Current political issues facing emergency medicine in Canada

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

Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding.

Important returns on investment: an evaluation of a national research grants competition in emergency medicine

OBJECTIVE

We sought to examine scholarly outcomes of the projects receiving research grants from the Canadian Association of Emergency Physicians (CAEP) during the first 10 years of national funding (i.e., between 1996 and 2005).

METHODS

We sent email surveys to 62 emergency medicine (EM) researchers who received funding from CAEP. We focused our data collection on grant deliverables and opinions using a 1-7 Likert scale with regard to the value of the award.

RESULTS

Fifty-eight recipients responded to our survey. Grants were most commonly awarded to residents (21 [36%]), followed by senior (16 [28%]) and junior (13 [22%]) emergency staff. Twenty-six applicants from Ontario and 11 from Quebec received the majority of the grants. Overall, 51 projects were completed at the time of contact and, from these, 39 manuscripts were published or in press. Abstract presentations were more common, with a median of 2 abstracts presented per completed project. Abstract presentations for the completed projects were documented locally (23), nationally (39) and internationally (37). Overall, 19 projects received additional funding. The median amount funded was Can$4700 with an interquartile range of $3250-$5000. Respondents felt CAEP funding was critical to completing their projects and felt strongly that dedicated EM research funding should be continued to stimulate productivity.

CONCLUSION

Overall, the CAEP Research Grants Competition has produced impressive results. Despite the small sums available, the grants have been important for ensuring study completion and for securing additional funding. CAEP and similar EM organizations need to develop a more robust funding approach so that larger grant awards and more researchers can be supported on an annual basis.

Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach

Social scientific and nursing studies, and the experiences of emergency department staff, have attested to the complex organisational and communicative work that accompanies emergency clinical work. Yet, little attention has been paid to developing a research framework to examine and develop communicative and organisational work in emergency departments (EDs). This paper explores the role of nurses in plugging gaps in the care of ED patients, and summarises the findings of a large, 3-year ethnographic study comprising 12 months of ethnography in two EDs in Sydney, Australia, and 2 years of analysis. The findings of the large study are summarised and exemplified here as part of a broader conceptual argument for the importance of ethnographic research in EDs. Ethnography involves capturing the moment-to-moment action of life when and where it happens, and in the context of, reflecting and amending, broader social patterns. The findings report on the relationship of communication, organisational and, in particular, interdepartmental and interorganizational work, to emergency clinical work and demonstrate that nurses play an important role in articulating and reconciling patients' and medical staff activities. The paper concludes that emergency nurses are well placed to use ethnographic research to advance the understanding and delivery of emergency care.

Emergency department overcrowding - implications for paediatric emergency medicine

Emergency department (ED) overcrowding has been an international phenomenon for more than 10 years. It is important to understand that ED overcrowding is a measure of health system efficiency and is not strictly related to ED volumes or capacity. ED overcrowding is defined as a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time. The major factor resulting in ED overcrowding is the presence of admitted patients in the ED for prolonged periods of time, not a high volume of low-acuity patients. While limited data are available for paediatric EDs, winter respiratory illnesses set the stage for ED overcrowding, which are epidemic in adult or general EDs. Prehospital-, ED- and hospital-related factors are described in the present article, and these may help prevent or manage this important patient safety problem.