title: Improving emergency care pathways: an action research approach.
abstract: BACKGROUND
  Clinicians and managers across specialities are under pressure to review treatment and referral pathways to enable evidence-based practice, improve patient flow and provide a seamless service. This study outlines the processes and outcomes of an action research study conducted to reduce inappropriate attendances and unplanned pressures on Emergency Department (ED) staff in an English hospital during 2006-2008.
  
  
  METHODS
  Action research, comprising three action/reflection cycles conducted with participants, was used. Data were collected using retrospective patient record review (n=35,200) interviews with staff members (n=28), observation of patient pathways (n=38 patients) and measurement of team climate (n=31) with literature reviews also informing each cycle of data collection.
  
  
  RESULTS
  ED attendance and hospital emergency admission data were largely similar to the national picture with regards to time/day of attendance and seasonal variation. However, in the 'adult majors' subgroup, mean attendance on a Monday was significantly higher than the rest of the week (p<0.001) and 36% were self-referrals. Observation data revealed that patients were informally assessed by reception staff and directed to majors or minors; this practice was replaced by reinstatement of triage. Patients identified as 'inappropriate' were managed inconsistently, irrespective of department workload. ED attendance decreased as the project progressed and the number of attendees resulting in hospital admission rose slightly.
  
  
  CONCLUSIONS
  Study data suggest that inappropriate attendances decreased; however, data collection exposed gaps in the existing management information systems and inconsistencies in working practices in the ED. Action research can have a practical value besides contributing to knowledge.
authors.affiliation: Faculty of Health, University of Plymouth, 8 Portland Villas, Drake Circus, Plymouth PL4 8AA, UK. ruth.endacott@plymouth.ac.uk
authors.forename: Ruth
authors.initials: R
authors.lastname: Endacott
authors.forename: Simon
authors.initials: S
authors.lastname: Cooper
authors.forename: Rod
authors.initials: R
authors.lastname: Sheaff
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Padmore
authors.forename: Gillian
authors.initials: G
authors.lastname: Blakely
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001071:Appointments and Schedules; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D004739:England; D006300:Health Services Misuse; D006302:Health Services Research / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D010360:Patient Transfer; D058996:Quality Improvement; D012189:Retrospective Studies; D057188:Workflow; D016526:Workload