This is a rough draft of the first paragraphs.

This is a rough draft of the first paragraphs.

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Develop a written proposal by doing the following: Identify a problem or issue related to practice, policy, population or education that aligns with organizational priorities that you seek to solve.

The problem or issue been explored is Been a ER nurse identifying the potential dangers of been a patient in the Er and to help implement safety measures for the patients and prevent injury. The proposal will focus on over crowding in the er nd the adequate amount of staff and  long wait time times. Hospitals are addressing the crowding by assigning more responsibilities to physician assistants and nurse practitioners and treating some patients without assigning them to a bed. Some hospitals are treating patients more quickly by using a team approach where patients are attended to by a doctor, nurse and registration worker at once who can immediately order needed tests and procedures as well as quickly treat patients with simple cases. Which is a potential danger to patients and staff.  There is need to  examined the dangers this might have an patients in the Er patients not beening attened to . work pressure on the staff which risk for the patients. Consider working with a Patient Safety Organization. Report and share patient safety information with Patient Safety Organizations (PSOs) to help others avoid preventable errors. By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and health care organizations can use common formats to collect, aggregate, and analyze data that can improve quality by identifying and reducing the risks and hazards associated with patient care.

Explain the problem or issue, including why it is applicable to the area of practice you choose and the healthcare environment.

I am currently employed in the emergency department as a registered nurse. When I first came to the Er to work I thought it would very interesting and not looking at the danger side of it. Pertaining to caring for the patients and long work and the nurse to patient ratio. Which often  left patients feeling neglected and staff feeling burnt out. Which leading to frequent error and putting patient lifes in jeopardy . The Joint Commission currently has standards, National Patient Safety Goals, survey activities, and educational services that address care in the er . However, these mechanisms have limited utility or reach. For example, the current standards and survey process address certain er  concerns within a health care setting, but neither “cross settings,” nor do they address what happens to patients with the staffing ratio.  The problem with the staffing lies with the Emergency room who gives local contract to outside nurses which are not educated enough with the system and procedures put in place. It should be up to the discretion of the ER nurse and admitting nurse to know how much patient can be admitted to Er and who needs to diverted because safety issues and the nurse to patient ratio. The hospital has safety protocols for there patients and nurses . However, nurses in the triage and admission do not fully understanding these protocols about over crowding the Er.

Discuss your investigation of problem or issue

Include evidence to substantiate the problem or issue ( e.g organizational assessment, national source documents, evidence from a stakeholder.

During my investigation I choose five of  the more experience nurses three from the facility and two that are contract nurses. This in vestigation was about how to prevent the dangers in the er with the patients and nurse to staff ratio.The interviews was very intense but will beneifical to patients and staff in er of how make it safer environment and less work load. The answer from both teams very varied . I found out that agency nurses didn’t know the correct policy or they wasn’t even keeping a track of how patients usually admitted to er on a daily basis. They stated have never taken any education classes for this hospital about the company. They both only had associate degrees and only had prior experience in one hospital. They stated when it come taking patients they try  admit everyone even if is overcrowded. They reviewed there history and even if not life threatening they still admit theses patitents. They stated they go back to there past medical record in the electronic medical record are sometimes ask the patient to determine what status they are in.

They were was admitting nurse on staff say sometime it would so overwhelmed . She wouldn’t get time to check in the medical records and she would just call  er send him to the er to be admitted to the floor are get time to ask family members.  Which is against Jacho policy and Florida Nursing laws.  As a result of there was several patients who were admitted not even seen for 12hrs because of the amount of work load. The admitting physician would visit the ER and want to admit every patient .Without properly assessed. The outcome of this was having patient been admitted that does not need to be admitted. Having patient not attending to in time who is sometime critical and having burnt out nurses that cannot provide the right care and more liable to make mistakes.

There was also an interview with a nurse that worked directly in the Er. It was a very shocking experience. She stated sometimes that admitting never doesn’t even tell what kind

of patient she’s getting because the overwhelmed amount patient they. Which takes time to ask patients all the question and review records from the . This not only affect the current patient but takes time away from attending to the other patients. Which places more workload on her.  The staff often times by the time she gets to assessed the some already frausted and ready to sign out and more critically ones off to units before properly assessed in the Er. They often miss signs of patient having heart attack or patient having change of altered mental status.

The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To continuously improve health care for the public, in collaboration with other stakeholders such as healtcare providers and state hospital association by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.  the Joint Commission recently announced four initial core measurement areas for hospitals, which included acute myocardial infarction (AMI) and heart failure (HF). That nurses must follow especially ones in the er.

Based on the review the evidence clearly points out that the er staff needs to retrained about certain policies and system about thehospital. After the amount of near misses and patient no  getting treated the correct way. It is evident that managers need to bemore aggressive with there employees about the policies of there hospital letting them know one will reprimanded if refuses to follow these policies for patients safety.

