New institutional setting, new organizational configurations: Redesigning the Danish emergency care system via a contingency approach

As a result of major administrative reform in 2007, the Danish emergency care system is undergoing the largest reorganization in decades (MHP, 2008; Vrangbaek, 2013). The number of acute hospitals has been reduced from more than 40 to 21 and new emergency departments (EDs) have been established (MHP, 2008; Wen et al., 2013, Mattsson, Mattsson & J\uf8rsboe, 2014). The EDs are the cornerstones of the Danish National Health System (NHS), as up to 70% of all acute care patients are evaluated there; they can be treated and discharged, or admitted for further care (MHP, 2008; Wen et al., 2013). The EDs therefore play a crucial role in determining the design of the overall healthcare, being a critical pathway for acute care and addressing hospital crowding. The Danish emergency care system represents an organizational field (DiMaggio & Powell, 1983) in which highly specialized healthcare actors, such as primary care physicians (PCPs), systems of out-of-hours care clinics, ambulance systems, and hospitals, have to coordinate their actions with the ultimate objective of providing a timely and appropriate response toward the collective. On the other hand, following the general reform of 2007, the National Board of Health in Denmark (NBHD) has recommended the delivery of emergency care through fewer, larger, and more centralized EDs. This was done to concentrate specialties and provide a higher level of care with greater efficiency in a system in which the patients\u2019 overall impression of hospitalization has traditionally been positive (MHP, 2008). Moreover, the overall reform generated (external) financial crunches for healthcare providers that predictably turned into internal pressures related to efficiency (e.g., Louis et al., 1999; Lega & DePietro, 2005; Reay & Hinings, 2005, 2009). The search for efficiency through the maximization of economies of scale, by concentrating specialized knowledge and equipment, is generating some symbiotic organizational effects. These can be studied at different levels of analysis (Hackman, 2003): a) at the macro level, through a general rationalization of public expense, in two ways: a.1) regions are in charge of the planning and delivery of healthcare, and new regional mechanisms for governance and funding, resulting in the diffusion of new performance appraisal approaches; a.2) positive operational spillovers are exploited amongst agents through coordination mechanisms based on healthcare networks, with several interdependent providers covering the various phases of emergency care; b) at the meso level, via the definition of structures, roles, and procedures of emergency care. In essence, each hospital designs its own ED, with different levels of managerial autonomy, human resource specialization, technological endowment, and design of internal processes. In short, the Danish emergency care system is trying to change toward a more cost-effective but also a more patient-oriented configuration; c) at the micro level, via the design of appropriate incentives for professionals. In Fearlie and Shortell\u2019s (2001) terms, \u201cA multilevel approach to change and the associated core properties can provide a framework for assessing progress on these and related issues over the next several years\u201d (p. 307). This paper presents the preliminary results of a larger research project called DESIGN-EM, aimed at designing effective and efficient EDs. In a dynamic environment, in which each of the 21 Danish hospitals is still configuring its own ED, this research project aims to determine if differences in organization designs affect efficiency, effectiveness, the quality of patient care, and resource utilization. It reports on the part of the project attempting to investigate the meso level of analysis (hospitals/EDs), and focuses on the research gap related to the adoption of the multi-contingency approach (Burton & Obel, 1988, 2004) in the design of emergency care, with a specific focus on the EDs (Table 1). Thus, this research addresses the following research question: How can hospitals design their EDs to adapt to institutional, technological, and clinical dynamics

Når metoder spiller hinanden gode: En reflektion over hvordan antropologi og aktionsforskning kan kombineres

I 2018 blev jeg spurgt, om jeg ville lede et projekt, hvori jeg som forsker skulle samarbejde med praktikere om at organisere et nyt patientforløb på tværs af hospital, almen praksis og kommuner. For at kunne dette søgte jeg inspirationi aktionsforskning. I denne artikel reflekterer jeg over, hvordan metoderne fra antropologi og aktionsforskning kan kombineres. Med udgangspunkt i projektet belyser jeg styrker ved henholdsvis antropologi og aktionsforskning, hvilke elementer af aktionsforskningen jeg mener, antropologer med fordel kan lade sig inspirere af, samt hvilke erfaringer jeg som antropolog har trukket på, idet jeg bevægede mig ud i ukendt land for at være med til at løse et samfundsproblem; et stærkt stigende antal ældre patienter

