Temporal typifications as an organizational resource: Experiential knowledge and patient processing at the emergency department

2021 ◽  
pp. 0961463X2110318
Author(s):  
Marius Wamsiedel
Keyword(s):  
Emergency Department ◽  
Temporal Distribution ◽  
Experiential Knowledge ◽  
Moral Evaluation ◽  
Sense Making ◽  
Healthcare Settings ◽  
Organizational Resource ◽  
Sociological Literature ◽  
Common Strategy ◽  
Admission Interviews

The connection between time and power has been studied extensively. A common strategy through which street-level bureaucrats exert power and dominance over their clients consists of imposing protracted waiting and maintaining uncertainty regarding the outcomes of waiting. In this study, I argue that another facet of power in organizations is related to the temporal typification of cases. By exploring the triage work in two emergency departments (EDs), I show that nurses and clerks identify patterns in the temporal distribution of visits and attach clinical and moral meanings to them. The temporal typifications are sense-making devices through which triage workers orient to patients. They form a stock of tacit experiential knowledge that delineates specific expectations about the legitimacy of cases and the worth of patients. These expectations impact the unfolding and structure of triage admission interviews and contribute to the prioritization of cases. The study brings into conversation the sociological literature on time and power with the study of the moral evaluation of patients to examine temporal typifications as an organizational resource in healthcare settings. It contributes to a better understanding of triage workers’ experiential knowledge and the practical accomplishment of moral evaluation in EDs.

scholarly journals Dismembering organisation: The coordination of algorithmic work in healthcare

2020 ◽  
Vol 68 (4) ◽  
pp. 546-571
Author(s):  
Simon Bailey ◽  
Dean Pierides ◽  
Adam Brisley ◽  
Clara Weisshaar ◽  
Tom Blakeman
Keyword(s):  
Acute Kidney Injury ◽  
Kidney Injury ◽  
Human Experience ◽  
Ethnographic Study ◽  
Care Work ◽  
Healthcare Settings ◽  
Expected Performance ◽  
Sociological Literature ◽  
Insight Into

Algorithms are increasingly being adopted in healthcare settings, promising increased safety, productivity and efficiency. The growing sociological literature on algorithms in healthcare shares an assumption that algorithms are introduced to ‘support’ decisions within an interactive order that is predominantly human-oriented. This article presents a different argument, calling attention to the manner in which organisations can end up introducing a non-negotiable disjuncture between human-initiated care work and work that supports algorithms, which the authors call algorithmic work. Drawing on an ethnographic study, the authors describe how two hospitals in England implemented an Acute Kidney Injury (AKI) algorithm and analyse ‘interruptions’ to the algorithm’s expected performance. When the coordination of algorithmic work occludes care work, the study finds a ‘dismembered’ organisation that is algorithmically-oriented rather than human-oriented. In the discussion, the authors examine the consequences of coordinating human and non-human work in each hospital and conclude by urging sociologists of organisation to attend to the importance of the formal in algorithmic work. As the use of algorithms becomes widespread, the analysis provides insight into how organisations outside of healthcare can also end up severing tasks from human experience when algorithmic automation is introduced.

Implementing an Emergency Department Information System

2014 ◽  
Vol 6 (1) ◽  
pp. 17-30
Author(s):  
Paraskevas Vezyridis ◽  
Stephen Timmons
Keyword(s):  
Emergency Department ◽  
Information System ◽  
Information And Communication Technologies ◽  
Clinical Information System ◽  
Clinical Information ◽  
Actor Network Theory ◽  
Linear Process ◽  
University Hospitals ◽  
Structured Interviews ◽  
Healthcare Settings

