Figure 4: Frequency of data collection with respect to country.

The research target major investigated in the empirical studies reviewed are: patients (10), medical staff (4), patients and medical staff (3). (Table 2).

Table 2: Frequency of research’ target investigated.

Most of the reviewed papers were published in the following Journals: Annals of Emergency Medicine, Academic Emergency Medicine, Cochrane Database of Systematic Reviews and Emergency Medicine Journal . All papers were found in Journals and Conference on healthcare field. (Table 3) listed the source title of reviewed studies.

Table 3: Frequency of the source title.

Themes and Sub-Themes on Quality and Risk Management Research

To extract, synthesize and analyze the results of studies, we used the content analysis in order to identify the main themes and sub-themes addressed in the reviewed papers. Indeed, through content analysis is possible to identify, analyze, and resume data in the form of themes within a text [29-31]. In particular, the title, abstract, author’s keywords context, aim and research gap of the 59 studies were reviewed and coded.

We summarized the results of the studies in order to identify the main results and further research for any theme identified in the emergency department context.

As shown Figure 5, our SLR reveals three main themes and four sub-themes: Quality Improvement (17 papers) topic composed ofEffectiveness of quality improvement strategies (9) and Medical scribes themes; (3) Risk Management (12), including Handoff (3) and Crowding (6) issues; and Resilience (9) theme.

Figure 5: Themes and sub-themes on quality and risk management research in Emergency Department (ED). Below, we better explained the contents and key findings of each theme and sub-theme.

Quality Improvement Theme

As shown in Table 4, most articles focused on the quality improvement theme, analyzing several processes or indicators that aim to enhance healthcare needs and focus on patient-centered satisfaction and medical staff [32,33]. Hansen et al. [34] analyzed how to improve the quality and safety in ED and triage process [35] even during the Covid-19 pandemic. Olry De Labry Lima et al. (2020) [36] summarized the effectiveness of de prescription interventions in primary care and described the barriers and enablers of the process from the viewpoint of patients and healthcare professionals in order to analyze the key current issues in ED safety to improve the patient safety [37]. Buttigieg et al. [38] developed an integrated patient-focused framework to improve quality of care in accident and emergency units as Lean [39] exploring the implementing systems of quality assurance [40], the customer service [41] and evaluating the impact of consultant-level doctors overnight [41]. Sinclair et al. [42] identified and appraised the evidence for the effectiveness of e-learning programs on health care professional behaviour and patient outcomes.

Other studies [43] presented a model web-based system for reporting errors that occur in patient care in the ED. Reznek & Barton (2014) [44] evaluated the effectiveness of an ED peer review process in promoting incident reporting the effectiveness of e-learning programs.

Jacobson et al. [45] highlighted that it is crucial to create a continuous quality improvement program using a suggestion-based model to empower physicians, increase communication effectiveness and reduce clinical risk [47-49].

Eighteen studies analyzed the Quality improvements theme: three conceptual research [34,37,49], four SLRs [37,43,48,50] and eleven empirical studies, in particular, three quantitative research respectively conducted in the USA [45] in Australia [46] and UK [41] one qualitative study carried out in the USA [41], one mixed method approach conducted in the USA (Reznek and Barton, 2014) [44], two experiments performed in USA [36,43], one random chart review conducted in the USA [35], one case study on a Maltese emergency department [38] and finally one study that implemented the Lean in an ED in the UK [39].

The reviewed studies showed that the implement quality management must improve an underdeveloped quality culture, inadequate data collection, poor incentives for improvement and high external pressures, including staff shortages, departmental crowding, overcrowding of patients, a shortage of beds and lack of public empowerment [38,40].

Quality measurement can play an essential role in improving the quality and value of ED care, including effective care measures for serious conditions and efficient use of resources, such as highcost imaging and hospital admission [48].

The combined QFD and LFA and also Lean [39,45] methods are effective to improve the quality and safety of care involving all stakeholders and adopting a process approach focused on patients [38]. For instance, the feedback supported quality improvement initiatives [43] in the emergency room by generating mental health support for staff. Programs (debrifing) that facilitate clinicians to communicate their concerns with team leaders reduce negative outcomes, improve processes, alleviate burnout and increase resilience [36]. In addition, Reznek & Barton (2014) [44] showed that a non-punitive peer review process provides feedback and is perceived as valuable for error identification and education can lead to increased incident reporting by Health Care Providers (HCPs) optimizing health care quality and safety.

