Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, Australia.
Acad Emerg Med. 2011 Oct;18(10):1045-52. doi: 10.1111/j.1553-2712.2011.01171.x.
In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding.
An ethnographic approach was used, which involved direct observation of on-the-ground behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses, emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and thematically analyzed more than 800 pages of field notes to identify indicators of and responses to pressure in the day-to-day ED work environment.
In response to the inability to control inflow, and the reactions of inpatient departments to whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions; negotiated and determined patients' admission-discharge status early in their trajectories; pursued predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised flexibility to reduce work pressure by managing scarce time and space in the ED.
To redress the linearity of most literature on patient flow, this study adopts a systems perspective and ethnographic methods to bring to light the dynamic role that individuals play, interacting with their work contexts, to maintain patient flow. The study provides an empirical foundation, uniquely discernible through qualitative research, about aspects of ED work that previously have been the subject only of discussion or commentary articles. This study provides empirical documentation of the moment-to-moment responses of emergency clinicians to work pressure brought about by factors outside much of their control, establishing the relationship between patient flow and work pressure. We conceptualize the ED as a dynamic system, combining socioprofessional influences to reduce and control work pressure in the ED. Interventions in education, practice, policy, and organizational performance evaluations will be supported by this systematic documentation of the complexity of emergency clinical work. Future research involves testing the five findings using systems dynamic modeling techniques.
在这项假设生成研究中，我们观察、识别和分析急诊临床医生如何在以延迟患者入院（就诊阻塞）和急诊部（ED）拥堵为特征的环境中管理工作压力，以最大限度地提高患者流量。
采用了一种民族志方法，包括直接观察实地行为以及它们发生的时间和地点。在 12 个月的时间里，我们观察了大约 260 名急诊医生和护士、急诊临床医生以及其他医院科室的临床医生之间的大约 4500 次互动，共花费了 1600 多个小时。作者对 800 多页的实地记录进行了内容分析和主题分析，以确定日常 ED 工作环境中的压力指标和应对压力的方法。
为了应对无法控制流入量的情况，以及住院病房对可能转院的患者的反应，急诊临床医生采取了以下措施：协调病情的紧急程度和严重程度；在患者的轨迹早期协商并确定其入院-出院状态；针对微观和宏观流量问题，按照预定但不断演变的路径进行操作；并通过管理 ED 中的稀缺时间和空间来减少工作压力，保持灵活性。
为了纠正大多数关于患者流量的文献的线性性，本研究采用了系统视角和民族志方法，揭示了个体在维持患者流量方面所扮演的动态角色，他们与工作环境相互作用。这项研究通过定性研究提供了一个独特的实证基础，揭示了 ED 工作中以前仅作为讨论或评论文章主题的方面。这项研究提供了急诊临床医生对其工作压力的即时反应的实证记录，这些压力是由他们无法控制的因素引起的，从而建立了患者流量和工作压力之间的关系。我们将 ED 视为一个动态系统，结合社会职业影响来减少和控制 ED 中的工作压力。这项系统记录急诊临床工作的复杂性将为教育、实践、政策和组织绩效评估方面的干预措施提供支持。未来的研究涉及使用系统动力学建模技术测试这五个发现。