Information and communication technologies (ICT) are increasingly used in healthcare settings. Despite their technical robustness, their implementation has not always been straightforward. This is a case study of the implementation of a clinical information system for patient registration and tracking in the busy emergency department (ED) of a large English NHS University Hospitals Trust. By adopting an Actor-Network Theory (ANT) approach, the authors explore the complex intertwining of people and machines in the local setting as they negotiate the success of the project. Based on the analysis of 30 semi-structured interviews with clinical and administrative staff and, of relevant policy and project documentation, the authors demonstrate how the technologically-mediated transformation of healthcare practices is not a fixed and linear process, but the interplay of various fluctuating, performative and co-constitutive technical and social factors.

scholarly journals Etiologies of abdominal pain emergencies in pediatrics

2021 ◽  
Author(s):  
Hala Atta Youssef ◽  
Aishah Mohammad Alkhaldi ◽  
Manar Mohammed Alshahrani ◽  
Abdullah Tariq Almalki ◽  
Amjad Ali Alahmari ◽  
...  
Keyword(s):  
Emergency Department ◽  
Abdominal Pain ◽  
Pediatric Patients ◽  
Surgical Intervention ◽  
Acute Abdominal Pain ◽  
Clinical Importance ◽  
Healthcare Settings ◽  
Common Causes ◽  
The Common ◽  
Attending Physicians

Reports showed that children usually complained of acute abdominal pain, which indicated the presence of severe underlying conditions and can have significant clinical importance. Serious challenges have been reported in healthcare settings where an urgent evaluation of the cases was necessary to adequately manage the patient before developing serious complications that might even end up with death. Some of these conditions included intussusception, appendicitis, volvulus and adhesions. Although estimates indicated that only around 1% of pediatric patients with acute abdominal pain usually required surgical intervention, concerns regarding the overlooking and misdiagnosis of significant conditions that might have severe prognostic outcomes were aroused among the different emergency departments. This study reviewed the common causes of acute abdominal pain among children admitted to the emergency department. Our results indicated that various etiologies can develop acute abdominal pain and therefore, establishing an adequate diagnosis by differentiating between the different etiologies should be done by the attending physicians to enhance the outcomes and adequately manage the admitted patients. Gastrointestinal causes of acute abdominal pain were the commonest to cause admissions to the emergency department. However, care should also be provided to the less common conditions, which might include genitourinary and pulmonary disorders and therefore, a thorough examination of children should be provided not to conduct a misdiagnosis of the underlying condition.

scholarly journals Emergency department admissions during COVID-19: explainable machine learning to characterise data drift and detect emergent health risks

2021 ◽  
Author(s):  
Christopher Duckworth ◽  
Francis P Chmiel ◽  
Dan K. Burns ◽  
Zlatko D Zlatev ◽  
Neil M White ◽  
...  
Keyword(s):  
Machine Learning ◽  
Emergency Department ◽  
Predictive Model ◽  
Clinical Outcomes ◽  
Health Risks ◽  
Concept Drift ◽  
Machine Learning Algorithms ◽  
Supervised Machine Learning ◽  
Healthcare Settings ◽  
Acute Healthcare

Supervised machine learning algorithms deployed in acute healthcare settings use data describing historical episodes to predict clinical outcomes. Clinical settings are dynamic environments and the underlying data distributions characterising episodes can change with time (a phenomenon known as data drift), and so can the relationship between episode characteristics and associated clinical outcomes (so-called, concept drift). We demonstrate how explainable machine learning can be used to monitor data drift in a predictive model deployed within a hospital emergency department. We use the COVID-19 pandemic as an exemplar cause of data drift, which has brought a severe change in operational circumstances. We present a machine learning classifier trained using (pre-COVID-19) data, to identify patients at high risk of admission to hospital during an emergency department attendance. We evaluate our model's performance on attendances occurring pre-pandemic (AUROC 0.856 95\%CI [0.852, 0.859]) and during the COVID-19 pandemic (AUROC 0.826 95\%CI [0.814, 0.837]). We demonstrate two benefits of explainable machine learning (SHAP) for models deployed in healthcare settings: (1) By tracking the variation in a feature's SHAP value relative to its global importance, a complimentary measure of data drift is found which highlights the need to retrain a predictive model. (2) By observing the relative changes in feature importance emergent health risks can be identified.