Organisationsdesigns betydning for kvaliteten af patientbehandling

Med udgangspunkt i de danske akutafdelinger belyses, hvordan organisationers design har betydning for organisationens målopfyldelse, herunder den kvalitet, organisationen leverer. Grundet få og ikke specifikke nationale retningslinjer er akutafdelingerne organiseret meget forskelligt. Nogle afdelinger ændrer også organisering i løbet af døgnet og ugen. Vi belyser, hvordan disse organisationsforskelle har betydning for kvaliteten af patientbehandlingen og risikoen for at dø efter en indlæggelse. Dødelighed er en hyppig anvendt parameter for kvalitet af patientbehandling. En patients risiko for at dø efter en indlæggelse bestemmes ud fra kliniske parametre. Risikoen er ligeledes afhængig af den behandlingskvalitet, hospitalet kan levere. Hospitalets ressourcer, organisering af ressourcerne, samt kommunikation og beslutningsprocesser spiller en væsentlig rolle. Vi giver i artiklen et overblik over de organisationsdesignelementer, der er væsentlige: den grundlæggende organisering, brug af IT-systemer og organisering på forskellige tidspunkter, herunder natte- og weekendskift. Vi præsenterer ligeledes et værktøj, der kan vurdere organisationsdesignet – et værktøj, alle kan anvende

Linking the severity of illness and the weekend effect: a cohort study examining emergency department visits

Abstract Background Despite extensive research on the “weekend effect” i.e., the increased mortality associated with hospital admission during weekend, knowledge about disease severity in previous studies is limited. The aim of this study is to examine patient characteristics, including disease severity, 30-day mortality, and length of stay (LOS), according to time of admission to an emergency department. Methods Our study encompassed all patients admitted to a Danish emergency department in 2014–2015. Using data from electronic patient records, this study examines patient characteristics including age, gender, Charlson Comorbidity Index score, triage score, and primary diagnosis. Triage score and transfer to intensive care unit (ICU) were used as indicators of disease severity. LOS within the department and within the hospital was examined. Age- and sex-standardized 30-day mortality rates comparing patients with the same triage score admitted at daytime, evening, and nighttime on weekdays and on weekends were computed. To test differences, a Cox regression analysis was added. Results We included 35,459 patient visits, of which 10,435 (32%) started on a weekend. There were no large differences in baseline characteristics between patients admitted on weekdays and those admitted on weekends. The relative risk (RR) for being triaged orange or red was 1.16 (95% confidence interval (CI) 1.06–1.28, P = 0.0017) for weekend admissions as compared with weekday admissions. Weekend admissions were twice as likely as weekday admissions to be transferred to the ICU (RR, 1.96; 95% CI 1.53–2.52, P = 0.0000). No significant changes were found in LOS. The 30-day mortality rate increased with disease severity regardless of time of admission. When comparing the 30-day mortality rate for patients with the same triage score, the trend was toward a higher mortality when admission occurred during the weekend. Increasing mortality rate was significant for patients admitted at evening on weekends with a hazard ratio of 1.32 (95% CI 1.03–1.70, P = 0.027) when compared with patients admitted on daytime on weekdays. Conclusions When comparing weekday and weekend admissions, the 30-day mortality rate increased for patients admitted at evening on weekends after adjusting for comorbidity and triage score, indicating that the weekend effect was independent of changes in illness severity

Geographic information system data from ambulances applied in the emergency department:effects on patient reception