Analyze the state of the situation using current data.

Analyze areas that might be contributing to the prolem or issue.


Emergency room ER crowding has become a wide spread problemin hospitals across the United States. Some areas that might be contributing to this problem is the triage and the admission department, are primary care providers are short in supply. Crowding in the Er has become more of hospital problem than related factors beyond the doors of the ER. In 2016 the risk management showed patients satisfaction survey from throughtout the hospital had the most things to say about the Er about there care and how they felt unsafe. Nursing turnover and burntout was on the highest rate. When reviewing the nursing notes and medical records it was found most of the patien that weren’t assessed was the er was too overcrowed and protocol wasn’t followed with nursing patients ratio. Because of bad communication from the triage and the admission department. It was also reported that on non crowded  and with adequate staffing  all patients admitted were seen and assessed. All protocols were followed those who needed to go to the critical care unit went there on time. Patients were happy they spent leat amount of time in the er.

Propose a solution or innovation for the problem or issue. Justify your proposed solution or innovation based on the results of your investigation and analysis.

The solution proposed for the problem is A number of solutions have been attempted to resolve ER crowding. Free-standing ERs not physically connected to hospitals are being used by some hospital systems to off-load some of the ER burden from the main facility. Other is to have  redirected patients with less-urgent conditions to alternative healthcare providers, fast tracks, urgent care centers, and primary care clinics. In the  institution, we have  instituted an electronic health record system to allow more precise tracking of resources and opened a transfer center to coordinate the flow of patient transfers into the facility, lessening this burden on the ER. We also realigned staffing during peak patient volume times to better match resources with needs. Others have streamlined processes and testing on admitted in-patients to shorten their hospital stays, thereby freeing up in-patient beds for “boarders” in the ER. All have realized that there are no “quick fixes” and that the problem of ER crowding is multi-factorial. This will better assist the nurses and much safer for. Which will eventually have  less turn over rates and better patient satisfaction. They have developed better health admission forms with question that are pertinent to there health. They have also suggested that admisision physical assessment should be done in two hours. All data collected should be entered an the admission assessment form. Data that is collected within two hours should be documented at the end of shift.

Recommend resources to implement your proposed solution or innovation. Include a cost benefit analysis of your proposed solution or innovation.

The resources one  would be use to implement change is  to used  multidiscilplinary team it is used in-hospital teams to  limits adverse events (AE), improves outcomes, and adds to patient and employee satisfaction. ,” multidisciplinary in-hospital teams include “staff” from different levels of the treatment pyramid (e.g. staff including nurses’ aids, surgical technicians, nurses, anesthesiologists, attending physicians, and others). Their enhanced teamwork counters the “silo effect” by enhancing communication between the different levels of healthcare workers and thus reduces AE (e.g. morbidity/mortality) while improving patient and healthcare worker satisfaction and over crowding in the Er ad decrease he length of stay.  Multidiscipliary stay together for greater good to improved policy by incorporating demand to server staffing models, getting patients out of the waiting room as soon as possible, It helps when staffing models and processes fail, transparency will goa long way, by Hire scribes to assists physician documentation. Also, set up staff training for there staff annual crises prevention intervention designed to control overcrowding and combative patients.  There are also multiple online Ce courses safety and overcrowed in the emergency room.

Implementing training classes to our unit and educating our staff about overcrowding can benefit the patient and hospital from overall costs such as shorter adimission stay or law suites. The costs of services provided by hospital emergency departments have become a major concern. Patients complain about the high costs of health care. It is widely believed that about half of all visits to emergency departments are for minor medical problems and that the cost of a nonurgent visit to an emergency department is triple the cost of a visit to a physician’s office.2,3 Diverting nonurgent visits from emergency departments to private physicians’ offices is viewed as a way to gain substantial savings. Visits to hospital emergency departments continue to increase. In 2013 the General Accounting Office reported that emergency department use had increased by 19 percent from 2014 to 2015. There was a 34 percent increase in visits by patients with Medicaid, a 29 percent increase in visits by patients with Medicare, and a 15 percent increase in visits by uninsured patients.

There will be changed in the Er admission and emergency visitation and communication between er physician and the er nurse and the triage nurse and the direct admitting nurse.  This changed will take place in October 2017, there will be aquistion of more experienced staff nursing , there will be less wait time . It will be mandatory for nurses to check on there patients every half hour. November 2017 , start to implement training classes for the er staff educational classes about caring for the patients. When patients and families come to the emergency department seeking medical attention, they come in with many mixed emotions and thoughts.  The fast paced, rapid turnover of patients and the chaotic atmosphere may leave patients who visit the emergency department with the perception that staff is uncaring. The purpose of these classes  is to implement a patient care delivery model, relationship-based care, in the emergency.

The Key skateholders in this proposal are Chief Nursing Officer CNO, Emergency Director, Chief Medical Officer, the Quality Assurance director, nurses and family members and patient.















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