Process improvement methodologies uncover unexpected gaps in stroke care

2018 ◽  
Vol 59 (9) ◽  
pp. 1126-1129
Author(s):  
Anthony D Kuner ◽  
Andrew J Schemmel ◽  
B Dustin Pooler ◽  
John-Paul J Yu
Keyword(s):  
Emergency Department ◽  
Process Improvement ◽  
Temporal Distribution ◽  
Stroke Care ◽  
Temporal Analysis ◽  
Stroke Patients ◽  
Time Period ◽  
Early Afternoon ◽  
Improvement Methodologies ◽  
Time Point

Background The diagnosis and treatment of acute stroke requires timed and coordinated effort across multiple clinical teams. Purpose To analyze the frequency and temporal distribution of emergent stroke evaluations (ESEs) to identify potential contributory workflow factors that may delay the initiation and subsequent evaluation of emergency department stroke patients. Material and Methods A total of 719 sentinel ESEs with concurrent neuroimaging were identified over a 22-month retrospective time period. Frequency data were tabulated and odds ratios calculated. Results Of all ESEs, 5% occur between 01:00 and 07:00. ESEs were most frequent during the late morning and early afternoon hours (10:00–14:00). Unexpectedly, there was a statistically significant decline in the frequency of ESEs that occur at the 14:00 time point. Conclusion Temporal analysis of ESEs in the emergency department allowed us to identify an unexpected decrease in ESEs and through process improvement methodologies (Lean and Six Sigma) and identify potential workflow elements contributing to this observation.

scholarly journals Improve the Design and Implementation of Metrics From the Perspective of Complexity Science Comment on "Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?"

2020 ◽  
Author(s):  
Junqiao Chen
Keyword(s):  
Emergency Department ◽  
Social Process ◽  
Complexity Science ◽  
Senior Management ◽  
Sense Making ◽  
Research Approach ◽  
Frontline Staff ◽  
Policy Makers ◽  
Design And Implementation ◽  
The Relationship

From the perspective of complexity science, this commentary addresses Tenbensel and colleagues’ study, which reveals varied gaming behaviours to meet the New Zealand Emergency Department (ED) metric. Seven complexityinformed principles previously published in this Journal are applied to formulate recommendations to improve the design and implementation of metrics. (1) Acknowledge unpredictability. When designing a metric, policy-makers need to leave room for flexibility to account for unforeseen situations. When implementing a metric, they need to promote sense-making of relevant stakeholders. (2) Sense-making shall be encouraged because it is a social process to understand a metric, align values and develop a coherent strategy. Sense-making is important to (3) cope with self-organised gaming behaviours and to (4) facilitate interdependencies between ED and other departments as well as organisations. (5) We also need to attend to the relationship between senior management and frontline staff. Additionally, to address one of the methodological weaknesses in Tenbensel and colleagues’ study, (6) adaptive research approach is needed to better answer emerging questions. (7) Conflict should be harnessed productively. I hope these recommendations could limit gaming in future metrics and encourage stakeholders to view inevitable gaming as an improvement opportunity.

Infection Prevention in Ambulatory and Emergency Department Settings

2019 ◽  
pp. 239-264
Author(s):  
W. Matthew Linam ◽  
Michele D. Honeycutt ◽  
Vini Vijayan
Keyword(s):  
Cystic Fibrosis ◽  
Emergency Department ◽  
Infection Prevention ◽  
Urgent Care ◽  
Standard Precautions ◽  
Ambulatory Surgery Centers ◽  
Healthcare Settings ◽  
Inpatient Settings ◽  
Basic Infrastructure ◽  
Outpatient Settings

Children receive care in a variety of outpatient settings, including ambulatory clinics, urgent care clinics, emergency departments, and ambulatory surgery centers. In general, the same infection prevention principles used in inpatient settings apply in ambulatory settings, but these locations also present unique challenges. This chapter provides infection prevention guidance in the ambulatory and emergency department settings, focusing on pediatric-specific issues in these healthcare settings. Basic infrastructure and processes needed to prevent HAIs in pediatric outpatient settings are outlined and strategies for implementation are reviewed. The use of standard precautions is emphasized. Specific guidance is described for the care of patients with cystic fibrosis.

