International Journal of Nursing Practice 2012; 18: 6067

RESEARCH PAPER

Rapid intervention and treatment zone: Redesigning nursing services to meet increasing emergency department demand
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Julie Considine RN RM BN GradDipNurs(AcuteCare) MNurs PhD FRCNA

Senior Research Fellow, Deakin UniversityNorthern Health Clinical Partnership, c/- School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia

Elspeth Lucas RN BN(Hons)

Registered Nurse, Emergency Department/Research Fellow Deakin UniversityNorthern Health Clinical Partnership, c/- Emergency Department, The Northern Hospital, Northern Health, Epping, Victoria, Australia

Roslyn Martin RN RM Emerg Cert GradDipCritCare GradDipMid IMNP

Critical Care Nurse Practitioner (Emergency), The Northern Hospital, Northern Health, Epping, Victoria, Australia

Helen E Stergiou BSc MSc MBBS FACEM

Director of Emergency Medicine, The Northern Hospital, Northern Health, Epping, Victoria, Australia

Matthew Kropman RN BN PGDACN(Emergency)

Nurse Unit Manager, Emergency Department, The Northern Hospital, Northern Health, Epping, Victoria, Australia

Herman Chiu MBBS FACEM

Emergency Physician, The Northern Hospital, Northern Health, Epping, Victoria, Australia

Accepted for publication July 2011 Considine J, Lucas E, Martin R, Stergiou HE, Kropman M, Chiu H. International Journal of Nursing Practice 2012; 18: 6067 Rapid intervention and treatment zone: Redesigning nursing services to meet increasing emergency department demand The impact of emergency nursing roles in demand management systems is poorly understood. The aim of this study was to evaluate emergency nurses role in a specic emergency department (ED) demand management system: rapid intervention and treatment zone (RITZ). A descriptive exploratory approach was used. Data were collected from audit of 193 randomly selected patient records and 12 h of clinical practice observation. The median age of participants was 31 years, 51.8% were males and 99.5% were discharged home. Nurse qualications or seniority had no signicant effect on waiting time or length of stay (LOS). There were disparities between documented and observed nursing practice. The

Correspondence: Julie Considine, Deakin UniversityNorthern Health Clinical Partnership, c/- School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, VIC 3125, Australia. Email: julie.considine@deakin.edu.au 2012 Blackwell Publishing Asia Pty Ltd doi:10.1111/j.1440-172X.2011.01986.x

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designation and qualications of RITZ nurses made little difference to waiting times and ED LOS. Specic documentation and communication systems for areas of the ED that manage large numbers of low complexity patients warrant further research. Key words: emergency department, emergency nursing, health-care access, health services research.

INTRODUCTION
Emergency department (ED) systems have evolved over recent years to manage increasing service demands. A major focus of ED demand management has been to improve the ED journey for patients with non-urgent complaints by decreasing waiting time and ED length of stay (LOS) and increasing patient satisfaction.13 ED demand management systems designed to expedite care for patients with non-urgent complaints, such as ED fast track, tend to target patients with specic non-urgent problems who are likely to go home after a short ED LOS and who do not require complex nursing care.3 Current guidelines suggest that ED demand management systems are optimized by dedicated geographical areas staffed by senior medical and nursing staff.1,2,4 In addition, use of senior medical staff or nurse practitioners has also been shown to improve patient throughput outcomes (waiting time and ED LOS).5 The positive outcomes from senior stafng are based on assumptions that increased experience and knowledge are aligned with timely assessment and decision-making, improved communication, lower requirements for consultation and competence to make discharge decisions.1,2,5,6 However, despite the proliferation of demand management systems in Australian EDs, the impact of various stafng proles is poorly understood. One study to date has examined the effect of medical/nurse practitioner stafng in an ED fast-track system,5 however there are no published studies to date about how emergency nursing roles contribute to ED demand management systems. Specically, there are few papers about whether redesigned emergency nursing roles are advantageous for expediting care of patients with non-urgent or low complexity complaints. The aim of this study was to evaluate the role of emergency nurses in a specic ED demand management system: rapid intervention and treatment zone (RITZ). The specic outcome measures were to (i) establish a prole of documented and observed nursing scope of practice of nurses working in RITZ and (ii) determine if the level of appointment or educational preparation of RITZ nurses affected patient throughput.

