Welcoming protocol in the maximum restriction of the emergency department of a tertiary hospital in Brazil

The moment of maximum restriction in ED is a complex issue caused by many extrinsic and intrinsic factors [1-4]. Despite the interaction between these causal factors, the consequence is the extreme decrease in the capacity to absorb new demand. However, according to the National Humanization Policy of Brazil (NHP), the patient has the right to welcoming, which presupposes “the change of the professional/user relationship and his/her social network through technical, ethical, humanitarian, and solidarity parameters, recognizing the user as a subject and active participant in the health production process” [5].


Introduction
The maximum capacity of the Emergency Department (ED) occurs when the need for emergency services exceeds the availability of its resources. At this moment, we can characterize the work in the sector as a maximum restriction [1].
Overcrowding is a worldwide and multifaceted phenomenon.
Its causes can be internal and external to the service, structural, and functional. Its consequences are harmful both to patients and health professionals, as well as to the services themselves, to the health care network, and, in a broader understanding, to society. For patients, the overcrowding of emergency services leads to increased waiting times for care and to obtain beds in units more appropriate for hospitalization, increased risk of adverse events, increased risk of worsening clinical conditions, autonomy loss, and mortality [2]. For health professionals, overcrowding creates work overload, culminating in stress, Citation: Prestes  the responsibility of the worker/team by the user, from his/ her admission until his/her discharge. Listening to his/ her complaint, considering his/her concerns and anxieties, using qualifi ed listening that makes it possible to analyze the demand and, placing the necessary limits, guaranteeing comprehensive, resolutive, and responsible attention through the activation/articulation of the internal networks of services (aiming at horizontal care) and external networks, with other health services, for continuity of assistance when necessary [5][6][7][8].
Here, we identifi ed a great similarity between the concepts of welcoming as a qualifi cation strategy and lean thinking in health. From the Toyota production system, lean when applied to health is understood as a means to provide changes in the organization and hospital management, improving the quality of patient care and reducing errors and waiting times, besides benefi ting the departments' joint functioning of the departments [9]. Because it is a change of culture and not just the application of tools, successful implementation of lean goes through, in addition to training, pilot project, and implementation of improvements through assistance teams.
In this sense, the welcoming demands an organization of the work processes, aiming to serve those who seek health services, listening to their requests, assuming a posture of listening and agreeing on appropriate responses, providing care with resolution and responsibility, "guiding, when if applicable, the patient and family in relation to other health services for the continuity of assistance and establishing links with these services to ensure the effectiveness of these referrals" [5].
The present study demonstrates the elaboration, implementation, and the fi rst results of the "Welcoming Protocol in the Maximum Restriction of the Emergency Department" by the nursing team.

Methodology
The nursing team carried out a descriptive study of the elaboration, validation, and implementation of a protocol at the ED of Hospital Nossa Senhora da Conceição (HNSC). These protocol creation processes, identifi ed as "Welcoming Protocol in the Maximum Restriction of the Emergency Department", followed some Lean healthcare guidelines and the application of validation instruments by a panel of experts [9,10]. The results of the pilot study of its use have also been described.

The creation and implementation of a welcoming tool in situations of overcrowding
Faced with situations of extreme capacity of the ED, the Hospital Nossa Senhora da Conceição (HNSC) adopted the so-called Full Capacity Plan. This contingency plan provides for the maximum restriction of services when the number of patients in care in the ED exceeds the capacity installed. The hospital's capacity does not allow the relocation of patients.
Monitoring the ED capacity takes place daily and is shown on a panel on the HNSC website, as shown in Figure 1.
However, the restriction measure needs to be based on welcoming and safety for patients and professionals. To this end, in December 2018, the HNSC started working on a way to better guide people who seek their emergency in times of overcrowding (maximum restriction). Such an action would be carried out before the risk classifi cation, aiming to offer welcoming with good guidance and safety to patients and professionals. In this way, an instrument was created with the defi nition of clinical criteria to provide security to the professionals who would receive the patients. It is a checklist form, including two groups of questions to be answered with yes or no.
The fi rst group of questions refers to how the patient is referred to the service and/or linked to the hospital:

Regulated by MECS: MECS assists emergency calls at home
and in urban areas -on public roads -directing patients to the most appropriate health care ED institution, as established by the SUS National Regulatory Policy [11]. In this way, prehospital screening of patients is carried out, referring cases with already evidenced severity classifi cation to the hospital's ED.
Prior acceptance of the IRN: One of the functions of the HNSC's IRN is the analysis of requests for assessments/ hospitalizations of critically ill patients via emergency, coming from less complex institutions such as, for example, the ECU. Therefore, every patient assessed and considered serious by the IRN must be seen even during a period of maximum restriction in the ED.
Cancer follow-up at the hospital: Cancer patients are potentially immunosuppressed, both due to aspects related to the disease and to the therapies used in the treatment, being considered vulnerable to infections and rapid evolution to septic shock. Also, the national policy for the prevention and control of cancer in the health care network of people with chronic diseases within the scope of SUS establishes emergency care for cancer patients in hospitals, ensuring comprehensive care within the health care network [12]. Thus, all patients undergoing cancer follow-up at HNSC must be seen at the ED, even during maximum restriction periods. Still, the emergency of HNSC has the Febrile Neutropenia Protocol, widely applied in these patients.

Instrument validation
The instrument, already organized and structured, was  [14].
At the HNSC, these four strategies were used to some degree to get to what we wanted at the beginning, the implementation of the welcoming protocol in the maximum restriction of the emergency. On this fi rst day, 123 people sought the Emergency. The outcomes were described in Table 1. After that date, the team of professionals met to assess what happened and considered the positive and negative aspects. As positive aspects, it was noticed:

Results -The HNSC experience
(a) greater physical protection for the nursing professional, who assesses the patient inside the lobby; (b) assessment close to the door facilitates referral to other services; (c) the security team is more available to control access to the service; (d) the security guard accompanies the nurse in vehicle assessment; (e) the external information (poster) obtained a satisfactory result, as 32.5% of users sought another service on their own.
On the other hand, it was understood that the professional's permanence at the door did not always provide an adequate assessment; in times of greatest demand, there was a queue at the door, and the nurses worked without registering their assessment. From there, some changes were proposed for the second phase of the pilot.
On 01/21/2019, the patient entered, registered, and waited for the nursing welcoming in the ED lobby. According to the instrument already presented, the nurse welcomed the patient to the screening offi ce and identifi ed the presence of any of the criteria established for care to defi ne which fl ow to follow (risk classifi cation or guidance to seek another service). Also, the welcoming was registered in a white bulletin. That day, the emergency door demand was 181 admissions. The outcomes were described in Table 2.  They were classifi ed in the blue area and referred to other services 2 1.6 They were assessed in the car (01 passed to RC and 03 were referred to other services) 4 3.3 Table 2: Outcomes on the second day (n.:181 people sought the Emergency).

OUTCOMES N %
They read the poster and sought other services 54 29.8% They requested care and went through the nursing welcoming 61 33.7% They were classifi ed in the blue area and referred to medical care 26 14.4% They were welcomed and did not present criteria for risk classifi cation 38 21.0% They were welcomed in the car and classifi ed 2 1.1% It is worth mentioning that, besides the total number of patients who sought care, other 70 knocked on the ED's door to request general information, such as scheduling tests, in addition to requesting the use of a bathroom and drinking fountain.
After that date, the team of professionals met again to assess what happened. As positive aspects, several points were This "pilot" experience was followed by the emergency care service organization and the computerization of the protocol, as shown in Figure 2. In this phase, all those aspects listed as important and priority in the assessment/welcoming of patients made up the checklist, as well as a space for other observations that could be part of the patient's assessment and be fundamental for decision making (observation fi eld).
Following the principles of continuous improvement and respect for people, advocated by the lean culture of lean in health, spaces for discussion, and collective construction of improvements to the protocol were created [15].
We were able to observe that the welcoming protocol in the maximum emergency restriction acts as an object of qualifi cation of the hospital door of urgency and emergency, besides organizing and qualifying the care when this situation is "maximum restriction", thus collaborating with the Urgency Care Network and Emergencies [16]. The protocol contributes to the humanization of care, focusing on comprehensive care for the user.

Discussion
In this study, we adopted embracement as a strategy to This study illustrates the complex characteristics of the ED overcrowding problem [2].
Another strategy available in the literature is the maximum capacity protocol that suggests that when a patient needs to be admitted to an inpatient unit from the ED and that unit cannot accommodate the patient due to the lack of available beds, he/she will be admitted to the next most appropriate bed. Although the impacts of this type of protocol on patients admitted to inpatient units have not been fully studied, they bring the possibility of decreasing the length of stay in ED, less waiting time, fewer patients leaving the ED unseen, less patient mortality, greater operating income, and greater patient satisfaction [3]. Despite these favorable points, this maximum capacity protocol would not be a feasible alternative for many hospitals, as there is still a lack of a standard defi nition of the maximum capacity protocol and implementation strategies, as well as an alternative to management when the inpatient units are overcrowded, at the same time as the ED (the one characterized with maximum restriction).
In this study, the moment of maximum restriction in the ED is a complex issue caused by many extrinsic and intrinsic factors, the consequence of which is the extreme decrease in the capacity to absorb new demand in the sector (capacity above the maximum number of beds arranged in the ED with hospital capacity preventing internal transfers). In hospital care, the aim was to implement reception mechanisms with welcoming to users and welcoming with risk classifi cation in the areas of access to the environment (emergency care/emergency room, outpatient clinic, and SADTs). In turn, specifi cally in urgent and emergency services, the aim was "the demand received and met according to the risk classifi cation, guaranteeing access referenced to other levels of assistance" [6]. Lean management is another quality assurance method that focuses on process improvement and change management. Reducing unnecessary delays in ED is the ultimate goal to assure better patient outcome. The lean approach, such as that proposed by the welcoming protocol, can improve the patient fl ow in ED [9]. Adequately welcoming users who arrive at the ED in times of maximum restriction is proposed as an objective in constructing a welcoming protocol.
As already identifi ed in the literature, the adoption of nonurgent referral measures and control of the patients' destination (adequate referral) are strategies that can assist in the management of ED overcrowding [1,2,7,8].