Importance of standardization and evidence-based practice among nurses and its outcomes

Angel Roselin S

Deputy Nursing Superintendent, Kauvery Hospital, Tirunelveli

Abstract

Nurses play an integral role in patient- triaging and initial management. Standardized management of the clinical features on presentation and critical thinking are necessary to manage the ER department efficiently.

Introduction

Emergency nursing care is a specialized area that mainly focusses on providing immediate care focusing on medical emergency or trauma. It includes an instant assessing of triaging, airway establishment, controlling bleeding and preventing lifelong damage/disability or death.

Ensuring patient safety and surveillance is essential for nurses in emergency departments, particularly with regard to the correlation between patient flow and direct nursing care.

Emergency nursing has been defined in many ways but is generally considered the ‘care of individuals of all ages with perceived or actual physical or emotional alterations of health that are undiagnosed or that require further interventions’ (Alpi, 2006).

Patient case-mix and annual patient visits per year are generally stable over time in emergency departments.

Emergency nurses face challenges in managing the complexity of the emergency department environment.

Review of the literature

Emergency department nursing involves more than just ensuring patient flow, and the perspective on patient flow should be considered in relation to other aspects of emergency department nursing (Benjamin and Wolf, 2022). This is particularly important in exploring the relationship between emergency department nursing and patient outcomes. Emergency department patient flow is often visualized in a linear way, as illustrated schematically in Fig. 1. For example, a recent study described the patient’s progress through the emergency department, from triage to the patient leaving the emergency department (Curtis et al., 2023). Two different flows are described, with the novel flow (EPIC-START) visualizing the emergency department nurse’s role more clearly (Curtis et al., 2023). In addition, EPIC-START illustrates some of the additional tasks emergency department nurses perform in the emergency department context. The linear description of the flow process indicates the order in which actions are taken and the dependencies between actions.

The flow process has become even more evident in the emergency department context during the past decade, partly due to quality improvement targets, such as time to be seen by a physician or advanced nurse practitioner and length of stay (Melon et al., 2013; NHS, 2019). Patient flow occurs during the throughput and output phases described by Asplin et al. (2003).

As mentioned above, the triage level refers to the maximum length of time estimated to be medically safe for a patient to wait before being seen by the primary care provider. Hence, the triage level relates to patient flow, indicating the amount of time in which the patient is expected to be taken care of during the initial part of the throughput phase. However, the timeframes stipulated within each triage level can be difficult to maintain, especially given crowding and patient complexity, and reassessments of waiting patients are increasingly required to ensure patient safety and to prevent patients from deteriorating. The timeframe for the patient’s entire emergency department visit, the emergency department length of stay, is another example of the flow perspective. Since the implementation of length of stay as a quality indicator, there has been an increased focus on the management of patients in the emergency department. The definition of an extended emergency department length of stay varies widely across countries but is often between four and 48 hours (Andersson et al., 2020).

Nurses play an important role in ensuring effective patient flow forward, and emergency department nurses are responsible for the logistics of this process. Benjamin and Wolf (2022) suggests that research on patient flow should also include the perspectives of frontline nurses. Notably, frontline nurses have been found to view themselves as external agents of the flow process (Sharma et al., 2020). Patient flow occurs as time goes by during the patient’s visit. Eventually, patients will reach their final emergency department outcome, that is, discharge or admission (including transfer). The patient flow may be fast or slow and may also be predictable or unpredictable for the nurse. Often, factors outside the emergency department nurses’ control influence patient flow (e.g. lack of beds, short-staffing, increased admissions) (Sharma et al., 2020). Hence, nurses must adapt their interventions and other actions in relation to variable patient flow aspects. Patient flow management allows nurses to incorporate patient flow with their other tasks. Benjamin and colleague defined patient flow management as ‘the application of holistic perspectives, dynamic data, and complex considerations of multiple priorities to enable timely, efficient, and high-quality patient care’ (Benjamin and Jacelon, 2022). Further, the role of frontline nurses in patient flow management has been highlighted (Benjamin and Wolf, 2022).