METHODS Study design

A descriptive exploratory approach was used to evaluate the role of emergency nurses in a specic ED demand management system: RITZ. This study was approved by Human Research and Ethics Committees at Northern Health and Deakin University.

Setting
The study setting was a 300-bed urban district hospital in Melbourne, Australia. The ED at this hospital provided care for 63 584 patients during 20092010.7 Children aged < 16 years comprised 18.2% (n = 11 243) of presentations and the admission rate was 26.4% including Short Stay Unit and Medical Assessment and Planning Unit admissions.

Intervention: RITZ system

RITZ was implemented in July 2009 to meet increasing service demands. In a specic geographical area of the ED, the RITZ has four cubicles with trolleys, six recliner chairs and a small sub-waiting area. The existing ED fasttrack area was closed and ED fast track was absorbed into the RITZ. The RITZ operates between 0700 and 0200 and is staffed by a designated registration clerk, senior emergency nursing staff with additional skills (advanced assessment, nurse-initiated X-ray, simple wound closure and simple plaster application) and an emergency registrar, emergency physician or nurse practitioner. Nursing staff work from 0700 until 0200 with one nurse rostered to four different shifts: 07001506, 10001806, 14002206 and 18000206. Medical stafng falls across two shifts: 08001800 and 13002300 with a registrar or senior medical ofcer rostered to each shift. Four to 5 days per week, a nurse practitioner works in the place of the medical staff and is rostered from 1000 to 1806 or 1400 to 2206. The improved physical space, capacity to provide trolley care or recline patients meant that the inclusion criteria for RITZ could be expanded and RITZ became a hybrid between an ED discharge stream and ED fast-track
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Table 1 Inclusion criteria for ED RITZ care RITZ-inclusion criteria Patient characteristics: aged between 5 and 70 years predicted ED LOS of < 4 h NOT have signicant relevant comorbidity or mechanism of injury and present with one of the following complaints Presenting problems cellulitis (localized) dressings/removal sutures epistaxis (asymptomatic, no anticoagulants) foreign body (soft tissue, eyes, ears, nose, ingested) insect bites minor burns minor eye complaints needle stick injuries/body uid exposures pathology tests, results, certicates, referrals, vaccinations, prescriptions plaster check, plaster complications PV bleeding (asymptomatic in early pregnancy) reviewoutside ED review clinic time single distal limb injuries supercial abscess/wounds/lacerations abdominal pain (under 50 years of age) loin pain/renal colic migraine hyper-emesis urinary tract infection gastroenteritis

ED, emergency department; LOS, length of stay; PV, per vaginal; RITZ, rapid intervention and treatment zone.

model of care. Patients targeted for management in the RITZ were patients aged 570 years of age with specic non-urgent complaints or single system problems who were expected to be discharged from the ED, had an expected ED LOS of < 4 h and did not require complex nursing care (Table 1).

Data collection
Data were collected by chart audit and clinical practice observation. Chart audit data were collected by a single researcher (EL) using a structured data collection tool to ascertain patient characteristics, triage category, nursing staff characteristics and nursing scope of practice. Clinical practice observation provided real-time understanding of nursing activities and compensated for the limitations of chart audit (missing data and lack of context). There were six occasions of observation, each of 2-h duration that occurred on various days of the week and various hours of the day. During each observation period, nursing activities were recorded on a running sheet by a single researcher (EL). Once informed consent was obtained from RITZ nursing staff, the researchers informed participants that they would minimize interpersonal interaction during the observation. The purpose of this agreement was to minimize any possible Hawthorne effect on staff

