Implementation of a Code Lobby Surge and the Impact on Left Implementation of a Code Lobby Surge and the Impact on Left Without Being Seen Rates Without Being Seen Rates

Practice Problem: Crowding of emergency departments contribute to higher-than-average left without being seen (LWBS) rates. LWBS patients pose risks to the hospital as well as to one’s own health. PICOT: The PICOT question that guided this project was in a pediatric emergency department (P), does implementation of a “Code Lobby Surge” (I), compared to standard care (C), decrease left without being seen rates (O) within eight weeks (T)? Evidence: Surge interventions and decreasing the visual of crowding have shown to decrease LWBS rates. Intervention : “Code Lobby Surge” was implemented to decrease LWBS rates and improve throughput within the pediatric emergency department. “Code Lobby Surge” is activated when the wait time for triage is over 30 minutes and the total number of patients pending triage exceeds 10 patients. Outcome: The intervention decreased LWBS rates by approximately four percent. Conclusion: “Code Lobby Surge” not only decreased LWBS rates, but also improved throughput of the emergency department. “Cody Lobby Surge” is an effective intervention to mitigate emergency department surges that contribute to LWBS rates.


Seen Rates
The Emergency Department Benchmarking Alliance defines left without being seen as a patient who leaves an emergency department before a medical screening exam (Smalley et al., 2021). The national average left without being seen (LWBS) rate is 2% (Smalley et al., 2021). Hospitals strive to have LWBS rates lower than the national average because the LWBS rate of an emergency department is one indicator that defines the quality of a hospital (Smalley et al., 2021). Every patient that does not have a medical screening exam after arriving to an emergency department poses a risk to the organization. With over half of all the emergency departments in the United States operating at or above capacity, there is potential for increased length of stays which directly impacts LWBS rates (Leggio et al., 2022).
This project aimed to implement a "Code Lobby Surge" in a pediatric emergency department to decrease LWBS rates. Code Lobby Surge was paged out to emergency department staff when there was an influx of patients in triage. This code alerted staff to prioritize discharging patients, fill unoccupied rooms and facilitate admissions to inpatient units. Available staff also reported to the triage area to aid in initial assessment and movement of patients. The pediatric emergency department in which this project took place is located in Orange County, California. The hospital is a not-for-profit organization. The pediatric emergency department is a Level I Trauma Center verified by the American College of Surgeons (ACS) and is also viewed as the pediatric expert in the geographical area. The emergency department had over 100,000 visits in 2022.

Significance of the Practice Problem
LWBS rates not only impact the patients, but also the healthcare system and society. When patients present to the emergency department and leave without being seen there are many consequences. There is a loss of revenue, risk for poor health outcomes, and dissatisfaction among patients (Gorski et al., 2021). When patients delay potential medical care, this may impact a patient's quality of life and increase the patient's risk of morbidity and mortality. LWBS patients are at higher risk for worsening health problems (Zodda & Underwood, 2019). The healthcare system not only loses revenue for each patient that is not seen, but may also lose credibility within quality indicators if LWBS rates are over the national average. The significance to society is that care may cost more on subsequent visits due to care not being initiated at the initial visit.

National, Regional and Local Incidence
LWBS rates are monitored on a national, regional, and local level. The national benchmark for LWBS rates is 2% (Smalley et al., 2021). This benchmark is used as a quality indicator and is reported to entities such as the Centers for Medicare and Medicaid Services (CMS). On a regional level, two hospitals were evaluated, and the average LWBS rate was 2.4% during the evaluation period (Li et al., 2019). This shows that hospitals are not meeting the national benchmark of 2%. The current LWBS rate for the organization in which this project will be implemented is 4.5%.

Financial Impact
Every patient that leaves without a medical screen exam can be viewed as a financial loss for the healthcare organization. The financial impact of each LWBS patient is a loss of approximately $1,096 (Zodda & Underwood, 2019). This cost represents the medical screening exam and potential treatment. If patients are admitted to the hospital, this approximate cost may be much higher.

