Impact of checklist-based process reengineering on emergency stay duration, rescue success rate, and satisfaction in consciousness-disordered patients

Abstract

BACKGROUND

Disorders of consciousness are critical emergencies requiring timely intervention to improve outcomes. Process reengineering using checklists can enhance efficiency in clinical settings.

AIM

To evaluate whether checklist-based process reengineering in the Emergency Department reduces emergency stay duration and hospitalization time, and improves rescue success rate, prognosis, and satisfaction among patients with disorders of consciousness.

METHODS

From January 2021 to December 2023, our hospital admitted 400 emergency consciousness disorders patients using purposive sampling. The first 200, undergoing rescue without the checklist-based process, formed the control group. The next 200, post-implementation, constituted the observation group. We collected data on emergency stay duration, rescue success rate, hospitalization duration, and patient satisfaction for analysis. Patient prognosis in both groups was compared.

RESULTS

The observation group showed significantly shorter emergency stay duration, time to recovery, and overall hospitalization duration (intensive care unit, general ward, total) compared to the control group (P < 0.05). The observation group had a higher rescue success rate (P < 0.05) and better recovery rate (P < 0.05) than the control group. Both medical staff and patients’ family members reported higher satisfaction with the emergency rescue model after checklist-based process reengineering compared to the conventional emergency rescue model (P < 0.05).

CONCLUSION

Emergency process reengineering based on checklists can effectively reduce the emergency stay duration for patients with consciousness disorders, improve rescue success rates, enhance patient prognosis, and increase overall medical and patient satisfaction.

Key Words: Emergency consciousness disorders; Checklists; Process reengineering; Emergency stay duration; Rescue success rate; Patient satisfaction

Core Tip: This study evaluated a checklist-based process reengineering (CBPR) model for emergency care of patients with disorders of consciousness. In a purposive sample of 400 patients, CBPR shortened emergency stay and hospitalization, accelerated recovery, and increased rescue success compared with conventional workflow. Multidisciplinary coordination, a mobile emergency platform, and a causation checklist improved timeliness and decision-making, leading to better Glasgow Outcome Scale prognoses and higher satisfaction among medical staff and families. CBPR offers an efficient, standardized pathway to enhance outcomes for emergency disorders of consciousness care.

INTRODUCTION

Consciousness disorders are a common critical condition in emergency medicine, characterized by a decreased ability to perceive the surrounding environment and one’s own state. This can manifest in varying degrees, including drowsiness, blurred consciousness, stupor, and coma[1]. Due to the complex etiology of consciousness disorders, involving both intracranial and extracranial lesions across multiple systems, and the irreversible nature of neurological damage, emphasis is placed on the timeliness of rescue efforts. Swift intervention holds significant importance for improving patient outcomes[2,3]. However, rapidly establishing the etiological diagnosis and promptly initiating targeted treatment for patients with consciousness disorders present challenges in the Emergency Department.

Process management, a commonly used systematic management approach in clinical settings, is effective in enhancing workflow efficiency. Process reengineering, based on process management principles, involves the reanalysis and evaluation of processes[4]. It includes the reexamination, reconstruction, and standardization of weak links and vulnerable segments that affect process effectiveness. This aims to make the entire process operate more smoothly, thereby improving overall quality and further enhancing operational efficiency. Previous studies by scholars have confirmed its positive effects in clinical management[5,6]. Checklists are also effective tools for improving efficiency at work. They can streamline repetitive tasks, operationalize procedural elements, and simplify complex tasks. Scholars proposed establishing a “causation checklist” in symptomatology to expedite systematic “slow thinking” clinical decision-making, thereby significantly enhancing the decision-making capabilities of clinical physicians[7,8].

Building on this foundation, the current study aims to bridge the gap in applying process reengineering specifically to emergency interventions for disorders of consciousness. By employing a checklist-based approach, the existing emergency procedures are reengineered. The study observes the impact of the refined emergency procedures on the emergency stay duration, rescue success rate, and patient satisfaction for patients with consciousness disorders. This research seeks to provide evidence-based guidance for clinical practice.

MATERIALS AND METHODS

Participants

Continuous enrollment and purposive sampling were employed to select 400 cases of emergency consciousness disorders patients admitted to our hospital from January 2021 to December 2023. The first 200 patients, who underwent emergency rescue before implementing the checklist-based process reengineering, were designated as the control group, while the subsequent 200 patients, who underwent emergency rescue after the implementation, were assigned to the observation group.

Inclusion criteria: (1) Patients meeting the diagnostic criteria for consciousness disorders[9]; (2) Initial hospitalization due to consciousness disorders; (3) Age ≥ 18 years; (4) No prior outpatient treatment measures; and (5) Obtained consent from patients and their families to collect relevant data.

