Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience

TY - JOUR

T1 - Emergency Department Escalation in Theory and Practice

T2 - A Mixed-Methods Study Using a Model of Organizational Resilience

AU - Back, Jonathan

AU - Ross, Alastair J

AU - Duncan, Myanna D

AU - Jaye, Peter

AU - Henderson, Katherine

AU - Anderson, Janet E

N1 - Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PY - 2017/11/1

Y1 - 2017/11/1

N2 - STUDY OBJECTIVE: Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying "normal" processes. The study objective is to examine escalation policies in theory and practice.METHODS: This was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n=12) and associated escalation actions (n=92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n=30 observations).RESULTS: The conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need ("work as done") was found to be incompletely specified in policies ("work as imagined").CONCLUSION: Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.

AB - STUDY OBJECTIVE: Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying "normal" processes. The study objective is to examine escalation policies in theory and practice.METHODS: This was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n=12) and associated escalation actions (n=92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n=30 observations).RESULTS: The conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need ("work as done") was found to be incompletely specified in policies ("work as imagined").CONCLUSION: Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.

KW - Journal Article

U2 - 10.1016/j.annemergmed.2017.04.032

DO - 10.1016/j.annemergmed.2017.04.032

M3 - Article

C2 - 28662909

SN - 0196-0644

VL - 70

SP - 659

EP - 671

JO - Annals of Emergency Medicine

JF - Annals of Emergency Medicine

IS - 5

ER -