Abstract
BackgroundIn the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues.MethodsA qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes.ResultsThe wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients.ConclusionsThe imposition of a wait-target in response to a perceived “crisis” of patients’ dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians’ experience and satisfaction.
Highlights
In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows
There were issues of security, privacy and dignity for their patients, inside the treatment rooms. They came to the conclusion that the emergency departments (EDs) building plan and patterns of space usage were good enough for the old service model of treating patients in priority order but not the new “See and Treat” model of patient streaming. They had to double the number of rooms and, their capacity to treat patients in dedicated spaces with dedicated staff
We found the 4 hour wait target supported the development of a new type of spatial and temporal regulation of ED staff ’s work
Summary
In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. Prolonged patient wait times in NHS emergency departments (EDs), here defined as the number of minutes between the time the patient arrives at the ED and the time the patient is admitted, transferred or discharged from the ED (length of stay), have traditionally been a major cause of patient dissatisfaction [1,2,3,4,5], as the demand for emergency care is rising and acuity is becoming increasingly complex [6] They are a cause of patients leaving the ED before being seen by a clinician [7,8,9], adverse events [10], restricted access to emergency care [11] and increased mortality rates [12]. Qualitative studies, focusing on clinicians’ understanding of the target’s impact suggest that patient flow and ED experience for staff and patients may have been improved, this has happened at the expense of quality time for communication and treatment [31]
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