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 2006e2008. Methods Action research, comprising three action/ reflection cycles conducted with participants, was used. Data were collected using retrospective patient record review (n¼35 200) interviews with staff members (n¼28), observation of patient pathways (n¼38 patients) and measurement of team climate (n¼31) 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