The emergency department "carousel": an ethnographically-derived model of the dynamics of patient flow

"Nurses are every bit of the flow:" Emergency department nurses' conceptualization of patient flow management

AIM

To validate and refine Benjamin and Jacelon's 2021 definition of patient flow management using the experience and knowledge of practicing emergency department nurses.

BACKGROUND

Patient flow requires complex, real-time decision-making to match patients to limited resources and facilitate their movement through care processes. A literature-based concept analysis of patient flow management was first performed in 2021, but the voice of nurses is largely absent from existing patient flow research.

DESIGN

This study employed an expanded concept analysis methodology, as articulated by Kathleen Cowles.

DATA SOURCE

Focus groups of nine emergency nurses were conducted.

RESULTS

Emergency nurses' conceptualization of patient flow management differs from the definition as it has emerged through patient flow literature. Patient flow management is a nurse-driven process that relies on nursing knowledge and the work of all emergency nurses, including bedside nurses. Emergency nurses perceive the ultimate goal of patient flow management to be the collective safety of patients, and they work to promote patient safety within their own scope of responsibility.

CONCLUSION

Understanding patient flow management as a nurse-driven process emphasizes the importance of nurse training and capacity to effective patient flow. Future research should explore the role of emergency nurses as active directors, rather than passive components, of patient flow. More work is needed to investigate this complex nursing task.

Working together in emergency care? How professional boundaries influence integration efforts and operational performance

Purpose

Emergency care delivery is a process requiring input from various healthcare professionals within the hospital. To deliver efficient and effective emergency care, professionals must integrate rapidly at multiple interfaces, working across functional, spatial and professional boundaries. Yet, the interdisciplinary nature of emergency care presents a challenge to the optimization of patient flow, as specialization and functional differentiation restrict integration efforts. This study aims to question what boundaries exist at the level of professionals and explores how these boundaries may come to influence integration and operational performance.

Design/methodology/approach

To provide a more holistic understanding of the inherent challenges to integration at the level of professionals and in contexts where professionals play a key role in determining operational performance, the authors carried out an in-depth case study at a busy, Level 1 trauma center in The Netherlands. In total, 28 interviews were conducted over an 18-month period.

Findings

The authors reveal the existence of structural, relational and cultural barriers between (medical) professionals from different disciplines. The study findings demonstrate how relational and cultural boundaries between professionals interrupt flows and delay service processes.

Originality/value

This study highlights the importance of interpersonal and cultural dynamics for internal integration and operational performance in emergency care processes. The authors unveil how the presence of professional boundaries creates opportunity for conflict and delays at important interfaces within the emergency care process, and can ultimately accumulate, disrupting patient flow and increasing lead times.

Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review

BACKGROUND

The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement.

METHODS

We used a scoping review methodology drawing on Arksey and O'Malley's methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 - April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills.

RESULTS

We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking.

CONCLUSIONS

We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers.

Areas of delay related to prolonged length of stay in an emergency department of an academic hospital in South Africa

Introduction

Globally, length of stay of patients in emergency departments remains a challenge. Remaining in the emergency department for >12 h increases health care costs, morbidity and mortality rates and leads to crowding and lower patient satisfaction.The aim of this research was to describe the areas of delay related to prolonged length of stay in the emergency department of an academic hospital.

Methods

A quantitative retrospective study was done. The Input-Throughput-Output model was used to identify the areas of patients' journey through the emergency department. The possible areas of delay where then described. Using systematic sampling, a total of 100 patient files managed in an emergency department of an academic hospital in South Africa were audited over a period of 3 months. Descriptive statistics and regression analysis was used to analyse data.

Results

The mean length of stay of patients in the emergency department was 73 h 49 min. The length of stay per phase was: input (3 h 17 min), throughput (16 h 25 min) and output (54 h 7 min). A strong significant relationship found between the length of stay and the time taken between disposition decision (throughput phase) disposition decision to admission or discharge of patients from the ED (output phase) (p < 0.05).

Conclusion

The output phase was identified as the longest area of delay in this study, with the time taken between disposition decision to admission or discharge of patients from the ED (patients waiting for inpatient beds) as the main significant area of delay.

Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study

BACKGROUND

The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake.

METHODS

Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups.

RESULTS

Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols.

CONCLUSIONS

Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective

Background

The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project.

Methods

The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015–2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis.

Results

Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels.

Conclusion

Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff’s experiences.

