What do emergency physicians in charge do? A qualitative observational study.

INTRODUCTION: The emergency physician in charge role has developed in many large EDs to assist with patient flow. We aimed to describe and classify the problem-solving actions that this role requires. METHODS: We interviewed senior emergency physicians and performed iterative, qualitative observations, using continuous reflective inquiry, in a single centre. We reviewed and classified these approaches by consensus. RESULTS: Nine different problem-solving approaches were identified. These are deflecting, front loading, placing, plucking, flooding, targeting, chasing, guiding and juggling. These are useful for training and developing our understanding of how to manage an ED. CONCLUSIONS: Emergency physicians in charge have a number of problem-solving approaches that can be readily defined. We have described and categorised these. These results are potentially useful for developing decision support software.

Reductions in hospital admissions and mortality rates observed after integrating emergency care: a natural experiment.

OBJECTIVES: Reducing emergency admissions is a priority for the NHS. A single hospital's emergency care system was reorganised with the principles of front-loaded investigations, integration of specialties, reduced duplication, earlier decision making by senior clinicians and a combined emergency assessment area. The authors relocated our Medical Assessment Unit into our emergency department in 2006. The authors evaluated changes in admissions and mortality before and after 2006, compared with other similar hospitals. DESIGN: Quasi-experimental before and after study using routinely collected data. SETTING AND PARTICIPANTS: 1 acute hospital in England, the intervention site, was compared with 23 other English hospitals between 2001 and 2009. OUTCOME MEASURES: Our outcome measures were hospital standardised mortality ratios (HSMRs) for non-elective admissions and standardised admission ratios (SARs). RESULTS: The authors observed a statistically and clinically significant decrease in HSMR and SAR. The intervention hospital had the lowest HSMR and SAR of all the hospitals in our sample. This was statistically significant, p=0.0149 and p=0.0002, respectively. CONCLUSION: Integrating emergency care in one location is associated with a meaningful reduction in mortality and emergency admissions to hospital.

Does integrated emergency care reduce mortality and non-elective admissions? A retrospective analysis.

OBJECTIVES: The authors reconfigured the emergency care system of Addenbrookes Hospital, Cambridge. The medical admissions unit and the emergency department (ED) have been combined into one emergency assessment unit. This paper aims to determine if reconfiguration has reduced non-elective hospital admissions and reduced mortality for non-elective admissions. DESIGN: A retrospective 'before and after' study in a teaching hospital. Routinely collected data were used to evaluate the effectiveness of this approach. Setting One acute trust in the UK. Main outcome measures Inhospital mortality rates and standardised admission ratios (SAR) between 2003 and 2009. RESULTS: There was a significant trend towards improved survival, both for non-elective admissions and deaths in the ED (z=-3.92; p>0.001), despite the age and acuity of patients increasing. There was a marked decrease in the SAR. Formal complaints, incident reports and the proportion of patients leaving before treatment declined, whereas the proportion of patients re-admitted as an emergency within 28 days did not change. CONCLUSIONS: Integrating emergency care within a hospital reduces hospital admissions, is associated with reduced inhospital mortality and a better quality of care.