Quality, Safety, Legal and Ethical Implications
LWBS rates impact the quality of care provided. When LWBS rates are high, emergency departments may try to implement procedures to improve throughput, such as seeing patients in hallways and chairs versus exam rooms. LWBS rates and the quality of care delivered are impacted when hospitals are overcrowded and waiting rooms are full. Quality of care is impacted by delaying treatment and orders such as antibiotics administration and pain control (McKenna et al., 2019). LWBS rates and poor-quality care can pose a safety issue for organizations and patients. Patients who LWBS may become frustrated and upset, translating to violence toward the staff involved.
In 2014, approximately 2.7 million people presented to the emergency department but left without a medical screening exam (Jesionowski et al., 2019). Every patient not seen is a medicolegal risk due to the fact that every patient not seen may potentially be severely injured or ill (Gorski et al., 2021). Consequently, hospitals have an ethical responsibility to provide adequate resources and staff to support emergency departments to sustain an LWBS rate that is at or below the national benchmark. When LWBS rates are higher than the benchmark, hospitals should reconsider operational practices to ensure throughput is maximized.

PICOT Question
The PICOT question was, in a pediatric emergency department (P), does implementation of a "Code Lobby Surge" (I), compared to standard care (C), decrease left without being seen rates (O) within eight weeks (T)?

Population
The population included patients who presented to a pediatric emergency department; however, there was no limitation on age range because patients cannot be denied care from emergency departments. The majority of the patients who presented to the pediatric emergency department were zero to 18 years old.

Intervention
The intervention included the implementation of a "Code Lobby Surge" that was paged out to emergency department staff when the triage and lobby areas were saturated. This page brought all available resources to the lobby to triage patients, facilitated the movement of patients to treatment areas and expedited pending discharges.

Comparison
The comparison was standard care in which patients were triaged as a triage nurse was available, and patients moved to treatment areas when a treatment area and staff were available. Discharges were completed by the primary nurse or a resource nurse when available.

Outcome
The outcome focused on left without being seen (LWBS) rates. Percentages were measured before and after the intervention.

Time
The LWBS rates were calculated daily by reviewing the pediatric emergency department's daily census. The impact of the intervention was evaluated over eight weeks.

Evidence-Based Practice Framework & Change Theory
The Johns Hopkins evidence-based practice (JHEBP) framework aided in developing and executing this project. Each tool provided in the framework ensured that the literature supported the PICOT question. Most importantly, the Practice Question, Evidence, and Translation (PET) Process Guide determined the need for the proposed practice change. The algorithm provided ensured an actual need for practice change within the proposed organization. The question development tool drove the evidence search and assisted in creating search terms for the project. The JHEBP framework supports and provides tools for the project's research, implementation, and evaluation (Dang et al., 2022).
The change theory that was utilized in the implementation plan is Kotter's 8-Step Change Model. Kotter's 8-Step Change model served as a foundation for the project by creating a step-by-step process that methodically changed practice (Kotter, n.d.). The model collectively identified an issue, built a team of stakeholders, established goals, and ensured the sustainability of the change (Mork et al., 2018). Each step of the model aims to ensure a change is successfully implemented by bringing awareness to the practice problem and engaging stakeholders. This model guided the project by ensuring all necessary steps are taken to ensure a practice change is appropriately vetted versus an anecdotal practice change.
The JHEBP framework and Kotter's 8-Step Change model was applied to the project. As mentioned, the JHEBP framework was used to determine the need for the proposed change and to appraise current research. Applying the framework tools appraised evidence individually with a level and grade. Synthesis and recommendation tools were also used to determine what evidence agrees on to determine the solution to the issue on hand. Kotter's 8-Step Change model was applied by laying the groundwork, creating the team and identifying those involved. The steps helped create attainable goals, address the need to make changes and continue to reassess to ensure the change is sustainable.

Evidence Search Strategy
A comprehensive literature search was performed. The databases utilized in the search strategy include CINAHL Complete, PubMed and ProQuest. Keywords included LWBS, left without being seen, surge capacity and patient flow. The search terms used in all databases were "((LWBS) and (surge capacity)" or "(LWBS) and (patient flow)" or "(left without being seen) and (surge capacity)," or "(left without being seen) and (patient flow))" and emergency department. An abbreviation was used for left without being seen (LWBS). No alternative spellings were used.
Filters applicable for all databases includes selecting English for the language and a publication date within the last 5 years. Inclusion criteria included articles directly related to the emergency department setting. Exclusion criteria eliminated articles that did not address LWBS rates or took place in a setting outside of the emergency department. CINAHL Complete and PubMed did not include additional filters. In the ProQuest database, additional filters were applied. The source type was filtered to scholarly journals. Subjects included emergency medical care, pediatrics, emergency medical services and children.

