title: The emergency department "carousel": an ethnographically-derived model of the dynamics of patient flow.
abstract: Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding.
authors.affiliation: Centre for Medical Education and Department of Family Medicine, McGill University, Lady Meredith House, 1110 Pine Avenue West, Room 205, Montreal, Quebec, Canada H3A 1A3. Electronic address: peter.nugus@mcgill.ca.
authors.forename: Peter
authors.initials: P
authors.lastname: Nugus
authors.affiliation: Australian Institute of Health Innovation, Faculty of Medicine, Level 1, AGSM Building (G27), University of New South Wales, Sydney, NSW 2054, Australia.
authors.forename: Roberto
authors.initials: R
authors.lastname: Forero
authors.affiliation: Emergency Care Institute, PO Box 699, Chatswood, NSW 2057, Australia.
authors.forename: Sally
authors.initials: S
authors.lastname: McCarthy
authors.affiliation: Australian Institute of Health Innovation, Faculty of Medicine, Level 1, AGSM Building (G27), University of New South Wales, Sydney, NSW 2054, Australia.
authors.forename: Geoff
authors.initials: G
authors.lastname: McDonnell
authors.affiliation: Australian Institute of Health Innovation, Faculty of Medicine, Level 1, AGSM Building (G27), University of New South Wales, Sydney, NSW 2054, Australia.
authors.forename: Joanne
authors.initials: J
authors.lastname: Travaglia
authors.affiliation: Australian Institute of Health Innovation, Faculty of Medicine, Level 1, AGSM Building (G27), University of New South Wales, Sydney, NSW 2054, Australia.
authors.forename: Ken
authors.initials: K
authors.lastname: Hilman
authors.affiliation: Australian Institute of Health Innovation, Faculty of Medicine, Level 1, AGSM Building (G27), University of New South Wales, Sydney, NSW 2054, Australia.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Braithwaite
mesh_terms: D000884:Anthropology, Cultural / Q000458:organization & administration*; D003441:Crowding; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D017146:Models, Organizational; D009517:New South Wales; D015279:Organizational Culture; D010343:Patient Admission / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D014218:Triage
keywords: Complex systems; Emergency department; Ethnography; Organizational learning; Organizations; Participant observation; Patient flow; Qualitative analysis