Participants
All patients triaged to RITZ from 1 January to 31 March 2010 were eligible for the chart audit (n = 3124). A random sample of 65 patients per month was selected resulting in a nal sample of 193 patients: there were two patients for whom the ED nursing chart was unavailable. Twelve hours of clinical practice observation was undertaken from 19th of March to 21st of April 2010 in 2-h blocks (n = 6) across various times of the day and evening: there were 12 nurses rostered to RITZ during these times who were observed.
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behaviour due to the researchers presence. To further minimize the Hawthorne effect, participants were aware of the broad aims of the study, however the exact nature of the data being collected was not disclosed to participants. During the data collection process, the observer sat at a desk located in close proximity to where participants were working where nursepatient interactions could be easily visualized. Following each period of data collection, a detailed transcript of observational data was prepared by the observer (EL).

Data analysis
Descriptive statistics was used to describe patient characteristics and summarizes the study ndings from the audit of ED nursing documentation. As the study data were not normally distributed, medians and interquartile ranges (IQRs) are presented and relationships between variables were examined using MannWhitney U-test. Statistical signicance was indicated by P value of < 0.05. Study data were analyzed using SPSS, Version 17.0 (SPSS, Chicago, IL, USA). The transcripts from the clinical practice observation were analyzed by two members of the research team (EL and JC). Analysis involved both researchers independently reading the data transcripts and then using a process of inductive analysis to identify patterns, themes and categories within the data.8 The two researchers then compared their ndings in order to identify differences and facilitate synthesis of themes. The synthesized themes were then presented to the clinical members of the research team (RM and HC) in order to validate that the themes identied were reective of the eld notes. Themes were not presented to the research participants.

RESULTS
A total of 193 patients were included in the chart audit. Males comprised 51.8% of patients (n = 100), the median age was 31 years (IQR = 2046) and only 6.7% of patients (n = 13) arrived by ambulance. The Australasian Triage Scale category distribution of RITZ patients was 1.6% in category 2 (n = 3), 15.5% in category 3 (n = 30), 76.7% in category 4 (n = 148) and 5.7% in category 5 (n = 11). Almost all patients were discharged (n = 192, 99.5%): one (0.5%) patient left the ED at their own risk. The median waiting time was 35 min (IQR = 1764) to be seen by a nurse and 51 min (IQR = 2284) for medical assessment. The median ED

LOS was 2.2 h (IQR = 1.43.2) and 85.5% of patients (n = 165) had an ED LOS < 4 h. The chart audit showed the following distribution of nursing staff: 30.6% (n = 59) registered nurses (RNs) without postgraduate emergency nursing qualications or postgraduate emergency nursing student, 34.7% RNs with postgraduate emergency nursing qualications (1-year university-based graduate certicate in emergency nursing) (n = 67) and 34.7% clinical nurse specialists (CNSs) (n = 67). CNSs have postgraduate emergency nursing qualications, at least 1 year of emergency nursing experience, and meet specic requirements related to clinical skill, professional behaviour and professional development.9 Excluding nurse practitioner, CNS is the highest level of appointment in clinical nursing in Victoria, Australia. Waiting times, ED LOS and proportion of patients with ED LOS < 4 h were unaffected by nurse designation (CNS vs. RN) or qualications (postgraduate emergency nursing qualications vs. no postgraduate emergency nursing qualications) (Table 2). Chart audit data showed that the common investigations undertaken by nurses were diagnostic imaging (n = 20), pathology testing (n = 18), blood glucose testing (n = 7), urinalysis (n = 6), limb assessment (n = 6) and 12 lead ECGs (n = 3). Of 52 patients who had a presenting problem that might require X-ray (typically distal limb injury), nurse-initiated imaging occurred in 38.4% (20/52) of cases. Furthermore, nurses participated in intravenous cannulation (n = 15), oral analgesia (n = 9), application of wound dressings (n = 4) and initiation of rest, ice, compression and elevation (n = 2). Twelve hours of RITZ nursing activity was observed (six occasions of 2 h of duration). During each observation period, there were two nurses rostered to the RITZ, so a total of 12 different nurses were observed: seven CNSs, three RNs without postgraduate qualications and two RNs with postgraduate qualications. During each 2-h period, RITZ nurses interacted with 816 different patients and the number of patient encounters ranged from 16 to 31. In total, RITZ nurses had contact with 60 patients on 160 occasions. RITZ nurses were frequently observed to ask questions about pain, past medical history, presenting complaint, drug allergies and usual medications. RITZ nurses were also observed to undertake patient assessments including obtaining a health history, vital sign measurement, neurovascular assessments and chest auscultation. The frequency of patient
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Table 2 Waiting times, ED LOS and proportion of patients with ED LOS < 4 h by nurse designation and qualications Postgraduate emergency nursing qualications Yes Waiting times Mdn IQR ED LOS Mdn IQR ED LOS < 4 h n % No P CNS Designation RN P*