Evidence Search Results
The evidence search resulted in 429,805 articles. CINAHL resulted in 56 articles.
PubMED resulted in 803 articles. ProQuest resulted in 428,946 articles. The inclusion criteria utilized is discussed in the Evidence Search Strategy. Twenty-four (24) duplicates were removed. The inclusion criteria were applied which resulted 427 articles. Articles were excluded for various reasons that were related to not being relevant to project. Excluded articles were discarded due to discussing inpatient flow versus emergency department, implementation of a provider in triage, utilization of a nurse practitioner and overall analysis of the characteristics of patients who left without being seen. The number of studies that were included in qualitative and quantitative synthesis was 14. PRISMA ( Figure 1) is included as a visual reference.
Within the 14 articles, there were nine quantitative studies and five qualitative studies. Majority of the articles were retrospective. There were two quality improvement articles, two quasi-experimental articles and two systematic reviews. The other articles were non-experimental, cross-sectional, prospective and a real time evaluation. John Hopkins EBP Model was utilized to appraise the articles for quality and strength (Dang et al., 2022).
There were three level II sources, seven level III sources and two level V sources. Table 1 illustrates the articles by category and overall quality rating. Tables are also included for primary research and systematic reviews (see appendices). The overall strength of the evidence was grade B.

Themes with Practice Recommendations
A thorough evaluation of the studies is provided in the evidence table in Appendix A. The three themes identified include implementation of a surge intervention, characteristics of LWBS patients and crowding as an indicator for patients to LWBS.
Throughout the studies there were similarities, differences, and controversies.
Similarities were the patient population studied. Differences between the studies were the practice setting and patient population. Studies included adult and pediatric patients and were not specially in a pediatric hospital. Controversies included the use of a provider in triage for patients.

Surge Intervention
The first theme within the research was implementation of a surge intervention.
Multiple studies have demonstrated that a surge intervention decreases LWBS rates . Implementing a surge intervention is shown to decrease door to physician assessment (Patey et al., 2019). Lastly, research shows that planning for surge interventions is key . Planning includes analyzing the issue on hand and defining the aim of the intervention.

Characteristics of LWBS Patients
A second theme within the research was the characteristics of LWBS patients including time of day of patient arrivals, age, sex, and acuity level (Almubarak et al., 2019;Chan et al., 2017;Suastegui et al., 2021). Patients who arrived later in the day were more likely to LWBS (Almubarak et al., 2019;Chan et al., 2017;Suastegui et al., 2021). Patients are also likely to LWBS depending on the acuity level. Patients with lower acuity were more likely to LWBS (Almubarak et al., 2019;Suastegui et al., 2021).
Patients who LWBS were at higher risk for readmission or adverse events (Plint et al., 2021). Males present more often than females. Urban and academic hospitals have higher acuity levels, but regional hospitals have shorter wait times (Rosychuk et al., 2020).

Crowding
Crowding influences LWBS rates. Overcrowding is a direct indicator of a higher rate of LWBS (Gorski et al., 2021;Rathley et al., 2020). LWBS rates are likely to increase according to patients' perception of a waiting room that appears to be crowded (Rathley et al., 2020). The intervention will improve flow which can make waiting areas appear less crowded.

Practice Recommendation
The practice recommendation presented with a Johns Hopkins Quality Grade of Level II. The SORT grade is B. The answer to the PICOT question is the implementation of "Code Lobby Surge." Implementing a "Code Lobby Surge" is expected to decrease LWBS rates and improve the safety of patients. The proposed intervention was a combination of what literature supports. Ensuring throughput is optimal in the ED by collectively heightening awareness of patients pending admission or discharge, unoccupied ED beds and where resources are needed was anticipated to decrease LWBS rates.

