Chapter # 1 Introduction
Introduction
The studies conducted by the National Heart, Lung, and Blood Institute predicted that every year about seven-hundred and eighty-five thousand and four-hundred and seventy thousand US people experience new coronary and recurrent attacks respectively . The diagnosis and treatment of chest chain are imperative because this syndrome exposes dangers to the life of an individual. The advent of overcrowding in hospitals is a significant problem and it is gaining momentum with the passage of time. The overcrowding at Emergency departments (EDs) confirms insufficient quality care and established a systematic issue pertaining to patients that have the right to quality care at the right time and in the right scenario . The authors observed that the existence of overcrowding in EDs hinders access to care and develops undesirable flow of patients through the system. These outcomes have a strategic influence with additional problems, including reduced patient’s fulfillment, deficiency in quality care, adverse patient results, below average productivity of doctors and nurses, improved danger of medical faults and damages to extents of service. They further declared that it is probable to tackle overcrowding at EDs and diminish the issues through desirable implementation of interventions. One instance of such interference is the launch of cardiac decision unit (CDUs) to Emergency Departments.
The application of this technique applied in most of the societies worldwide, however, the scholar quotes the instance of Ontario where varied companies followed the method and enhanced ED wait times. The existence of CDU in an ED adds value in including objectives of enhancing access to urgent care. It is very important to note that the attainment of favorable wait time scenario demands the advanced attitude of ED and the incorporation of CDU within hospital. The researchers received support from that the presence of CDUs at hospitals resolve issues linked with EDs’ overcrowding. The application of CDUs in EDs helps software installed at hospitals to track particular patients that are in the queue of taking pressures off ED wait times, and enhance prices of release from the hospitals. The authors also suggested that the sole establishment of objectives does not reveal desired outcomes in terms of transition, and the favorable rewards and capital must accompany with transition for achieving mandatory infrastructure. Moreover, senior executives play critical role in contribution of transition success. The Ministry of Health and Long-Term Care (MOHLTC) at Ontario in the year 2008 proposed a pilot study on CDUs. The focus of CDUs were to procure treatment, care, and monitoring of patients prepared for discharge with twenty-four hours through fulfillment of patient’s surgical, medical and psychosocial needs. The pilot approach designed by MOHLTC helped in fulfilling requirements of patients on ED and inpatient services.
The patients of emergency department are free to take admission in either a virtual CDU or co-based CDU, if they find convenience. A co-based CDU means the segregated space occupied for the sole purpose of addressing issues of CDU patients, whereas, a virtual CDU entail beds in the premises of ED that serve the CDU patients specifically. A virtual CDU contributes in assigning patients in the category of CDU, however, the assigned patients encompass whole of the ED. Moreover, the significance of virtual CDUs is that they address maximum number of CDU designations immediately. In comparing these two forms of CDU, a co-based CDU does not cover segregated assigned officials for the unit, whereas, a virtual CDU also does not have segregated assigned officials, but it contains ED team individuals allocated to numerous ED patients that may entail or not CDU patients on the grounds of designations established by doctors.
The institution is an academic healthcare organization that encourages research activities within its boundaries. The infrastructure of an institute comprises of one-hundred inpatient beds and varied specialty segments including outpatient services, accident and emergency departments in which the highly significant is the emergency department (ED). The institute gained reputation due to its wider span of its inpatient and outpatient services in the society and it became recognized among the greatest healthcare organizations in the Northern Emirates having numerous divisions in the additional emirates. The Head of the institution, director, hospital director, and managing director are the foundation of an organization and in upper management. The umbrella of an organization covers various departments in which each of them formulates the team of head, operational core, and assisting workers. A professional bureaucracy has major ingredients but organization structure is an element that is quite relevant in the discussion of organization context . The organization is the foremost JCIA accredited medical care institute in its district with more than two-thousand two-hundred workers within boundaries of numerous branches. The institute promotes unique schemes to procure reasonable medical facility with extraordinary focus on quality variables. Additionally, the institute encourages institutionalization of controls and quality systems with the global healthcare benchmarks.