Key High-efficiency Practices of Emergency Department Providers: A Mixed-methods Study

OBJECTIVE

The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs).

METHODS

A mixed-methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety-nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000- to 55,000-visit) community EDs during two 4-hour periods and recorded in minute-by-minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site.

RESULTS

Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, "inefficiency practices," demonstrated significant negative correlations: non-work-related tasks and documentation on patients no longer in the ED.

CONCLUSIONS

Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine

Background

The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments.

Methods

We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015–2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study,

Results

We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement.

Conclusion

Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2915-2) contains supplementary material, which is available to authorized users.

Review article: A systematic review of emergency department incident classification frameworks

As in any part of the hospital system, safety incidents can occur in the ED. These incidents arguably have a distinct character, as the ED involves unscheduled flows of urgent patients who require disparate services. To aid understanding of safety issues and support risk management of the ED, a comparison of published ED specific incident classification frameworks was performed. A review of emergency medicine, health management and general medical publications, using Ovid SP to interrogate Medline (1976-2016) was undertaken to identify any type of taxonomy or classification-like framework for ED related incidents. These frameworks were then analysed and compared. The review identified 17 publications containing an incident classification framework. Comparison of factors and themes making up the classification constituent elements revealed some commonality, but no overall consistency, nor evolution towards an ideal framework. Inconsistency arises from differences in the evidential basis and design methodology of classifications, with design itself being an inherently subjective process. It was not possible to identify an 'ideal' incident classification framework for ED risk management, and there is significant variation in the selection of categories used by frameworks. The variation in classification could risk an unbalanced emphasis in findings through application of a particular framework. Design of an ED specific, ideal incident classification framework should be informed by a much wider range of theories of how organisations and systems work, in addition to clinical and human factors.

Implementing evidence-based practices in an emergency department: contradictions exposed when prioritising a flow culture

Background

An emergency department is typically a place of high activity where practitioners care for unanticipated presentations, which yields a flow culture so that actions that secure available beds are prioritised by the practitioners.

Objectives

How does the flow culture in an emergency department influence nurses’ use of a research‐based clinical guideline and a nutrition screening routine.

Methods

Ethnographic fieldwork was carried out over three months. The first author followed nurses, medical secretaries and doctors in the emergency department. Data were also collected by means of semi‐structured interviews. An activity system analysis, as described in the Cultural Historical Activity Theory, was conducted to identify various contradictions that could exist between different parts of the activity system.

Results

The main contradiction identified was that guidelines and screening routines provided a flow stop. Four associated contradictions were identified: insufficient time to implement guidelines; guilty conscience due to perceived nonadherence to evidence‐based practices; newcomers having different priorities; and conflicting views of what constituted being a professional.

Conclusion

We found that research‐supported guidelines and screening routines were not used if they were perceived to stop the patient flow, suggesting that the practice was not fully evidence based.

Barriers and facilitators for implementing a new screening tool in an emergency department: A qualitative study applying the Theoretical Domains Framework

AIM

The aim was to identify the factors that were perceived as most important as facilitators or barriers to the introduction and intended use of a new tool in the emergency department among nurses and a geriatric team.

BACKGROUND

A high incidence of functional decline after hospitalisation for acute medical illness has been shown in the oldest patients and those who are physically frail. In Denmark, more than 35% of older medical patients acutely admitted to the emergency department are readmitted within 90 days after discharge. A new screening tool for use in the emergency department aiming to identify patients at particularly high risk of functional decline and readmission was developed.

DESIGN

Qualitative study based on semistructured interviews with nurses and a geriatric team in the emergency department and semistructured single interviews with their managers.

METHODS

The Theoretical Domains Framework guided data collection and analysis. Content analysis was performed whereby new themes and themes already existing within each domain were described.

RESULTS

Six predominant domains were identified: (1) professional role and identity; (2) beliefs about consequences; (3) goals; (4) knowledge; (5) optimism and (6) environmental context and resources. The content analysis identified three themes, each containing two subthemes. The themes were professional role and identity, beliefs about consequences and preconditions for a successful implementation.

CONCLUSIONS

Two different cultures were identified in the emergency department. These cultures applied to different professional roles and identity, different actions and sense making and identified how barriers and facilitators linked to the new screening tool were perceived.

RELEVANCE FOR CLINICAL PRACTICE

The results show that different cultures exist in the same local context and influence the perception of barriers and facilitators differently. These cultures must be identified and addressed when implementation is planned.