Fig (1): Flow of work

Emergency nurses’ conceptualization of patient flow management differs from the definition as it has emerged through patient flow literature. Patient flow management is a nurse-driven process that relies on nursing knowledge and the work of all emergency nurses, including bedside nurses. Emergency nurses perceive the ultimate goal of patient flow management to be the collective safety of patients, and they work to promote patient safety within their own scope of responsibility.

Fig (2): Patient flow through the emergency department. Infographic describing the patient flow from arrival in the emergency department(ED) through discharge or admission to the hospital

Community satisfaction with the good services provided by the hospital will have an impact on the value of the hospital in society (Bakan et al., 2014; Swain & Kar, 2018). If the services provided do not satisfy the people who receive the services, of course this will have a negative impact on the services provided, and similarly, if the community is satisfied with the services provided, it will certainly have an impact on the selling value of the hospital.

The application of standard operating procedures for patient care in the emergency room of dr. MM. Dunda Limboto, Gorontalo District. The research method used is a qualitative research approach with descriptive research type. The results showed that the Application of Standard Operating Procedures (SOP) for Patient Services in the IGD RSUD dr. MM. In general, Dunda Limboto Gorontalo District has not been implemented optimally. This can be seen from the 7 SOP indicators, only 4 have been implemented properly. As for the results of the research on these indicators are: 1) the procedure for registering patients in the ER has not been running optimally, 2) the procedure for receiving patients in the patient reception room has not been optimally carried out, 3) The doctor prepares for the examination including: Patient preparation , tools, washing hands and wearing PPE, the results of the study found that this procedure was carried out well, 4) The doctor carried out the examination including: history taking, physical examination and checking the patient’s vital signs, supporting examinations, had not been carried out properly, 5) The doctor determined the diagnosis meanwhile, it has been carried out properly, 6) The doctor determines the treatment and medical action on the patient, this procedure has been carried out in accordance with the SOP, and 7) The doctor observes and evaluates the results of treatment or action, this procedure has been carried out in accordance with the existing SOP.

Fig (3): This guide was created as an adaptation from the Evidence Based Medicine: Emergency Medicine Library guide created and managed by Taira Meadowcroft at the University of Missouri.

Example of case with successful practice

Vascular trauma clinical pathway

Vascular Trauma – Team

  1. Doctor Head
  2. ER Consultant & Anesthetist
  3. Nursing Department Head
  4. OT-In-charge
  5. On Duty Supervisor

ER (To be on shift) → OT (To be on shift) → Radiology (1) → Staff (4 nos, 1 in each shift)
→ Lab (1) → Counselling to the relative – ER executive → Patient-relative management – PSO

Code – Violet to be announced

SOP – Vascular Trauma

  • On receiving the patient to ambulance
  • Code to be announced
  • ER executive inform the nursing team & Doctor
  • Arrange PSO for the relative counseling with billing team
  • ER – Nursing In-charge will coordinate with OT In-charge.
  • Team activation – Consultant (Vascular &Ortho), ER (Team) OT(Team) ,CT scan & Lab.
  • ER Team (coordination with vascular & ortho surgeon) for the primary assessment & Orders to be carried out.
  • OT Team (Inform the OT anesthesiologist and prepare the OT for the procedure)
  • Lab (will collect the SOS report to given
  • CT Person will push for the investigation (radiologist arrangement immediately)
  • Coordinate with the surgeon for the report

European Guidelines for the Vascular Trauma management

Case 1

Case Presentation

Example of vascular trauma injury

A 31Y/M, alleged history of workplace injury, hit by train & train run over right hand in railway station around 1 PM on 02.04.2025 and sustained injury over right hand / forearm. History of profuse bleeding right hand injury site. No history of LOC, Vomiting, seizures or ENT bleed.  History of decreased range of movement’s right hand. Initially evaluated at TVMCH and then shifted to our hospital for further management.  Not a known case of T2DM/ HTN/ BA/ Thyroid/ Epileptic disorders.  No history of surgeries in past.