Setting, Stakeholders, and Systems Change
The setting, stakeholders and systems change for the project were elucidated.
The setting was evaluated and was deemed an appropriate location for the proposed change project. The culture and mission of the organization supports the change. The stakeholders were defined as well as how the project will be sustained. The systems change analysis provided a SWOT (strengths, weaknesses, opportunities and threats) and identified the level of change.

Setting
The setting in which the project took place in is a 35-bed pediatric emergency department in an independent pediatric hospital in the southwestern United States. The hospital is a growing organization that has become the pediatric resource for the regional area. The emergency department sees approximately 100,000 patients per year. This annual census mixed with the size of the emergency department can cause an increase for LWBS rates.
The culture of the hospital is to provide health services to patients and families utilizing family-centered and evidence-based care. The mission is to provide excellent healthcare to improve the well-being of pediatric patients and to get pediatric patients back to normal state as soon as possible. The culture and mission of the organization supports change that provides better care to patients.

Stakeholders
There are many stakeholders that have buy-in for this proposed project.
Stakeholders within the pediatric emergency department include the staff nurses, support staff including monitor technicians and emergency medical technicians, charge nurses, mid-level providers and physicians. These roles are important to be included within the stakeholders because of the direct impact of their daily operations.
On a management level, stakeholders include the emergency department nursing manager, nursing director, medical director and chief nursing officer. Having management support helped support on the staff level.
Stakeholder involvement and organizational support were crucial to the sustainability of the problem. More specifically, the support from staff nurses and support staff was the most important. These individuals saw the direct impact of the implementation of "Code Lobby Surge." Earning buy-in from these roles helped gain champions of the practice recommendation who can further the sustainability of the project.

Systems Change
A SWOT (strengths, weaknesses, opportunities, and threats) analysis was performed. The SWOT analysis is provided in Figure 2. The level of system change was micro and meso. The change at the micro or unit level, included the implementation of "Code Lobby Surge." The unit was changed the most due to the implementation of several practice changes that were included within the new surge code. This included immediate bedding of patients, discharging pending discharges, movement of patients to waiting areas and bringing all available staff to triage areas. The change at the meso or hospital level provided a solution to high LWBS rates. The change decreased LWBS rates and ensured hospital benchmarks were met.

Implementation Plan with Timeline and Budget
Three objectives drove the implementation of this project. The goals were created using the SMART format. The goals were as follows. Implementation of "Code Lobby Surge" will be implemented within two weeks of educating staff members within the emergency department. "Code Lobby Surge" will decrease LWBS rates within eight weeks of implementation. Project stakeholders will meet weekly for twelve weeks to discuss project updates. The objectives were met by ensuring the timeline was followed.

Implementation Plan
The Johns Hopkins evidence based practice framework and Kotter's 8-Step Change model was used to guide the recommended practice change of implementing a "Code Lobby Surge." The evidence showed that ensuring all ED beds are full and increasing resources to improve flow can impact LWBS rates (Ioannides et al., 2018;Vashi et al., 2019). The practice change involved several moving parts, but the moving parts collaboratively improved practice. Kotter's 8-Step Change model provided a methodology approach to implementing a successful change (Kotter, n.d.).
Kotter's 8-Step Change model set the stage in the first step by bringing awareness and creating the urgency for the change followed by steps to a successful change initiative. This involved stating the impetuous for a change and sharing the evidence-based research with the stakeholders who were involved. This also involved collecting baseline data which supported the need for change. The second step was to build a guiding coalition that identified stakeholders and set up weekly meetings. The third step was to form the change with buy-in from the stakeholders. The plan was to implement a "Code Lobby Surge" in the ED when the department was saturated. The fourth step was to create a volunteer army which involved those outside of stakeholders who were impacted and interested in the change. This involved the staff members who were directly involved in the change. The feedback from these members and support were required for success. The fifth step was to remove any possible barriers. A SWOT was performed in this stage. The sixth step was to create attainable short-term goals.
The SMART goals stated are attainable and created small wins for each phase of the practice change. The seventh step was to ensure change is moving forward. Data was collected and shared. Project champions were identified which included charge nurses and lead support staff to sustain the change. The eighth and last step was to make the change part of standard of care by sharing results with stakeholders, staff involved and throughout the organization (Kotter, n.d.).
Interprofessional collaboration was required to implement this project. As mentioned, "Code Lobby Surge" consisted of several changes under one activation.
Activation of "Code Lobby Surge" occurred when the time for patients to be triaged was over 30 minutes and there were more than ten patients waiting to be triaged. The changes included ensuring all ED beds were full, admissions and discharges were facilitated and available resources were reallocated to needed areas. This change mostly impacted the nurses, emergency medical technicians and medical providers in the emergency department, however it also impacted inpatient staff as well.
Stakeholder training on the project was provided during shift staff huddles.
Huddles occur every day for every shift within the emergency department. The education that was provided is in Appendix E. The majority of changes were focused around the emergency department, but facilitating patients who were admitted impacted the inpatient staff. The change required effective communication and interprofessional collaboration which was essential to the success of the project. Admitting and discharging patients as well as creating optimal throughput involved all the aforementioned roles.
Risks with this intervention were minimal. The intervention as a whole was a new process, however each aspect of the intervention was performed within the practice setting on a daily basis. A potential risk of the intervention was that stakeholders may face code fatigue which means "Code Lobby Surge" may not have had optimal participation. This risk was minimized by utilizing appropriate activation criteria.