30 1746 2.2 1.43.2 111/134 82.8

54 2099 2.3 1.33.2 54/59 91.5

0.053

34 1248 2.3 1.33.0 56/67 83.6

35 1868 2.3 1.53.4 109/126 86.5

0.603

0.860

0.860

0.114

0.583

* MannWhitey U-test. CNS, clinical nurse specialist; ED, emergency department; IQR, interquartile range; LOS, length of stay; Mdn, median; RN, registered nurse.

assessments ranged from 6 to 24 assessments in the 2-h observation periods. RITZ nurses were observed to initiate urinalysis on seven occasions, order X-rays on four occasions and initiate pathology testing on 13 occasions. Intravenous cannulation was the most common intervention observed in the RITZ and 100% of intravenous cannulations (n = 15) were undertaken by nurses. The need for intravenous cannulation was determined by both doctors (33%, n = 5) and nurses (66%, n = 10). Preparation and administration of analgesia and intravenous uid therapy were key nursing activities. During each observation period, preparation and administration of medications were observed on 519 occasions and preparation and administration of intravenous uid therapy were observed on 07 occasions. There were 109 episodes of RITZ nurses engaging in verbal communication with other ED staff during the 12 h of observation. Of these, 37 (34%) were nurse/nurse communications and 72 (66%) were nurse/doctor communications. During each 2-h observation period, there were 48 nurse/nurse communications and 617 nurse/ doctor communications. RITZ nurses were engaged in discussions about discharge advice on 22 occasions: discharge discussions between nurses, doctors and patients occurred between one and six occasions during each observation period. During each 2-h observation period, nurses were observed to leave the RITZ area on 714
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occasions to collect equipment, cover meal breaks for other areas of the ED, send pathology specimens or obtain medications.

DISCUSSION
In this study, there were three major ndings related to emergency nurses roles in a specic ED demand management system. Firstly, the RITZ was an effective demand management strategy for a specic cohort of ED patients. All but one patient went home, median waiting time for nursing care was short (23 min) and 85.5% of patients were discharged from ED within 4 h which complies with the Victorian Government Department of Health targets.10 Previous studies of fast track as an ED demand management system have also shown reductions in ED LOS and high proportion of patients leaving the ED within 4 h.2,5,1115 Secondly, the level of educational preparation or designation of RITZ nurses had no signicant effect on waiting time, ED LOS or proportion of patients with ED LOS < 4 h, challenging the notion that senior emergency nurses are required to staff areas such as RITZ. The only difference that might have clinical signicance was a median 24-min reduction in waiting time for patients managed by RNs with postgraduate emergency nursing qualications. An average of 35 patients per day were managed in the RITZ, so a 24-min difference per patient might save 14 h of patient waiting time per day.