Exclusion criteria: (1) Individuals with a history of psychiatric illness or cognitive impairment; (2) Cases with missing data; and (3) Individuals unwilling to participate in the study.

Control group

The control group was treated using the conventional emergency rescue process, which involves receiving patients in the Emergency Department. After admission, patients are treated in relevant areas according to the three-level, four-zone principle of emergency and pre-check triage. The nurse conducts pre-diagnosis triage, informs the on-duty physician, and simultaneously transfers the patient to the resuscitation room. The physician conducts a preliminary assessment, issues relevant rescue instructions, and instructs the emergency nurse to immediately perform basic operations such as electrocardiographic monitoring, establishing intravenous access, and collecting blood samples. Simultaneously, preparations are made for cranial computed tomography or magnetic resonance imaging examinations, and neurology consultations are notified for definitive diagnosis and treatment.

Observation group

The observation group is treated using the emergency rescue process reengineered based on the checklist.

Establishment of emergency process reengineering team: (1) Led by the director of the Department of Emergency and the head nurse; (2) Includes a senior emergency physician and two nursing leaders, each with over 10 years of clinical emergency experience; and (3) Defined the goal of process reengineering: “Reduce emergency stay time and improve rescue success rate”.

Creation of the checklist: (1) Analyzed previous cases and evidence from the literature to understand the characteristics, conditions, and urgent needs of patients with emergency consciousness disorders; and (2) Developed a checklist with key points on cardiopulmonary resuscitation measures, airway management, blood pressure monitoring and control, brain function assessment, laboratory and imaging examinations, etiological diagnosis, and treatment.

Process reengineering: (1) Established a multidisciplinary emergency rescue team led by the Emergency Department; (2) Integrated medical resources across the hospital to enhance collaboration efficiency between different disciplines; (3) Introduced a mobile emergency platform for quick assessment, documentation, and initiation of necessary actions for patients received by emergency 120 services; (4) Implemented a pre-diagnosis triage system with automatic information reception and consultation notification for neurology specialists; (5) Conducted simulated drills and collected feedback to assess the effectiveness and feasibility of the redesigned process; and (6) Adjusted and improved the process as needed.

Validation and optimization: (1) Simulated the redesigned process, collected feedback, and evaluated its effectiveness and feasibility; and (2) Adjusted and improved the process based on feedback.

Training: (1) Provided training to all emergency department staff; (2) Conducted simulations and assessments for various scenarios; (3) Enhanced staff familiarity with the new emergency mode and process; and (4) Offered training and assessments on professional knowledge and emergency awareness to improve emergency response capabilities.

Observation indexes

Collect the data of the two groups of patients, statistically compare the emergency stay time, rescue success rate, hospitalization time and doctor-patient satisfaction of the two groups; compare the prognosis of the two groups of patients. Hospitalization time includes intensive care unit (ICU) hospitalization time, general ward hospitalization time and total hospitalization time. Doctor-patient satisfaction, including healthcare personnel satisfaction and patient family satisfaction, was assessed using a general satisfaction questionnaire, and was divided into 4 levels: Very satisfied, satisfied, general, dissatisfied. Dissatisfaction was assessed at 4 levels, with 10 randomly selected members of the medical staff (5 doctors and 5 nurses). Prognosis was assessed using the Glasgow Outcome Scale (GOS) with 5 grades of good recovery, mild disability, moderate disability, severe disability, vegetative and death.

Statistical analysis

Data compilation and entry were conducted using the double-check method. Statistical analysis was performed using SPSS version 21.0 statistical software (IBM, Armonk, NY, United States). For continuous data (mean ± SD), independent sample t-tests were employed. Categorical data n (%) underwent χ² tests, while ordinal data were subjected to the Mann-Whitney U test. A significance level of P < 0.05 indicated statistical significance.

RESULTS

Comparison of general information between two groups

There were no significant differences in general patient characteristics between the two groups (P > 0.05, Table 1), including gender (male/female: 136/64 vs 124/76, P = 0.208), age (54.68 ± 11.25 vs 55.17 ± 10.69, P = 0.655), time from onset to treatment (9.57 ± 1.25 vs 9.86 ± 2.12, P = 0.096), degree of impaired consciousness (mild/moderate/severe: 42/106/52 vs 36/110/54, P = 0.751), and cause (craniocerebral trauma/cerebrovascular accident/other: 54/118/28 vs 50/116/34, P = 0.687).

Table 1 Comparison of general information between two groups, mean ± SD.