Timeline and Budget
The schedule of activities and budget for the project are included in Appendix C and Figure 2. The timeframe for the change process took into account necessary approvals prior to implementation of the change. The implementation and evaluation phases were eight weeks. There were weekly meetings with the preceptor of the project, stakeholders and project manager. The project manager was the DNP student responsible for this project. The project manager was in charge of assuring the project was following the timeline and making sure the budget was met. The project manager was required to utilize leadership qualities and skills to ensure a successful completion of the project. These skills included communication, time management, transparency, active listening and transformational leadership.

Results
The identified outcome of the PICOT question focused on LWBS rates. The primary focus evaluated the average LWBS percentage per week pre-and post-intervention. All patients that arrived at the emergency department served as a data point to evaluate LWBS rates during the implementation of Code Lobby Surge. To calculate the LWBS percentage, the number of patients who LWBS was divided by the number of patients who were seen on that day. No patient information was collected as the focus was on numerical metrics.
The effectiveness of the intervention at decreasing the average LWBS rate was determined by the data collected. Data collection occurred each time a "Code Lobby Surge" was triggered and initiated. The data that was collected, in relation to emergency department metrics, included the number of patients who checked in per day, the number of staff on shift per role, and the LWBS rate per day. The data collection tool also captured the average LWBS rate during the eight-week implementation phase. The data collection tool is shown in Table 2.
The integrity of the data source was reliable and consistent. The electronic medical record (EMR) was utilized to collect data related to emergency department visits. The daily staffing sheets were used to collect staffing information. All information collected did not include patient information. Medical records and patient information were not accessed. If data was missing, there was an attempt to complete it. If the information was not available, the information was thrown out. The data was stored on a secured shared drive to ensure confidentiality. All data was collected, analyzed and stored by the project manager.
The comparison data was pre-intervention data. The evaluation included different categories of measures. Measures included an assessment of the outcome and financial benefits of decreasing LWBS rates. An excel spreadsheet was the tool used to collect data. Table 2 illustrates the benchmarks and types of data that were collected. Table 3 illustrates the aggregate data collected within the implementation phase. This table evaluated if the factors noted played a role in LWBS rates. Appendix D illustrates the pre-and post-intervention average left without being seen rates by week.
Analysis was completed using Intellectus Statistics to complete a paired T-test.
This test was used because pre-and post-intervention sample sets were related. A Shapiro-Wilk test was used to determine normal distribution. The assumption was met.
An alpha value of 0.05 was used to determine statistical significance. The p value was <.001 indicating statistical significance. Results are shown in Appendix F.