The mission statement of the institute is to procure patients with care through considering of ethical standards and emphasizing security of their lives at reasonable and competitive monetary values. The institute achieves its mission through incorporating the innovative healthcare practices, adapting to the contemporary transitions in the subject domain worldwide and striving for quality and accreditation practices beyond benchmarks.
Rationale for Research Project
The exposure of chest pain is a fundamental complexity for numerous professionals in the field of medicine. The frequent practice adopted by patients is to approach Accident and Emergency Department due to medical grounds . The establishment of reason for the chest ache is critical to the forthcoming patients’ management, and the adequate and desirable application of healthcare resources. A CDU reveals realistic gains that promote substantial degrading in the hospitalization whilst fundamentally transforming the appraisal and supervision of patient with cardiac diseases. The tendency of mortality and morbidity rate decreases upon in time diagnosis of chest pain along with adequate treatment.
The application of innovative IT practices is imperative in the healthcare sector of the Middle East after the assessment of needs. The care of patients is improvable upon incorporation of electronic clinical decision support as it encourages healthcare provisions, integrates and streamlines the data, gets staff busy in the transition procedure and procures desirable instruments to enhance flow of work and results of patients. The establishment of chest pain clinic is highly significant in the Middle East because it enhances the numerous medical decision-making procedures including diagnosis, prevention, treatment and particular test ordering on the grounds of patient-oriented consultation. The design of qualitative multi-attribute model enhance the functionalities of CDU in terms of selective explanation, extraction of outcomes from the researches, the pros and cons of research-oriented domains, procure favorable situations to diminish deficiencies and bring value addition through suggesting appropriate consultations to experts based at hospitals.
Research project’s Aim and Objectives
Almost every patient shows his/her presence in the ED that has ache relevant to his or her chest in the hospital. These patients get them either released or admitted directly into the Coronary Care Unit (CCU). The continuous flow of patients into the ER results in shortage of beds and the chance exists for overlooking of numerous chest pain cases of patients. Nevertheless, few cases receive inattentiveness due to few hours monitoring at ER to identify the existence of heart infection, whereas, supplementary chest pain patients do not receive attention if they are unable to bear the expense of CCU.
The study focuses on establishment of a “HEARTER Project” or CDU with an emergency department. The chronic heart disease patients face extensive evaluation and treatment at ED within the duration of twenty-four hours, thus the successful incorporation of CDU helps removal of cardiac occurrences. Currently, the organization addresses chest issues as common diseases due to which there is an existence of below average treatment of cardiac illness at hospital.
When patients arrive for routine checkup at hospital, they emphatically form a queue with additional patients for medical facilities due to the directives passed from the hospital. Ultimately, the wastage of time creates greater severity in the chests of patients. The present scenario is highly undesirable as it leads to the life risk of patient and it is effectively addressable through entertaining patients in time. The existence of CDU at hospitals diminishes the probability of death and it is possible through outpatient care (Gaspoz, et al., 1994; Goldman, 1995; Graff, et al., 1995; Gibler, et al., 1995).
Aim
The aim of this study is to propose measures for the foundation of CDU in an emergency department that must exceed expectations of acute chest-pain patients in terms of their care.
Objectives
The study set the following objectives in order to achieve its aim:
Numerous dangers and barriers may influence the achievement of the goals. The initial barrier is the insufficient funds to address the establishment of the clinic due to its span over new buildings, amenities and substantial staff. The challenge is effectively addressable through the foundation of a clinic at the hospital premises and the requirements of amenities are present in the cardiology OPD for the immediate trail. Other challenge is the renunciation of an operating license that happens in the case of not fulfilling the particular verges, thus the existence of a project becomes unfeasible. However, additional obstacles incorporate the lack of experts in the domain of chest pains, scarce materials, and the existence of confrontation from the present workers and the public.
