understanding resilient clinical practice in emergency
TRANSCRIPT
Understanding resilient clinical practice in Emergency Department ecosystems
Jeffrey Braithwaite, PhDRobyn Clay-Williams, PhD
Australian Institute of Health InnovationAustralian Institute of Health InnovationAustralian Institute of Health InnovationAustralian Institute of Health Innovation
Presentation to the Resilient Healthcare Net Conference
Middlefart, University of Southern Denmark12 August 2014
Australian Institute of Health Innovation’s mission
Our mission is to enhance local, institutional and international health system decision-
making through evidence; and use systems sciences and translational approaches to provide innovative,
evidence-based solutions to specified health care delivery problems.
http://www.med.unsw.edu.au/medweb.nsf/page/ihi
Australian Institute of Health Innovation• Professor Jeffrey BraithwaiteFoundation Director, AIHI; Director, Centre for Clinical
Governance Research
• Professor Enrico CoieraDirector, Centre for Health Informatics, AIHI, UNSW
• Professor Ken HillmanDirector, Simpson Centre for Health Services Research,
AIHI, UNSW
• Professor Johanna WestbrookDirector, Centre for Health Systems and Safety Research,
AIHI, UNSW
Resilient health care is taking root
• Two scholarly compendiums: • Hollnagel, E., Braithwaite, J. and Wears, R. (eds) (2013) Resilient
health care, London, Ashgate.
• Wears, R., Hollnagel, E., Braithwaite, J. (eds) (In press) The resilience of everyday clinical work, London, Ashgate.
but • There is much further to go to add to our
understanding of when things go right
• We need to appreciate the habituationsand routines that characterise clinical work
How?
• Complement theories to account for clinical coalface processes with a set of effective empiricisations
• Capture and report on salient examples of how, when nothing goes wrong, things are done
Why Emergency settings?• Emergency Departments (EDs) are
fascinating habitats which are:• time-critical, richly interactive • idiosyncratically hierarchical and heterarchical• intermittently time-pressured, and …• complex adaptive systems [CASs]
• EDs mostly get things right, despite • temporal demands• resource constraints • expansive casemix and• workplace complexity.
However most people have this mental model
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But healthcare really looks like this …
ED Study #1 – flow structures
• Nugus et al – emergency clinicians create a “carousel” providing the greatest good for the greatest number of patients• ED clinicians are rationing time to provide beds
to meet the needs of future patients
• Work is therefore inherently clinical-organisational
• Time and motion are chief characteristics• Therefore flow/trajectories of patients is what is
really managed by ED [Nugus et al. Int Emerg Nurs, 2014]
The carousel model of the ED.
ED Study #2 – flow pressures
• Junior nurse perspective on role of Clinical Initiatives Nurse (CIN): “To save time; they speed things up, especially in sub-acute.”
• A senior nurse: “We take every chance we can get to free up a bed.”
• “For each patient as soon as they come in you’ve got to think of the best way to get them out.”
ED Study #3 – A riot of a study
• The Stanley Cup Riots, 2011, Vancouver, Canada• 500 people into city every 90 seconds by
SkyTrain alone• Big surge of patients to ED
• Key take-outs: capacities for Speedup, Slowdown,
resource flex, margin for manoeuvre
[Hunte, In: The resilience of everyday clinical work, 2014]
ED Study #4 – tribal characteristics
• Micro-structural dimensions of interactive behaviours to reveal tribal characteristics
• Social network analysis to illuminate the social-professional structures
• An anaesthetist now working in ED: “I bag [criticise] anaesthetists even though I’m an anaesthetist.”
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Ward asst 1
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[Creswick, Westbrook and Braithwaite, BMC HSR, 2009]
• Problem solving networks in an ED
Nurses DoctorsAllied healthAdmin and support
ED Study #4 – exposing tribes
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[Creswick, Westbrook and Braithwaite, BMC HSR, 2009]
• Medication advice-seeking networks in an EDNurses DoctorsAllied healthAdmin and support
ED Study #4 – exposing tribes
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Ward asst 1Ward asst 2
[Creswick, Westbrook and Braithwaite, BMC HSR, 2009]
• Socialising networks in an ED
Nurses DoctorsAllied healthAdmin and support
ED Study #4 – exposing tribes
ED Study #5 – external connections
• ED clinicians work in environment of flexible dynamic interconnectedness
• Negotiate with other departments and “package”the patient for a category [Aged care? Cardiology?]
• Specialist ED physician: “We were trying to sell the patient for review. It’s easier to ask them to review. Admission comes later.”
• Registrar: “Are you a medical registrar?” [No] “Oh well, I won’t try and sell you a patient.”