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It is difcult to ascertain whether decision accuracy and performance efciency are a function of experience, knowledge or both. There is evidence that factual knowledge is more important than experience in triage decisionmaking,16 however there are few studies of the effects of knowledge and experience in other areas of emergency nursing. Further, emergency nursing guidelines have been shown to improve documentation of patient assessment17 but whether specic educational preparation and appropriate decision support tools can enable less experienced nurses to work effectively in RITZ warrants further investigation. Thirdly, there were clear differences in documented vs. observed scope of nursing practice. There were 160 occasions where RITZ nurses were observed in direct patient contact equating to an average of 13 patient encounters per hour or one patient encounter every 4.6 min. During each observation period, the frequency of patient assessments ranged from 6 to 24 equating to one patient assessment as often as every 5 min. Observation data suggest that the RITZ nurses provide high levels of direct patient care even though documentation of these encounters does not always occur. As the nature of emergency care changes, care delivery systems including documentation systems need greater scrutiny. Current recommendations are that emergency nursing assessment includes documentation of a health history, primary survey assessment, focused symptom assessment, focused physical assessment, investigations and interventions.17,18 It might be argued that patients with minor illnesses and injuries do not need extensive nursing assessment and documentation, however there needs to be balance between safe levels of documentation of care and optimizing patient throughput. RITZ nurses initiated a number of investigations and interventions. Nurse initiated that imaging was documented for approximately one-third of patients with distal limb injuries, however RITZ nurses were observed to order X-rays on four occasions but presenting complaint data was not collected. Chart audit showed pathology testing occurred for almost 10% of patients, however pathology testing initiated by RITZ nurses was observed in 22% of patients. There are few studies of nurseinitiated pathology testing. One randomized trial showed that blood tests by nurses (compared with residents) decreased ED LOS by 49 min (P < 0.05).19 In this study, all of the pathology testing occurred early in the nurse patient encounter, so positive effect on ED LOS is logical,

however the denitive effect of nurse-initiated pathology warrants further investigation. Nurses engagement in communication was highlighted by observation but not apparent from the chart audit. Given that 99.5% of RITZ patients were discharged home, discharge advice is an important part of RITZ management and there were 22 discussions about discharge advice observed. In the 12-h observation, there were 109 episodes of communication with other health-care professionals: this equates to an average of nine communications per hour. Only one-third (34%) were nurse/nurse communication and the remaining two-thirds (66%) were nurse/doctor communication. The most common method of information ow in health care is verbal communication between professionals, and information requests by clinicians are more often met by colleagues than documented sources.20,21 The high levels of verbal communication in this study might explain, in part, the low levels of documentation of these encounters. Further research is needed to better understand team communication in the context of large numbers of low complexity patients. During each observation period, nurses left the RITZ on 714 occasions to collect equipment, cover meal breaks for other areas of the ED, send pathology specimens or obtain medications. Appropriately skilled staff, functional working environment and ready access to pathology, pharmacy and diagnostic imaging are vital components of ED function, particularly in areas where the aim is rapid patient throughput.1 In the ED fast-track context, interruptions or redeployment of staff has a negative impact on the effectiveness of rapid assessment and treatment initiatives.1,6 It is also estimated that, in general, clinicians spend 2428% of their time in non-value adding activities.22 Further investigation of workow practices, stafng and system optimization and the impact of stafng interruptions and redeployments on patient throughput and clinical care for all patients in the ED requires detailed investigation.

Limitations
There are a number of limitations that should be considered when interpreting the results of this study. Firstly, this study was conducted in one ED and variability in the geography, resources, stafng and patient proles in other EDs might limit generalizability. Use of chart data has the inherent limitation of missing data, so it was not possible to ascertain whether care had occurred but was not
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documented or whether care had not been delivered. Clinical practice observation was a deliberate methodological choice to overcome the limitations of chart audit and although redeployment of RITZ nurses was not evident in observation transcripts, there were many periods where RITZ nurses were required to leave the RITZ.

CONCLUSION
The designation and qualications of RITZ nurses made little difference to waiting times and ED LOS. There were disparities between documented and observed nursing practice, so further evaluation of emergency nursing care should use a multi-method approach. Specic documentation and communication systems for areas of the ED that manage large volumes of patients with low complexity problems warrant further research to determine the balance between safe patient care and optimizing patient throughput.

ACKNOWLEDGEMENT
This study was generously funded by the Nurse Policy Branch, Victorian Department of Health.