The Health Service Executive in Ireland suggested the HSE Change Method for the purpose of implementation at hospitals . The proof reveals that it assists workers and groups in improving services at workplace, and encouraging a reliable method to change across the network. The basis of this model set on the growth approach that emphasized on the change aspect of individuals. This model helps researcher to approach the fundamental stakeholders in the study involving greater-risk cardiac patients, the ED physicians, organizational director, triage nurses, and a cardiologist.
Role of the Student in the organization and project
I am a general practitioner who has worked in the emergency department for the past six months. I have worked in the internal medicine and cardiology department for the previous five and a half years, in the same organization. I will be the project leader in the present project and will outline the methods and stages of the project’s implementation. Other members of staff have expressed interest in the project with some researching the best way to set up a chest pain clinic. The following table 1 shows a group of nine staff members involved in the plan. Experts with technical knowledge in the field will be engaged to ensure the project succeeds. During the implementation of the proposed plan, informed consent from the participants sought, and the protection of individual identities ensured. The data collected from the organization handled on a strict confidentiality basis. In addition, the whole process will go through an ethics committee approval in order to meet the need for the protection of the participants.
Summary and Conclusion
The requirements exist to explore more in gauging the influences for better outlining the processes of EDs . This study highlights the areas for future studies through identifying the influences of CDU’s forms in hospitals and how the existence of CDUs contribute in emergency departments for the minimization of issues faced by patients specifically in their chronic cardiovascular diseases. The connection to the literature on theories of transition and the historical knowledge on the implementation of transition at workplaces, the perceptions of the hospitals illustrate the differences and similarities among the CDUs. The literature review executes comparison of the hospitals, and reveals the implementation practices at hospitals. The application of change theories also helps detailing the subject hospitals in this study comprehensively in implementing change.
The objective and significance of a method shows the application of techniques from data gathering tools. The method also outlines the forms of phenomenon and associations to look for in a search strategy . The methodology employed in this project is an exploratory case study method. This research attempts to gauge the influence of CDU in terms of delivery of care after its implementation in ED, because, the exploratory case study method enables detailed comprehension of contextual situations pertaining to the implementation of change . Moreover, the application of change theories is in consideration to comprehend the implementation of CDUs at emergency departments. This research entails the advanced qualitative methods in order to address the deficiencies in the literature of CDUs. The exploration of such qualitative methods enable researcher to gain detailed comprehension pertaining to the perception and experiences that appear after change implementation. The present literature on CDUs contains restricted qualitative elements and the researcher covers the deficiencies through exploratory case study approach employed for this research. The assessment of case studies and the comparisons amongst the cases are available in the data-reporting chapter. After the analysis of data and reporting of cases, the discussion chapter uncovers aims to link the literature on transition theories to the change implementation.
Chapter # 2 Literature Review
Introduction
The most of the studies carried out on CDUs procure explication of these units, their objective and roles to curtail emergency wait times for patients. In the literature, a term observation unit used to represent CDU. The findings of the appear credible as the scholars suggested that CDUs help to address pressure in an ED through targeting particular bunch of patients that demand intensive care services. The identification of a specific bunch of ED patients that demand care may experience release from hospital within the period of twenty-four hours, CDUs changes the route of these forms of pressures far from an ED that consequently influence the admission ratio in hospital. Another research conducted by emphasized on decreasing the influx of patients at CDUs. This research focused on CDUs investigation in which there were majority of patients’ that had chest pains and presenting clinical syndrome. Patients that had chronic clinical presentations were addressable through CDUs that ultimately resulted in inpatient’s admissions at hospital. The authors claimed that foundation of CDUs serve the purpose of lessening the inpatient admissions at demanding hospitals along with preventing ED from patients’ admission in order to accommodate adult patients that demand extensive care that are in a queue of release with twenty-four hours or in a day. These two researches proved that the existence of CDUs influence on reduction of patients’ admissions and encourage effective care and treatment within the duration of one day at hospitals. The allocation of patients to a CDU lessens patients’ intake at hospitals due to which other patients waiting for care are effectively addressable. The researches of and that encouraged implementation of CDUs at ED in order to address wait time reduction match with these two studies substantially.