[Nugus, Bridges and Braithwaite, BMJ, 2009]
ED Study #5 – external connections• Cardiology registrar: “We’re overloaded. I mean,
I’m a human being … We’re just so … short of time what are you going to do? ... You try not to come down unless you’re convinced there’s a good chance it’s one of ours ….”
• ED registrar: “A frustration is that we have to do the work of the inpatient team. We do the ‘work-up’. It stresses us out and we turn that stress onto the nurses. We’re Cinderella. We do the dirty work but don’t get invited to the party.”
ED Study #6 – technology use
Supportive artefacts and technologies, e.g.:• computers,• pens-and-paper, • stethoscopes, • medical records,• sticky notes, • bed allocation boards, • referral and discharge letters.
ED Study #7 – secret second handover
• Ambulance paramedics determine when a secret second handover is needed with cubicle nurses
• Eschews formality in favour of informality• An adjustment strategy• Constitutes a dynamic trade-off between
efficiency and thoroughness
[Sujan, Spurgeon and Cooke, In: The resilience of everyday clinical work, 2014]
ED overall – a “resilient ecosystem”• ED clinicians demonstrate:
• Handling of complexity• Discursive competence• Communicative flexibility• Working organisational-clinical interfaces• Sacrificing lower for higher order goals• Future-orientation in their work• Nuanced understanding of
interdepartmental working
The rich tapestry of EDs … ☺.
• Other ED-focused work in The resilience of everyday clinical work is: • Nakijima on blood transfusions in ED• Stephens, Woods and Patterson on
patient boarding and capacity for manoeuvre [CfM] in EDs
Lessons
• Lots of knowledge operates to create resilience in EDs moment-to-moment, day-to-day, week-to-week
• Resilience is continually created in such circumstances
• People exercise their capacity for manoeuvre amongst the ebbs and flows of patients, tribal relationships, internal and external connections and varied modes of operating
Finally …
• We have our own ideas on the next generation of research questions to ask
• But what’s the next set of questions you would ask if you were doing work on the resilience of EDs?
Selected ReferencesBraithwaite, J., Clay-Williams, R., Nugus, P. and Plumb, J. (2013) Health care as a
complex adaptive system. In: Hollnagel, E., Braithwaite, J. and Wears, R. (eds) Resilient health care, London, Ashgate.
Creswick, N., Westbrook, J. and Braithwaite, J. (2009) Understanding communication networks in the emergency department. BMC Health Services Research, 9:247 doi:10.1186/1472-6963-9-247 .
Hunte, G. (2014). A lesson in resilience: the 2011 Stanley Cup riot. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate.
Nakijima, K. (2014). Blood transfusion with health information technology in emergency settings from a Safety-II perspective. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate.
Nugus, P., Bridges, J. and Braithwaite, J. (2009) Selling patients. British Medical Journal, 339:b5201.
Nugus, P., Carroll, K., Hewett, D.G., Short, A., Forero, R. and Braithwaite, J. (2010) Integrated care in the emergency department: a complex adaptive systems perspective. Social Science & Medicine, 71 (11): 1997-2004.
Selected ReferencesNugus, P., Forero, R., McCarthy, S., McDonnell, G., Travaglia, J., Hillman, K. and
Braithwaite, J. (2014) The emergency department “carousel”: an ethnographically-derived model of the dynamics of patient flow. International Emergency Nursing, 22: 3-9.
Nugus, P., Holdgate, A., Fry, M., Forero, R., McCarthy, S. and Braithwaite, J. (2011) Work pressure and patient flow management in the emergency department: findings from an ethnographic study. Academic Emergency Medicine, 18(10): 1045-1052.
Nugus, P., Sheikh, M. and Braithwaite, J. (2012) Structuring emergency care: policy and organisational behavioural dimensions. In: Dickinson, H. and Mannion, R. (eds) The reform of health care: shaping, adapting and resisting policy developments, London, Palgrave Macmillan, pp 151-163.
Stephens, R., Woods, D. and Patterson E. (2014). Patient boarding in the emergency department as a symptom of complexity-induced risks. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate.
Sujan, M. A., Spurgeon, P. and Cooke, M.W. (2014). Translating tensions into safe practices through dynamic trade-offs: the secret second handover. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate.
Contact detailsContact detailsContact detailsContact details
Jeffrey Braithwaite, PhD
Foundation Director Australian Institute of Health InnovationDirectorCentre for Clinical Governance ResearchProfessor, Faculty of MedicineUniversity of New South WalesSYDNEY NSW 2052AUSTRALIA
Email: [email protected]: http://en.wikipedia.org/wiki/Jeffrey_BraithwaiteWeb: http://www.aihi.unsw.edu.au