On evaluation, patient conscious, oriented, vitals stable.

Local Examination: Right hand extensive crush injury of hand, Right Thumb, index & middle finger noted, Right Lower leg incised lacerated injury noted, multiple Injuries over chest, Left arm, back noted.

Baseline blood investigations were done. Whole body CT scan taken.

Patient was planned for emergency wound debridement procedure. After counselling patient attenders and prior preparation and informed consent taken, around 5:30 p.m. Patient underwent wound debridement and amputation of right thumb, index and middle finger done since it’s crushed stay suturing given, subsequently patient right distal radius fracture site debrided fracture reduced fixed with ‘ K’ wire under ‘C ‘ arm guidance of orthopaedician, dressing done, below elbow slab applied.

Post procedure period uneventful. Patient was started on IV fluids as per need, IV antibiotics, PPIs, antiemetic’s, antipyretics and other supportive medications. On POD1, oral diet initiated which patient tolerated. Patient was reassessed and dressing changed on POD-1. Wound is healthy, no oozing.

Case 2

Example of cardiovascular emergency

A 63Y/M, came with complaint of chest pain since 3pm on 13.04.2025, after he developed severe chest pain and sweating. Patient initially went to nearby clinic (outside). ECG was taken and treated with Inj. Pan 40 mg, Inj. Emeset, Tab. Sorbitrate 40mg SL.

Unreadable? BP? Pulse Rate

He was a known case of CAHD/Old AWMI/ S/P PTCA to LAD (2000)

Outside echo done which showed severe LV dysfunction.

In Emergency: The staff in the ER was able to recognize the importance of golden hour started with IV inj. Noradrenaline infusion. Inj. Duron 150mg, Patient BP was not recordable, PR 200/min, ECG showed VT. Without delay the nurses immediately informed on the importance of defibrillator and administered- 150J defibrillator shock. ECG showed reveersion Patient was symptomatically better. Now Hr 85/min, BP 120/ 80mmHg. Pocus dilated LV, dilated cardiomyopathy. IVC 1.8cm not collapsible. Poor LV function.

Course of treatment: After stabilization of the patient within 15 min of the arrival patient shifted to critical care unit and treated with iv inj. heparin 5000u, Tab. Clopilet 75mg, Tab. Ecosprin 150mg, Tab.Atorvastatin 40mg. Advise for fluid restriction < 1 litre. Routine blood report showed WBC 14760, PT/INR 17.9/1.36, Trop I < 0.1, Urea 25.7, Creatinine 1.30, CRP 4.0. Electrolytes normal. Triglyceride 114.0, Total cholesterol 184.0, RBS 215.8. On 14.04.2025, Repeat RFT normal.  Echo done which showed CAD involving LAD territory, Severe LV systolic dysfunction, stage I diastolic dysfunction. LV dilated, added Tab. Concor 1.25mg, Tab. Dytor plus 10mg, Tab. Oxra 5mg, Tab. Cardarone 200mg, Tab. Sacurise 50mg given. Total fluid 1400ml/day. Need of AICD to be discussed to be patient’s relatives. On 15.04.2025, RFT normal. Patient had no further episode of VT. Patient was clinically stable. Added Tab. Cronotril 0.5mg, Tab. Rivaflo 2.5mg and other drugs were continued. On 16.04.2025, Patient had no complaints. Repeat RFT normal. ECG showed SR/Old AWMI. Patient was hemodynamically stable. Hence patient is being discharged with the following medical advice.

Conclusion

Standardization and continuous evidenced based practice is important to save the golden hours and also to improve the confidence among the nurses and the allied health personnel in managing emergency care and also timely management to improve the prognosis and good outcome of the patient. Even in the management of the patient flow the standardization will help in the quick assessment and also to shift the patient according to the criteria and requirement of the patient condition.

Reference

Kauverian Bookshelf

Applied Medical Statistics

Journals

Kauvery Hospital
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