CDU in the Middle East
Patients that do not demand for at once hospital treatment, the existence of chest pain clinic allows instant confirmation of the syndrome, onset treatment, and executes advanced examination and interference. The chest pain clinics at UAE hospitals ensure advanced analysis and management that diminish cardiac mortality and morbidity. Patients comprehend that extra analysis bring to a confirmation for advanced invasive treatment. The basis of the medical situation of the patients and probable myocardial infraction of patients, they demand instant switching to hospitals before the performance of any examination. The investigations are necessary to eliminate non-cardiac causes of chest pain including chest X-ray, cardiac enzymes, fasting glucose, anemia, resting ECG, aortic aneurysm, angina pectoris, echocardiogram coronary angiography, and gastro-esophageal efflux syndromes. The chests pains do not necessary contain cardiac but it may as well non-cardiac. The coronary heart syndrome depicts the fundamental reason of mortality in the UAE and a substantial space of these mortalities happen before the age of retirement. The fundamental danger factors are hypertension, smoking, diabetes, hyperlipidemia, and obesity. Most of the patients bear completely normal investigation results. However, a comprehensive cardiovascular examination of patients is mandatory.
It is imperative for the societies to establish professional ground that focus on chest ache research by incorporating academic and pertinent field gurus for gaining valuable advice. The unique treatment delivered from the ground highlights the importance of CDUs. The CDUs do not solely diminish the time required by the patients for treatment access, but explores chest pain study for the effective mechanism in dealing these units .
The clinical decision support system is a favorable instrument for data assessment and modeling in the context of clinical decision-making process and it is greatly significant for suggestions in managerial domains to eliminate deficiencies and to enhance positive scenarios.
Search Strategy
This study collects knowledge from the articles that emphasized on implementation of chest pain clinics in the emergency departments of the hospitals. The extraction of the research articles and relevant literature gathered from the renowned databases including Google Scholar, ProQuest, BioMed Central, Rare disease database, HubMed, Alt-Health Watch, Arctic Health, Bioethics Information Resources, Database of Abstracts of Reviews of Effects (DARE), and through exploration of varied clinical websites, books, and journals. The group of words selected for researching the topic includes Chest Pain Clinic at Emergency Departments, Implementation of a Chest Pain Clinic at Hospitals, Significance of Emergency Departments, and Relationship of CDU with Emergency Departments. For a comprehensive evaluation of a search, the strategy is available in the Appendix 2. The criteria for finalizing the research articles made on the grounds suggested by.
Review of Themes
Emergency Departments
The over-sighting in one domain of a hospital significantly influences on another due to the complexities of the institution. The procurement of desirable and 24/7 care, an ED shows its importance in a hospital.
There are certain variables that bring overcrowding at hospitals that include input, throughput, and output of patient flow. The authors also noted that significance of throughput of an ED and its association with overcrowding. The internal care processes form the throughput of an ED that influence significantly on the length of stay, and application of resources in the boundaries of an ED. The variables of the internal processes comprise of room placement, diagnostic testing, triage, initial provider assessment, and ED treatment.
In the context of ED that incorporates a CDU, Hassan (2003) explicates the positive impact of CDU for a particular range of patients, for instance, patients that arrived to checkup their chest pain, a general situation that can lead to a chronic illness. The erroneous assessment of chest pain reveals substantial severe outcomes. The application of diagnostic care by CDUs for patients is highly cost-effective rather forwarding to in-hospital bed for patients that have below average and average-risk chest ache. Moreover, there were many studies conducted in the subject domain in the US and associated cost-effectiveness with the implementation of CDUs in the emergency departments (Farkouh, et al., 1998; Gomez, et al., 1996; Roberts, et al., 1997).
The comprehension of the ED Model is mandatory for the presence of CDUs. As illustrated before, ED encompasses input-throughput-output Model that uses the ideas of operations management to patient influx in the boundary of sensitive care network. The variables described under reveal the significance of an ED Model.