BACKGROUND: Emergency departments (ED) recognize crowding and handover from prehospital to in-hospital settings to be major challenges. Prehospital Geographical Information Systems (GIS) may be a promising tool to address such issues. In this study, the use of prehospital GIS data was implemented in an ED in order to investigate its effect on 1) wait time and unprepared activations of Trauma Teams (TT) and Medical Emergency Teams (MET) and 2) nurses’ perceptions regarding patient reception, workflow and resource utilization. METHODS: Intervention: From May 1st 2014 to October 31th 2014, GIS data was displayed in the ED. Data included real-time estimated time of arrival, distance to ED, dispatch criteria, patient data and ambulance contact information. Data was used by coordinating nurses for time activation of TT and MET involved in the initial treatment of severely-injured or critically-ill patients. In addition, it was used as a logistics tool for handling all other patients transported by ambulance to the ED. Study design: The study followed a mixed-methods design, consisting of a quantitative study (before and after intervention) and a qualitative study (survey and interviews). Participants: Participants included all patients received by TT or MET and coordinating nurses in the ED. RESULTS: 1.) Quantitative: 599 patients were included. The median wait time for TT and MET was 5 min both before and after the GIS intervention, showing no difference (p = 0.18). A significant reduction in the subgroup of waits >10 min was found (p < 0.05). No difference was found in unprepared TT and MET activations. 2.) Qualitative: Nurses perceived GIS data as a tool to optimize resource utilization and quality of all patients’ reception, critically or non-critically ill. No substantial disadvantages were reported. DISCUSSION: The contradiction of measured median wait time and nurses perceived improved timing of team activation may result from having both RT- ETA and supplemental patient information not only for seriously-injured or critically-ill patients received by the TT and MET, but for all patients transported by ambulance. The reduction in waits > 10 minutes may have contributed to the overall perception of reduced wait time, as avoidance of long waits is clinically more important than reduction in the median wait time. CONCLUSION: A comparison of the use of prehospital GIS data in the ED with the control period showed no effect on median wait time for TT and MET, however, the number of waits of >10 min was reduced. On the other hand, nurses perceived implementation of GIS data as improving workflow, resource utilization and quality of all patients’ reception, critically as well as non-critically ill. There were no substantial disadvantages to the GIS application. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02188966). ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13049-016-0232-5) contains supplementary material, which is available to authorized users

Modelling the emergency care system in Denmark: Reacting to institutional changes via a contingency approach

In consequence of a major administrative reform in 2007, the Danish emergency care system is undergoing the largest reorganization in decades (MHP, 2008; Vrangbaek, 2013). The number of acute hospitals has been reduced from more than 40 to 21 and the new emergency departments (EDs) have been established (MHP, 2008; Wen et al., 2013, Mattsson, Mattsson & J\uf8rsboe, 2014). The EDs are the cornerstones of the Danish National Health System (NHS), since up to 70% of all acute care patients are evaluated there, where they can be treated and discharged, or admitted for further care (MHP, 2008; Wen et al., 2013). The EDs therefore play a crucial role in determining the design of the overall health assistance, being a critical pathway for acute care and for hospital crowding. The Danish emergency care system represents an organizational field (DiMaggio & Powell, 1983; Scott, 1995; Wotten & Hoffman, 2008) in which highly specialized healthcare actors such as Primary Care Physicians (PCPs), systems of off-hours care clinics, ambulance systems and hospitals have to coordinate their actions with the ultimate objective to be timely and appropriately responsive towards the collectivity. On the other hand, following the general reform of 2007, the National Board of Health in Denmark (NBHD) has recommended that the delivery of emergency care through fewer, larger, and more centralized EDs. That in order to concentrate specialists and provide a higher level of care in a more efficient way, in a system in which the patient overall impression of the hospitalization has traditionally been positive (MHP, 2008). Moreover, the overall reform generated (external) financial crunches towards healthcare providers that predictably turned into internal pressures towards efficiency (e.g. Louis et al., 1999; Lega & DePietro, 2005; Reay & Hinings, 2005, 2009). The search for efficiency via the maximization of economies of scale, by concentrating specialized knowledge and equipment, is generating three symbiotic organizational effects, that can be studied at different level of analysis (Hackman, 2003): a) at a macro-level, via a general rationalization of the public expense, in two ways: a1) since the regions are in charge the planning and delivery of health care, new regional mechanisms for governance and funding, the diffusion of new performance appraisal approaches; a2) via the exploitation of operational positive spillovers among agents, through coordination mechanisms based on healthcare networks (Lomi et al., 2014) with several interdependent providers covering the various phases of emergency care ; b) at a meso-level, via the definition of structures, roles and procedures of emergency care: in fact, each hospital is designing its own ED, with different level of managerial autonomy, human resource specialization, technological endowment, design of internal processes. In short, the Danish emergency care system is trying to change towards more cost-effective but also more patient-oriented configurations; c) at a micro-level, via the design of appropriate incentives for professionals. To say with Fearlie and Shortell \u201cA multilevel approach to change and the associated core properties can provide a framework for assessing progress on these and related issues over the next several years\u201d (2001: 307). The paper presents the preliminary results of a larger research project called DESIGN-EM aiming at designing effective and efficient EDs. In a dynamic environment, in which each of the 21 Danish hospitals is still configuring its own ED , the research project aims at understanding if differences in organization designs affect efficiency, effectiveness, quality of patient care, and resource utilization

Additional file 2: of Geographic information system data from ambulances applied in the emergency department: effects on patient reception

Interview guide used for semi-structured interviews with coordinating nurses at RHH’s ED. (PDF 14 kb