To improve patient safety in the ED it is crucial to decrease the length of time at triage, assessment, intervention and disposition. To improve patient safety, have to create specialized patient care units, strategic staffing, admission lounges, streamlining communication, and medical record delivery systems [37]. Overnight ED waiting time performance issues are rooted in process problems occurring during the day and early evening. Night working harmed sleep patterns, performance, and wellbeing but did not significantly impacts on the total time patients spend in the department by the consultant night working [41]. Nurses need to be involved and trained to identify problems and solutions to improve the triage process [35]. EDs improvement strategy include audits, incident monitoring, guidelines, morbidity and mortality review, integration and communication with an ambulance, hospital specialties and primary care [34].

It is necessary to improve communication with patients as well as other colleagues involved in inpatient care. The study conducted by Olry De Labry Lima et al. [36] showed that the identified barriers in ED were lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. Indeed, healthcare professionals must cooperate, communicate, and share documentation responsibilities [46].

Table 4: Quality improvement theme.

Effectiveness of Quality Improvement Strategies Sub-Theme

The effectiveness of quality improvement strategies theme evaluates several interventions in ED to enhance the service quality provided and medical staff and patients’ satisfaction (Table 5).

Several studies evaluated the effectiveness of quality improvement strategies, which translates into improving the coordination and organization of health care [51,52]. Team changes and multidisciplinary teams were likely effective in reducing emergency department visits and admission [53,54]. Patient education and self-management were quality improvement strategies targeting patients that reduces resource usage in the hospitals [55].

This theme is described by nine articles: eight SLRs [51,53,56-61] and one empirical research conducted in the USA using mixed-method approach [62].

The study conducted by Tsou et al. [56] highlighted the effectiveness of telemedicine services for their economy especially in emergency.

Interdisciplinary teams can improve the quality of healthcare provided through a more collaborative and global approach to the patient [57]. The studies reviewed confirmed that interventions targeting and case management to frequent users reduce emergency room visits and costs [53]. Targeted interventions must include the implementation of team changes, case management and the promotion of self-management in order to reduce the use of healthcare [51,59,60].

Cost is important when determining the sustainability of interventions. The total cost of an intervention includes the costs of the intervention itself (medical time, paramedical staff, infrastructure, services), savings deriving from a lower use of health care (emergency room visits, hospitalizations), costs of greater use of the service (e.g. community or outpatient services), and savings from increased productivity of more medically and socially stable patients (employment gain, stable housing) [53,58].

In addition, coordinated, team-based Drop-In Group Medical Appointments DIGMAs integrating medical and behavioral health care and care management services is a cost-effective model to reduce ED visits and charges [62].

Reay et al. [61] found that a standardized approach to healthcare ensures the creation of a dialogue between doctor and patient while meeting the needs of patients.

Table 5: Effectiveness of Quality Improvement Strategies Sub-Theme.

Medical Scribes Sub-Theme

Medical scribes theme is a sub-category of the Quality improvement theme. A scribe assists medical staff with primary documentation and nonclinical functions. In fact, through the medical scribes, it is possible to implement and pursue the continuous improvement process in the Emergency Departments to enhance patient-provider interaction (i.e. productivity, efficiency, patient and provider experience) and patient satisfaction [63].

The studies included in the literature review aimed to assess the effect of scribes on throughput, revenue, provider satisfaction, and patient satisfaction and safety in the emergency department.

The theme is composed of three articles, two of which are a SLR [64,65], and an empirical study [66] that shows the results of a mixed method approach with interviews and observations in the USA (Table 6).

The empirical study showed that medical scribes reduce perceived risks in the emergency room, but suppliers and scribes must receive training to improve safety [66].

Scribes strengthened the patient-provider relationship and improved provider experience, for instance, enhanced Relative Value Units (RVUs) per hour, RVUs per encounter, patients per hour, and enhanced patient satisfaction but not an improvement in ED length of stay. Medical staff are more engaging with patients increasing the interaction during the visit face-to-face and reducing, through the scribes work, the interaction with a computer [64].

Furthermore, spending more time visiting the patient enhance the patient care experience and patient satisfaction. Indeed, scribes increase patients seen per day and decrease the length of stay, improving emergency department efficiency. A lack of studies emerged that examined the effects of scribes based on compensation structure, qualifications or duties [65].

Following the quality improvement lens, integrating medical scribes with medical providers improve access, quality of care, enhance patient/medical staff satisfaction, and increase productivity revenue.

Table 6: Medical Scribes Sub-Theme.

Risk Management Theme

Risk management theme analyzes how improves the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability harnessing health information technology [67]; for instance, to enhance a triage process [68,69].

The studies evaluate telephone follow-up systems and their effect on patient care and satisfaction [52] considering causes patient safety incidents in emergency departments [14,70].

Welch & Jensen [71] showed that the differences in culture between emergency medicine and other high-risk organizations and points to the qualities that promote reliability.