Group	n	Gender (male/female)	Age	Time from onset to treatment	Degree of impaired consciousness (mild/moderate/severe)	Cause (craniocerebral trauma/cerebrovascular accident/other)
Observation group	200	136/64	54.68 ± 11.25	9.57 ± 1.25	42/106/52	54/118/28
Control group	200	124/76	55.17 ± 10.69	9.86 ± 2.12	36/110/54	50/116/34
t/χ2		1.582	0.447	1.666	0.573	0.752
P value		0.208	0.655	0.096	0.751	0.687

Comparison of emergency stay, time to recovery, and hospitalization duration between two groups

The observation group demonstrated significantly shorter emergency stay, time to recovery, and hospitalization durations (ICU, general ward, and total) compared to the control group (P < 0.05, Table 2). Specifically, emergency stay was 40.65 ± 3.84 minutes vs 48.24 ± 4.36 minutes (P = 0.000); time to recovery was 215.65 ± 90.24 minutes vs 232.87 ± 82.63 minutes (P = 0.047); ICU hospitalization was 2.36 ± 1.35 days vs 2.67 ± 1.23 days (P = 0.017); general ward hospitalization was 7.65 ± 1.12 days vs 8.12 ± 1.36 days (P = 0.000); and total hospitalization was 10.01 ± 1.23 days vs 10.79 ± 1.17 days (P = 0.000).

Table 2 Comparison of emergency stay, time to recovery, and hospitalization duration between two groups, mean ± SD.

Group	Cases	Emergency stay (minutes)	Time to recovery (minutes)	ICU hospitalization (days)	General ward hospitalization (days)	Total hospitalization (days)
Observation group	200	40.65 ± 3.84	215.65 ± 90.24	2.36 ± 1.35	7.65 ± 1.12	10.01 ± 1.23
Control group	200	48.24 ± 4.36	232.87 ± 82.63	2.67 ± 1.23	8.12 ± 1.36	10.79 ± 1.17
t/χ2		18.475	1.990	2.401	3.773	6.498
P value		0.000	0.047	0.017	0.000	0.000

ICU: Intensive care unit.

Comparison of rescue success rates between two groups

The observation group exhibited a higher rescue success rate compared to the control group (92.50% vs 86.00%, P = 0.036, Table 3). Correspondingly, the mortality rate was lower in the observation group (7.50% vs 14.00%).

Table 3 Comparison of rescue success rates between two groups, n (%).

Group	Cases	Rescue success	Death
Observation group	200	184 (92.50)	16 (7.50)
Control group	200	172 (86.00)	28 (14.00)
t/χ2		4.404
P value		0.036

Comparison of prognosis between two groups

The observation group exhibited a better recovery rate compared to the control group (P < 0.05, Table 4), with higher rates of good recovery (55.98% vs 50.00%) and mild disability (22.83% vs 16.28%), and lower rates of severe outcomes.

Table 4 Comparison of prognosis between two groups, n (%).

Group	Cases	Good recovery	Mild disability	Moderate disability	Severe disability	Vegetative state
Observation group	184	103 (55.98)	42 (22.83)	20 (10.87)	11 (5.98)	8 (4.35)
Control group	172	86 (50.00)	28 (16.28)	22 (12.79)	22 (12.79)	14 (8.14)
Z		3.907
P value		0.048

Comparison of satisfaction between two groups

Both medical staff and patients’ family members showed higher satisfaction with the emergency rescue mode after process redesign compared to the conventional emergency rescue mode (P < 0.05, Tables 5 and 6). Medical staff satisfaction showed 80.00% very satisfied in the redesigned mode vs 30.00% in conventional (P = 0.036). Patient family satisfaction showed 38.00% very satisfied in redesigned vs 28.00% in conventional (P = 0.029).

Table 5 Comparison of medical staff satisfaction between two groups, n (%).

Group	Cases	Very satisfied	Satisfied	Neutral	Dissatisfied
Observation group	10	3 (30.00)	4 (40.00)	2 (20.00)	1 (10.00)
Control group	10	8 (80.00)	1 (10.00)	1 (10.00)	0 (0.00)
Z		4.374
P value		0.036

Table 6 Comparison of patient family satisfaction between two groups, n (%).

Group	Cases	Very satisfied	Satisfied	Neutral	Dissatisfied
Observation group	200	56 (28.00)	102 (51.00)	18 (9.00)	24 (12.00)
Control group	200	76 (38.00)	89 (44.50)	27 (13.50)	8 (4.00)
Z		4.785
P value		0.029

DISCUSSION

Observation indexes in this study were selected to comprehensively evaluate the efficiency and effectiveness of the reengineered process. Emergency stay duration reflects workflow timeliness, crucial for minimizing neurological damage in disorders of consciousness. Rescue success rate and mortality assess life-saving outcomes, while hospitalization duration indicates recovery speed. Prognosis via GOS measures long-term functional recovery, and satisfaction gauges practical acceptance by staff and families.

