaching (overall satisfaction) and large facilities (satisfaction with admissions, nursing, and tests/treatments) might especially benefit from the presence of hospitalists. Exploring how specific hospitalist functions influence patient satisfaction may reap rewards.

Non-housestaff medicine services in academic centers: models and challenges

Non-housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non-housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the "academic hospitalist"), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission.

Research on the Frontlines of Healthcare

BACKGROUND

Evidence-based practice is a common goal in hospitals, but learning about research so that the practice can be done is often challenging for clinicians.

OBJECTIVES

The aims of this study were to (a) develop a process that supports organizational and staff development while conducting research and (b) conduct a research study in the emergency department (ED) to examine patient population, satisfaction, and waiting room issues.

METHODS

A multidisciplinary team of clinicians and scientists was assembled to learn and do research while evaluating the ED waiting room of a Level I trauma center. A cooperative learning method approach was used to teach research concepts as the study was designed and implemented.

RESULTS

The team demonstrated their knowledge and understanding of research concepts by being involved actively in the creation and implementation of the preintervention study. Using information from photographs, observations, and a questionnaire, the team identified the following key dissatisfaction areas: (a) atmosphere (including comfort with environment, neatness and cleanliness, and noise), (b) telephones, (c) parking and thoroughfare, (d) professional behavior and staff presence (including personal attention), (e) security, and (f) triage and confidentiality.

DISCUSSION

The model of working in partnership with researchers and using cooperative, collaborative research is an effective way to evaluate and address issues related to quality of care while learning about the research concepts needed to put evidence into practice.