Recent studies have instead investigated benefits and risks generated from Covid-19 [72,73] in particular investigates the hospital risk analysis and management (the indoor air quality and determination of microbial load, surface management and strategies in cleaning activities, ventilation and air conditioning systems’ management and filters’ efficiency) [74] and assesses the effectiveness of screening for Covid-19 infection compared with no screening [75]. Furthermore, during the health crisis, the number of nurses was optimized [6].

As shown in Table 7, twelve studies analyze risk management topic: four conceptual research [71,72,73,74], two SLRs [70,75] and six empirical studies that adopted a qualitative approach in the USA [76] and in Australia [77], a quantitative approach in Iran (Apornak, 2021) [78] and in Canada [60], a mixed-method approach in Australia and a study has implemented in an Italian ED the root cause analysis.

The main critical issues that emerged from the studies highlighted a lack of resources such as intensive care unit beds, emergency room beds, ventilators, personal protective equipment and, medications. A crisis standard of care can serve as a guide for rationing supplies and care [73]. ED triage is one of the innovations in the provision of current emergency services to regulate the flow and trajectory of patient care within the emergency room [68]. Facial covers, physical distance, quarantine and appropriate personal protective equipment for frontline workers are required to prevent transmission. In high prevalence settings such as congregated housing facilities, universal testing with RTPCT (Reverse Transcription-Polymerase Chain Reaction) may be a preferred strategy for screening [71,75]. Multilevel telemedicine with tele-triage and therefore a virtual visit of the ED doctor could improve the quality of the service provided to patients [72].

The most common incidents were related to patient behavior, patient management, and medications. The mixed method approach captures the experiences and opinions of patients and doctors to improve communication and resource management [67]. Differences in the personal and clinical characteristics of patients whose emergency room care involved reported incidents highlights the need for a better understanding of incidents occurring in the emergency room in order to improve systems for high-risk patients [77].

The pressure, in addition to reducing the accuracy of nurses and increasing the likelihood of error in care, leads to stress for nurses. Due to the shortage of nurses in the emergency room to maintain the quality of the nursing service, some programming was done to create motivation and enthusiasm in the staff. The regulation of the 9-hour shift for part of the nursing staff, approaches such as the use of part-time nurses and the rotation of nurses between the various departments of the hospital may be useful [78]. However, it is crucial to provide nursing education, since training programs allow to develop technical, scientific and interpersonal skills [69]. Participation in efforts to reduce risk and improve patient safety through adequate incident reporting,

communication and collaboration is critical to removing barriers to the safety of care [70].

A follow-up call system for selected patients is an effective method of demonstrating patient concern, improving quality assurance, and providing helpful feedback to emergency personnel [76]. A reliability model for designing emergency medicine for the masses rather than the individual aims at safety, efficacy, patient-centeredness, timeliness, efficacy and equity [71].

Table 7: Risk Management Theme.

Crowding Sub-Theme

Among the risks that affected access and quality of care in ED, crowding emerged. Crowding harms patients and medical staff [79], involving the healthcare delivery process and outcomes. Crowding generates delays or no visits for patients or to the abandonment of patients due to the long perceived length of stay [80]. Indeed, the existing literature has shown excess mortality in crowded emergency departments [81,82]. This issue generated a lack of privacy and dignity [83] for patients. The most affected by the harms of crowding are the elderly, the critically ill, the mentally ill and the vulnerable [84]. Delayed patient assessment and delivery of care can generate medical errors as well as negatively impact the cost of treatment and patient satisfaction [85] and an increase in bed occupancy rate [86]. The increased flow of patients generates a delay in the provision of health care, increasing stress and burnout of the medical staff.

As shown in Table 8, this theme evaluates the effectiveness and efficiency of interventions on reducing emergency room crowding also considering the effects of locating primary care professionals in the emergency room to provide care to patients with non-urgent health problems [87-89]. In particular, some studies analyze the crowding within EDs, the most appropriate access target, the clinical effects of the 4-h rule and to delve the evidence on the effectiveness and safety of short-stay units, compared with usual care [90,91]. While, the study conducted by Aacharya et al. [92] provide an ethical analysis of emergency department triage considering the biomedical ethics principles (i.e. respect for autonomy, beneficence, non-maleficence and justice).

The Crowding theme includes six papers, two of these conceptual [90,92], three SLRs [87,88,91] and one empirical study conducted in Germany [89].

The main cause for crowding in ED is the slow transfer of emergency patients to in-patient beds. Several remedial strategies parallel the processing of probable admissions, direct-to-ward admissions, and single-point medical registrars for receiving and processing all referrals directed at specific speciality units [90]. Furthermore, to reduce the negative consequences on hospital costs and patient satisfaction, the study conducted by Galipeau et al. (2015) [91] highlighted that a short-stay unit is a cost-savings option for the effectiveness and safety of short-stay units, compared with inpatient care.