Consciousness disorders often accompany the occurrence of emergency and critical conditions, with a high mortality and disability rate. Emphasizing rapid rescue is crucial, as swift intervention can reduce neurological damage and improve patient prognosis. Given the complex and diverse etiology of consciousness disorders, timely diagnosis of the underlying causes can secure more time for effective rescue efforts. Previous research has demonstrated that redesigning emergency protocols for critically ill patients can significantly enhance rescue efficiency and improve patient outcomes[10,11]. However, studies focusing on patients with consciousness disorders are still incomplete. To address this gap, this study aimed to improve the success rate of emergency rescues for consciousness disorders.

The optimization principle for emergency rescue work is to streamline the workflow in pre-hospital, in-hospital, and preoperative stages, eliminating intermediate steps to achieve the utmost urgency[12]. Prior research has suggested that intra-hospital transfers for critically ill patients are a necessary step in the emergency treatment process. Prolonged intra-hospital transfer times may cause irreversible harm to patients and, in severe cases, may even be life-threatening[13,14]. The study shows that the observation group had a shorter emergency stay time than the control group, indicating that the newly designed emergency protocol is more efficient, effectively reducing waiting times at various stages. The reasons for this improvement may include: (1) The creation of a checklist to identify processes in need of optimization, facilitating targeted process redesign and improving the quality of process redesign; (2) The establishment of a multidisciplinary emergency response team in the new emergency process, enhancing collaboration efficiency among different disciplines; (3) The introduction of a mobile emergency platform, allowing for immediate hospital admission upon arrival, reducing redundant medical history inquiries and the process of establishing medical records, shortening admission times, and facilitating early consultations and examination requests, thereby reducing the time patients wait for examinations; and (4) The creation of a causative thinking checklist that assists physicians in rapid screening, facilitating a quick diagnosis in collaboration with examination results, and shortening the diagnosis time. By optimizing the pre-hospital and in-hospital handover process, simplifying admission procedures, requesting examinations and consultations earlier, and aiding in causative diagnosis, the study aimed to improve the efficiency of emergency rescue work, reduce patients’ emergency stay times, and ensure their life and health safety.

The study shows that the treatment-to-awakening time, ICU stay, and total hospital stay times for patients in the observation group were shorter than those in the control group, indicating better recovery in the observation group. The reasons for this may be that with a shorter emergency stay time, indicating a lower degree of neurological damage, patients had better neurological recovery after corresponding treatment. The shorter emergency stay time effectively provided the optimal window for subsequent treatment, reducing neurological damage, and promoting patient recovery[15]. Previous studies have also mentioned that reducing the time for each step in the emergency rescue process can effectively improve rescue efficiency and patient outcomes[16,17].

In comparison, this study also demonstrates that the observation group had a higher rescue success rate and lower mortality, as the emergency response team members underwent assessments of professional knowledge and emergency awareness, which can enhance the overall emergency response capabilities of emergency department medical staff[18]. Repeated learning and drills for typical emergency cases, drawing experiences and lessons, can effectively improve the success rate of emergency rescues. Additionally, this study included a professional and efficient pre-hospital emergency response team and an in-hospital emergency response team, which had good planning and purposefulness, contributing to increased cooperation among medical staff, thereby improving work efficiency[19]. Unnecessary waiting times at various stages were reduced, allowing for a timely diagnosis and treatment plan development for patients within a short time. This approach increases the success rate of emergency rescues. Previous studies have also emphasized the advantages of multidisciplinary collaborative emergency rescues[20].

The study results also indicate a better prognosis in the observation group, further highlighting the effectiveness of emergency process redesign based on the thinking checklist. Compared to the control group, the observation group showed improved GOS scores, with fewer cases in vegetative states or death, underscoring the clinical value of reduced delays. The study shows that both medical staff and patients’ family members expressed high satisfaction with the new emergency mode, indicating an overall improvement in the quality of the new emergency mode, which is beneficial for both medical staff and patients seeking medical attention.

CONCLUSION

In summary, this study demonstrates that checklist-based process reengineering significantly shortens emergency stay and hospitalization durations, increases rescue success rates, reduces mortality, improves prognosis, and enhances satisfaction among medical staff and patient families. These findings provide valuable evidence for optimizing emergency protocols in disorders of consciousness, potentially guiding broader clinical implementations to improve patient outcomes.