Input
The input in an ED model comprises of three basic elements including unscheduled, safety net, and emergency care. The emergency care refers to the patients referred by additional providers and procures actions to chronic ill and wounded patients. The reflection of EDs reveals referral sites that correspond to the objectives of a CDU, where the form of ED patients that faced reference is on the grounds of symptoms that are ready for submission. Most of the patients that faced reference to an ED submit with conditions that confirm the type of mandatory care procured to them, and the existence of a CDU generates organization through raising observations and giving care to patients with particular clinical features that are imperative for a CDU (Asplin et al., 2003; Redstone et al., 2008).
The existence of frequent restricted access in additional segments of the sensitive care network, unplanned immediate care is a persistent requirement that EDs receive. The presence of post-hours care procured by an ED generates a favorable opportunity for patients that have disagreements with task, school and household liabilities, thus enhances the quantity of patients for unplanned ED care. The residual of unplanned care visits were effectively addressable by CDUs that enabled the influx of ease for patients through reducing pressures from EDS and beds of hospitals with the help of listening to patients’ queries having symptoms that are ready for release within one day.
Another element of an input in an ED model is safety net of care that listens and addresses the obstacles of patients. For instance, it outlines the deficiency of a household doctor in approaching unplanned care for patients. The ED behaves like a safety net for patients that have household doctors, as at time, the additional clinical choices get weaken and the patients have only option to approach ED for seeking care. The team of patients that emphasize ED like a safety net of care because of the unavailability of household doctor, they in majority of cases demand care and release from the hospital within the duration of one day. Hence, the launch of a choice like CDUs for clinical care inside the ED diminishes the forces by patients that prefer ED as their safety net.
Throughput
There are two fundamental phases of throughput of an ED Model including diagnostic testing and ED treatment; and early provider assessment, triage, and room placement. There are numerous methods to manage the initial segment of throughput in an ED Model. In one way, the CDU locates specific patients while the early periods of an ED checkup. The second throughput segment of ED treatment and diagnostic testing associated with numerous components include group consistency, the physical sketch of the ED, the recruitment balance of doctors and nurses. Whereas, the application and effectiveness of diagnostic checkup includes radiology and labs, the availability of clinical knowledge, the worth of communication networks and records, and the presence of precise unique consultation . The variables that influence the throughput segment reveal numerous significant elements that may enhance efficiency in an ED, and every variable investigated and presented in this research while the determination of CDUs’ influence on EDs’ throughput.
Output
Problems associated with patients’ release surround against the period passed by the ED in managing adequate follow-up processes and it reveal the efficiency damages in terms of care and extended ED length of stay (Asplin et al., 2003; . The launch of CDU in an ED, the workers of ED are liable to cooperate with each other in order to confirm the desired follow-up processes and balance the ED extended stay of patients at hospital through the expected care procurement. The individuals that add value in planning of patients’ release from hospital are geriatric emergency management (GEM) nurses, Community Care Access Centre (CCAC) case supervisors, triage nurses, and social staffs. The said individuals in relation to CDU perform significant role in patients’ release planning procedure and had great reference by ED group individuals throughout the questions asked pertaining to their tasks and association to the CDU.
Cardiac decision unit
The fundamental objective of a CDU is to lessen the burdens from the ED through suggesting measures for low-danger and stable patients that involve chest pain individuals (Mace, 2004; Quattrini & Swan, 2011). Mace focused on illustrating the influence on CDU in enhancing ED flow for implementing medical protocols/pathways that lead towards the effective application of services at a cheaper value. The authors illustrate the advantages associated with sensitive care pathways that impart clinical practice, advance worth-oriented care and they are dissimilar in every ED due to the facts of hospital’s capacity in procuring quality care and its abilities, the numerous forms of management approach and the demographics of patients within a group of people. The existence of comprehendible vision, plans and operational laws at hospital; sensitive care pathways enable workers with a general comprehension of the CDU goals and benchmarks. There are two forms of CDUs fundamentally including co-located and virtual. Numerous variables determine the size of a CDU in which they include objectives and benchmarks established for the unit, the ED and hospital potential, the ED’s size and its survey involving admission record and patients and their stay period. The quantity of beds