Clinical relevance is equally important compared to statistical significance.
Clinical significance is the most important in EBP projects. This is because the intervention proposes a project change that will need to be effective, sustainable, and logical. A decrease in LWBS rates was the anticipated clinically significant change of this project which was shown. The average LWBS rate in the eight weeks prior to intervention implementation was approximately five percent where the average eight weeks post-intervention was approximately one percent. This shows that implementing a Code Lobby Surge decreased the number of patients who LWBS. This means a Code Lobby Surge resulted in more patients being seen when presenting to an emergency department. This project was approved by both the facility site and the University of St. Augustine.

Impact
The goal of the scholarly project was to decrease LWBS rates. Patients who leave without being seen pose a potential medicolegal issue for the organization.
Additionally, and perhaps most importantly, the patient who presented to an emergency department is not being seen by a medical professional. The scholarly project reviewed the literature to ensure a practice change was placed that is backed with evidence.
The project positively modified the workflow of the emergency department. For example, the project highlighted individual tasks that contribute to high left without being seen rates. The department's LWBS rates are not just focused on how many patients are seen, but the bigger picture was addressed. The project shared the importance of throughput within the department by prioritizing admissions and discharges during surge times. It has also enhanced practice by promoting teamwork by bringing resources to areas when needed.
Future implications of this project are important for the department it was implemented in. The project was implemented to be sustainable; however, continued data collection will need to be continued by stakeholders. The data will need to be analyzed to evaluate the sustainability of the intervention over a longer period of time.
As a result, the applicability of the intervention can be determined during different times throughout the year. This is important in view of the fact that, historically, emergency departments can predict higher patient volumes based off cyclical cycles such as respiratory and influenza season.
To further improve the practice problem the project needs to be continued to capture the fluctuating patient census. Further improvements should focus on when the LWBS rates are higher to identify any additional barriers contributing to the higher rate.
This will also support sustainability because it will engage stakeholders by looking to further opportunities of improvement. The ongoing evaluation of effectiveness will continue to be the LWBS rates for the department.

Limitations
A limitation of this EBP project is that the intervention of Code Lobby Surge was implemented at a single institution. Additionally, the implementation period could be viewed as brief and limiting, especially because the daily patient census ranged from 250 to 450 patients. There was a decline in the daily patient census during the implementation period.

Dissemination
The results were shared through multiple modalities. The results were shared throughout the organization through a presentation. The stakeholders and staff members who were impacted by this project were invited to this presentation. The results were published to SOAR at the University of Saint Augustine. The process to disseminate the project at the University of Saint Augustine included a submission application and review by librarian. Disseminating the project at the practice change location and at the university level allows for a peer review process and feedback prior to submission of an abstract or article publication.
The topic of this project was most appropriate for professional societies related to emergency departments. The Emergency Nurses Association would be a professional society that could benefit from this project. The presentation could consist of oral presentations at local meeting sand also a poster or oral presentation at the national conference. This topic would also be appropriate to submit for a publication within the Journal of Emergency Nursing. The professional entities mentioned are most appropriate based off the milieu of those who hold memberships or belong to the entities.

Conclusion
"Code Lobby Surge" optimizes the intake and throughput of the emergency department. Any patient who presents to an emergency department and leaves without being seen poses many risks. These risks include not only legal implications but personal risks to the patients. The goal is to ensure patients who present for medical care are provided the opportunity to receive a timely medical screening exam. The utilization of Johns Hopkins evidence-based practice framework and Kotter's 8-Step change theory guided this practice change through a literature search and appraisal that supports the evidence-based change to the project implementation. Implementing "Code Lobby Surge" decreased LWBS rates in the pediatric emergency department in which this project was implemented. Implementation of "Code Lobby Surge" should be considered by impacted emergency departments.

Figure 2
SWOT Analysis Strengths -Decreased LWBS rates -Improve patient satisfaction -Improve staff satisfaction Weaknesses -New process change -Process change may create resistance -Education will need to be provided due to current lack of knowledge regarding practice change Opportunities -Support from staff -Staff buy-in -Staff recommendations -Meet benchmark for LWBS rates Threats -Staff resistance -Management resistance -Decrease in patient census therefore new process cannot be truly tested

Figure 3
Budget Males presented more often than females. Urban and academic hospitals had higher acuity. Regional hospitals had shorter times than urban and academic hospitals. Gorski  Legend: