DHA 700 Week 7 Reading and Synthesizing Research Example

Forty-One Thousand Admissions and a Million Visits: Learning to Read, Appraise and Synthesize Research on Emergency Department Boarding

[Student Name]

University of Phoenix

DHA/700: Introduction to Health Administration in Doctoral Study

Week 7 Assignment

[Instructor Name]

[Date]

The health system, its boarding data, the search and the synthesis matrix are composites written for a model paper; research findings come from the sources cited.

The chief operating officer's first attempt at a literature review on emergency department boarding was a list of fifteen article summaries, one per paragraph. Her faculty mentor returned it with a single comment: this is a book report, not a synthesis. The executive realized that reading research for doctoral work differs from skimming it for meetings. This paper describes how she learned to search, read, appraise and synthesize the literature, using boarding at the system's regional hospital as the problem. At that hospital, admitted patients spent a median of seven hours in emergency bays waiting to go upstairs during the previous winter, and some waited more than a day.

Sharpening the Question

Her first question, what is known about boarding, was too broad to guide a search or a synthesis. She narrowed it using the elements of a focused question: among adult patients admitted through the emergency department of community hospitals, what is the association between boarding time and outcomes such as mortality, length of stay and costs, and which hospital-level strategies reduce boarding? The narrower question told her which studies to include, which outcomes mattered and which settings were most relevant to a rural regional hospital.

Documenting the Search

She searched three databases covering medicine, nursing and health management, using combinations of terms for boarding, crowding and admission holds with terms for mortality, length of stay and interventions, limited to English-language studies from the past twenty years. She screened 412 titles and abstracts, read 58 full texts and kept 23 studies. She recorded every step, so a reader could repeat the search, and she saved reasons for excluding studies, such as pediatric settings or outcomes unrelated to her question.

Choosing a Review Approach

Not every review is systematic. A typology of review types analyzed 14 types, from narrative and critical reviews to systematic, scoping, rapid and umbrella reviews, using a framework of search, appraisal, synthesis and analysis, and found that few review types have explicit, prescribed methods and many overlap (Grant & Booth, 2009). For a doctoral course paper with limited time, she chose a structured literature review with a documented search and appraisal, short of a full systematic review, and she named that choice and its limits openly in the paper.

Reading a Paper: Getting Your Bearings

Before reading deeply, she applied three orienting questions: why was the study done and what question did it address, what type of study was it and was that design appropriate for the question (Greenhalgh, 1997). The questions saved time by screening out studies whose designs could not answer her question, and they framed how to read the rest. A descriptive report from a single hospital's quality project, for example, could suggest strategies but not establish effects, while a cohort with adjustment for illness severity could support a claim of association.

Appraising Study One: Boarding Time and Mortality

A retrospective cohort at a suburban academic emergency department with 90,000 annual visits examined 41,256 admissions over three years. Death rates climbed step by step as boarding lengthened, from 2.5% for patients moved upstairs within two hours to 4.5% for those held twelve hours or longer, and mean hospital length of stay rose from 5.6 days to 8.7 days for those boarded more than 24 hours, with associations persisting after adjustment for comorbidities and other factors (Singer et al., 2011). The longer patients waited in the emergency department, the more likely they were to die in the hospital.

Strengths and Limits of Study One

The study's strengths are its large sample, dose-response pattern and adjustment for comorbidity. Its limits are that it comes from a single academic hospital, uses a retrospective design and cannot rule out that sicker patients both board longer and die more often for reasons the adjustment missed. It establishes association, not cause. For a rural regional hospital, its setting is different, but the mechanism, patients receiving care in a space not designed for inpatients, applies across settings.

Appraising Study Two: Crowding Across a State

A statewide study of 995,379 emergency department visits resulting in admission to 187 California hospitals used ambulance diversion hours as a measure of crowding and compared days within each hospital's top quartile of diversion with other days. Patients admitted on high-crowding days had 5% greater odds of inpatient death, 0.8% longer stays and 1% higher costs, amounting to an estimated 300 excess deaths, 6,200 hospital days and $17 million in costs in one year (Sun et al., 2013).

Strengths and Limits of Study Two

The study's strengths are its statewide scope and its comparison of each hospital with itself on crowded and uncrowded days, which controls for fixed hospital differences. Its limits are that diversion is an indirect proxy for crowding, the design remains observational and effects per patient are modest even if the total is large.

The Synthesis Matrix

She built a matrix with a row for each of the 23 studies and columns for design, setting, sample size, how boarding or crowding was measured, outcomes, adjustment, findings and limitations. Reading across rows revealed patterns that summaries had hidden, such as how many studies came from large academic centers and how few from rural hospitals, and which outcomes were measured consistently.

Patterns in the Evidence

Across studies, longer boarding and crowding were consistently associated with higher mortality, longer stays and higher costs, and the two appraised studies, one measuring individual boarding time in a single hospital and the other measuring hospital-level crowding across a state, pointed the same direction despite different designs. Agreement across designs with different weaknesses strengthens confidence in the association.

Gaps in the Evidence

The synthesis also revealed gaps. Few studies came from rural or small hospitals, few tested interventions with strong designs and fewer still measured staff outcomes. Evidence on strategies, such as early discharge, full-capacity protocols and inpatient bed management, relied largely on before-and-after reports.

Writing a Synthesis, Not a Summary

Her revised paper organized findings by theme rather than by study: outcomes associated with boarding, measurement approaches, strategies tested and gaps. Each paragraph cited several studies and compared them. Her mentor's second comment was brief: now it is a synthesis. The revision took twice as long as the first draft, mostly in building the matrix, but the writing itself went faster once patterns were visible.

Implications for the System

For the system, the synthesis treats boarding as a threat to patient safety rather than merely a flow problem, justifying board attention. It also suggests the system could contribute evidence by carefully evaluating its own interventions, since rural data are scarce.

Conclusion

Learning to read and synthesize research turned a list of summaries into an argument. A focused question, a documented search, an appropriate review type, orienting questions for reading and careful appraisal of two key studies led to a synthesis showing that boarding and crowding are consistently associated with worse outcomes, with gaps in rural and intervention evidence that the executive's doctoral work can help fill.

References

Grant, M. J., & Booth, A. (2009). A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information and Libraries Journal, 26(2), 91-108. https://doi.org/10.1111/j.1471-1842.2009.00848.x

Greenhalgh, T. (1997). How to read a paper: Getting your bearings (deciding what the paper is about). BMJ, 315(7102), 243-246. https://doi.org/10.1136/bmj.315.7102.243

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329. https://doi.org/10.1111/j.1553-2712.2011.01236.x

Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., & Asch, S. M. (2013). Effect of emergency department crowding on outcomes of admitted patients. Annals of Emergency Medicine, 61(6), 605-611. https://doi.org/10.1016/j.annemergmed.2012.10.026