The rapid evaluation of care for the elderly based on time efficiency objectives by dedicated staff reduces the length of stay in the emergency department, but quality methodological approaches are needed to highlight the effectiveness of the intervention in reducing crowding [87].

The Event-Process-Chain is a useful tool for understanding the complexity of emergency medical care and identifying key performance indicators for effective quality management, reducing crowding and improving patient safety and satisfaction. This tool supports hospital managerial leaders to identify critical process steps in the ED [89]. The studies conducted in Ireland, the UK, and Australia have not shown the effectiveness and safety of care provided to non-urgent patients by general practitioners and nurse practitioners versus emergency physicians in the ED to mitigate problems of overcrowding, wait times, and patient flow [88].

It is crucial to give a clinical-ethical-based triage planning process to provide support on educational (communication, stress and aggression management), psychological (feedback), and ethical level. The triage planning phase is crucial for the hospital context to reduce risks such as crowding, adopting a comprehensive ethics perspective [92].

Table 8: Crowding sub-theme.

Handoff Sub-Theme

The Handoff theme evaluates the effectiveness and safety of this phase between physicians in the ED analyzing a novel model attending physician staffing to decrease patient handoffs through the standardized procedure in providing diagnostic and follow up care [93-95]. The literature review emerged that the handoffs topic is connected to the risk management theme, as it represents a criticality to be overcome within the healthcare field. A key role during handoffs is played by nurses who provide all information about the patient. This phase allows for identifying predictive actions or interventions on patient care [96,97].

Three papers focused on the handoff theme: two empirical studies conducted in the USA, using quantitative [94] and mixed method approach [93] and one conceptual paper [95]. The papers are summarized in Table 9.

The study conducted by Cheung et al. (2010) [95] showed that handoff aims to provide a clear summary of the patient’s visit.

Indeed, the medical staff must receive a complete overview of all information on the patient’s health status to reduce handoffs by communicating outstanding activities, anticipating changes and making information readily available for direct review.

From empirical studies, it showed that standardizing handoff communication from the Emergency Department to Primary Care Providers improves the quality of patient care by ensuring timely diagnostic and follow-up care. Using the electronic Emergency Provider Written Plan of Discharge (eEPWPD) template, medical staff provides immediate diagnostic and follow-up care reducing waiting times for the patient and improving the service provided [94]. In addition, in a Pediatric Emergency Department in the USA, a multidisciplinary team has redesigned an attending physician staffing model in which there are two zones with overlapping “waterfall” shifts in order to reduce patients handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. This overlapping staffing model improved patient safety, emergency department flow, and job satisfaction, reducing the proportion of patient handoffs [93].

Table 9: Handoff sub-theme.

Resilience Theme

Resilience is the ability to react to complex and emergency situations to strengthen ED’s staff integrity [98-100].

Medical staff, through resilient strategies, reduce moral distress, increase workplace engagement, reduce turnover and improve patient satisfaction [101].

Nine studies analyzed the resilience theme (Table 10): two conceptual papers [102,103], one SLR [104] and six empirical researches: qualitative studies conducted in Italy [105] and UK [106], two mixed method approach in the UK [107,108], one experiment conducted in USA [109] and one study that implemented discrete event simulation and system dynamics methodology in Italian emergency department.

The reviewed studies analyze social reality and rethink resilience among health professionals identifying system vulnerabilities and quality improvement interventions [102,106]. The studies describe some processes to prevent fatigue in ED nurses and the mental health problems of healthcare professionals, people in isolation, and general citizenship [105,109]. The resilience theme examines the effects of interventions aimed at supporting the resilience and mental health of medical staff identifying barriers and facilitators of these, analyzing also the increase in demand of patients or a reduction in the capacity of beds and the different hospital’s adaptive resource allocation strategies in emergency situations [103,104,107,108,110].

Anxiety, loneliness, depressive symptoms and fear of contagion were the main motivations prompting population and health-care professionals to ask for a psychological help highlighting the detrimental role of COVID-19 on both physical and mental health [105].

Monitoring patients and workflow in the ED was identified as a priority for supporting staff to manage the complexity of the work. Staff who are resilient, engaged and enjoy their work provide better quality care to patients and their families [102,106].

Personal Reflective Debrief process alleviates the stress of nurses promoting their resilience. Increasing nurses’ resilience to workplace stress can counter compassion fatigue by providing planned, proactive resources to positively improve resiliency [109]. Even monitoring escalation is essential in understanding how to manage workload, analyzing the barriers and facilitators to improvement [107].

Learning through systematic training (for instance workshops and symposia) and simulation can be an important tool for identifying factors that have an impact on adaptive capacity of a resilient culture and to transfer skills [103,108].

Table 10: Resilience theme.