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Waiting Times In Emergency

Posted on September 24, 2008 by Guenther Krueger. No Comments

Can They Be Improved?

One of the most controversial hot-button issues in the health care system is waiting times in an emergency department. Everyone seems to agree that sick people spend too long before someone sees them, but determining how to streamline the system and facilitate better patient care is a task that even professional researchers find daunting.

Someone who is trying to make a difference in how quickly people are seen is Dr. Pernille Bjorn, who worked with the Action for Health project as a postdoctoral fellow. Dr. Bjorn’s background is in computing science within a health care environment and she spent time examining what happens when children arrive in the emergency department at the British Columbia Children’s Hospital in Vancouver.

Like hospitals around the world, Children’s hospital uses a way of prioritizing patients called triage, a way of assigning degrees of urgency to patients for the purposes of deciding who will be seen immediately, and who can wait a bit before busy hospital staff can examine them. It’s a system that developed in the battlefield when something needed to be done to determine which wounded soldiers needed attention the most.

How this translates into a busy modern emergency department is surprisingly complicated. Dr. Bjorn was interested in whether technology might assist the nurses who undertake the task of doing triage work. It’s a fascinating area, since the task of triage is anything but simple. Experienced nurses go through many steps to determine what’s wrong with a small child who is often unable to articulate exactly what they are experiencing. There is a type of disconnect between the way a human being solves problems—a nurse using all her senses to make decisions, and incorporating experience and ways of making inferences—versus  a computer that can process large amounts of information but really can’t consider and reflect on what is going on. The nurse can use the art and science of decision making, the computer can just…well it can really just compute. So how can the two work together? Maybe by using the strengths of each in tandem.

Nurses may be skillful, but things can get messy. A pile of charts with post-it notes may not be the best way to work. Let’s face it, people can be sloppy, those little notes can fall on the floor (which actually happened as Dr. Bjorn was watching), and people make mistakes and have lapses in judgment. So the question became, can one combine the best of both?

Dr. Bjorn began with a phone call to other children’s hospitals across the country  to determine who was doing what. While everyone was using some form of information technology (IT) in their emergency departments, there were a range of systems, no single one that was commonly used. The ones that seemed to be the most suitable also allowed everyone to see what was going on through the use of more low-tech devices such as a whiteboard, something everyone could glance at and see.

The challenge for researchers like Dr. Bjorn is attempting to understand how a complex human activity such as becoming an expert triage nurse, can be translated into the rules and protocols. Hopefully these can then be somehow incorporated into software design that further helps those same people making all the decisions. Obviously if the system were perfect using only flesh-and-blood nurses, no technology would be needed. But as we have seen throughout this series, hospital administrators are constantly fighting the forces of increased emergency department usage, higher expectations, and the need for cost containment. The nurses need help.

Experts such as Dr. Bjorn have a unique set of skills that they bring to this type of task. With a background in computing science, she was able to understand some of the software problems involved. And, as a researcher, she was able to design ways to observe the interactions that occurred in a real-life situation as parents came into the emergency department with their children and interacted with an expert triage nurse. She was then also able to see how those nurses used the hardware and software to make decisions, change the work practices accordingly, and then use her observations and conversations with staff to tweak and adjust things. One of the things that became very apparent to her was that any implementation of an electronic triage system requires extensive customization. In one hospital in Canada this has been going on for years and is still not perfected.

The system is far from perfect and still evolving, but there are elements that have improved. One of the interesting spin-offs was the working relationship that evolved as a researcher came in to observe what was going on. Busy hospital staff could easily have become non-cooperative as they felt judged and evaluated. However, what actually happened was a spirit of collaboration as everyone pulled together to solve common problems.

 

Contact Guenther with questions or comments at gkrueger@knowitallhealth.com

 

 

What is a case study?

Examining how triage is conducted in an emergency department is an example of a research strategy called a case study. Rather than relying on many examples of something, a case study does an in-depth analysis of a single instance, in this case all aspects of what happens in this one particular area. By doing things such as comparing it to other institutions, reading and learning about how people behave and what their training and expertise is, the researcher is able to build a case that can then be generalized to other instances of the same thing elsewhere. A well-known example is the description of cities in Jane Jacobs work. Although she wrote about New York City, many of her ideas on what makes communities work can be extrapolated to other urban sites.

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