AUTHOR CONTRIBUTIONS
JC and RM designed the study. EL collected the study data. Data analysis was performed by JC, EL and RM. HS, MK and HC interpreted the study data. JC, EL, RM, HS, MK and HC prepared the manuscript.

REFERENCES
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4 Meislin HW, Coates SA, Cyr J, Valenzula T. Fast track: Urgent care within a teaching hospital. Can it work? Annals of Emergency Medicine 1988; 17: 453456. 5 Considine J, Kropman M, Stergiou H. Effect of clinician designation on ED fast track performance. Emergency Medicine Journal 2010; 27: 838842. 6 Ieraci S, Digiusto E, Sonntag P, Dann L, Fox D. Streaming by case complexity: Evaluation of a model for emergency department fast track. Emergency Medicine Australasia 2008; 20: 241249. 7 Victorian Government Department of Health. Your hospitals: A six monthly report on Victorias public hospitals. June 2009 to July 2010. Melbourne: Hospital and Health Service Performance Division, Victorian Government Department of Health, Melbourne, Victoria. 2010. Available from URL: http://www.health.vic.gov.au/yourhospitals/ downloads.htm. Accessed 18 May 2011. 8 Patton M. Qualitative Research & Evaluation Methods. Thousand Oaks, CA, USA: Sage, 2002. 9 Victorian Government Department of Human Services. Nurse recruitment and retention committee government response. Melbourne: Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services. 2001. Available from URL: http://www. health.vic.gov.au/__data/assets/pdf_le/0015/17610/ govresp.pdf. Accessed 28 May 2011. 10 Victorian Department of Human Services. Your hospitals: A report on Victorias public hospitals July 2007 to June 2008. Melbourne: Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services. 2008. Available from URL: http://www. health.vic.gov.au/yourhospitals/downloads.htm. Accessed 18 May 2011. 11 Kilic YA, Agalar FA, Kunt M, Cakmakci M. Prospective, double-blind, comparative fast-tracking trial in an academic emergency department during a period of limited resources. European Journal of Emergency Medicine 1998; 5: 403406. 12 Fernandes CM, Christenson JM. Use of continuous quality improvement to facilitate patient ow through the triage and fast-track areas of an emergency department. The Journal of Emergency Medicine 1995; 13: 847 855. 13 Sanchez M, Smally AJ, Grant RJ, Jacobs LM. Effects of a fast-track area on emergency department performance. The Journal of Emergency Medicine 2006; 31: 117120. 14 Nash K, Zachariah B, Nitschmann J, Psencik B. Evaluation of the fast track unit of a university emergency department. Journal of Emergency Nursing 2007; 33: 1420. 15 Considine J, Kropman M, Kelly E, Winter C. Effect of a fast track service on emergency department performance and patient ow. The Australasian Emergency Nursing Journal 2007; 10: 194.

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16 Considine J, Botti M, Thomas S. Do knowledge and experience have specic roles in triage decision-making? Academic Emergency Medicine 2007; 14: 722726. 17 Considine J, Potter R, Jenkins J. Can written nursing practice standards improve documentation of initial assessment of ED patients? The Australasian Emergency Nursing Journal 2006; 9: 1118. 18 Curtis K, Hoy S, Murphy M, Lewis MJ. The emergency nursing assessment process: A structured framework for a systematic approach. The Australasian Emergency Nursing Journal 2009; 12: 130136. 19 Singer AJ, Chretien J, Viccellio AW, Schiavone F, Thode JHC. Insertion of IVs by residents: Does it save time? The American Journal of Emergency Medicine 2002; 20: 385387.

20 Parker J, Coiera E. Improving clinical communication: A view from psychology. Journal of the American Medical Informatics Association 2000; 7: 453461. 21 Covell DG, Uman GC, Manning PR. Information needs in ofce practice: Are they being met? Annals of Internal Medicine 1985; 130: 596899. 22 Victorian Department of Human Services. Redesigning hospital care program: Framework for health services. Melbourne: Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services. 2008. Available from URL: http://www.health.vic.gov. au/redesigningcare/downloads/framework.pdf. Accessed 22 September 2009.

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