The prevalence of pathological findings identified by next day abdominal ultrasound in patients discharged from the emergency department

CJEM ◽  
2019 ◽  
Vol 21 (6) ◽  
pp. 793-797
Author(s):  
Stephanie Cargnelli ◽  
Cameron Thompson ◽  
Taylor Dear ◽  
Aislinn Sandre ◽  
Bjug Borgundvaag ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Emergency Department ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Abdominal Ultrasound ◽  
Pathological Findings ◽  
Resonance Imaging ◽  
Patients Âgés ◽  
Common Strategy

ABSTRACTObjectiveA common strategy for managing emergency department (ED) patients with low-risk abdominal pain is to discharge them home and arrange for next day outpatient ultrasound for further assessment. The objective was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days.MethodsThis was a retrospective chart review of non-pregnant patients ages 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound.ResultsOf the 299 included patients, 252 (84.3%) were female and mean (SD) age was 28.4 (6.0) years. Twenty-three (7.7%) patients had ultrasounds requiring intervention within 14 days of imaging. Of these, eight (34.8%) had appendicitis, five (21.7%) had cholecystitis, four (17.4%) had urological pathology, three (13.0%) had gynecological pathology, and three (13.0%) had gastrointestinal diagnoses. Of note, 14 (60.9%) patients requiring follow-up or intervention within 14 days had symptoms that improved or resolved at the time of the outpatient ultrasound. For the 277 (92.6%) patients not requiring intervention, 117 (42.2%) had improved, 89 (32.1%) were unchanged, 50 (18.1%) had resolved, and 5 (1.8%) had worsened symptoms at the time of the follow-up ultrasound. Of the non-intervention patients, 13 (4.7%) went on to have alternative imaging, including magnetic resonance imaging, computed tomography, and a sonohysterogram.ConclusionsNext-day ultrasound imaging remains a good way of identifying patients with serious pathology not appreciated at the time of their ED visit.

scholarly journals LB18. Healthcare Utilization for Acute Respiratory Illness by Race/Ethnicity across Ambulatory, Emergency, and Hospital Settings

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S814-S815
Author(s):  
Alexandra M Mellis ◽  
Matthew Gilmer ◽  
Carrie Reed
Keyword(s):  
Emergency Department ◽  
Ambulatory Care ◽  
Ethnic Group ◽  
Healthcare Utilization ◽  
Respiratory Illness ◽  
Acute Respiratory Illness ◽  
Emergency Visits ◽  
Healthcare Settings ◽  
Race Ethnicity ◽  
Racial Ethnic

Abstract Background Given the disproportionate impact of COVID-19 among racial/ethnic minority groups across the United States on emergency visits, hospitalizations, and deaths, we examined healthcare utilization more broadly for acute respiratory illness (ARI across healthcare settings by racial/ethnic group. Methods Using data on 33,992,254 unique nonpharmacy healthcare encounters from the IBM Explorys Electronic Health Record database from January 1, 2020–May 1, 2021, across healthcare settings (ambulatory care or telehealth, emergency department, and hospitalizations) with nonmissing bridged racial/ethnic data. Encounters were classified as ARI based on ICD-10 and SNOMED codes and aggregated by month and US Census region. We estimated the population denominator as the total number of persons by bridged racial/ethnic group with encounters recorded during 2019. We both estimated the rate of ARI visits per 100,000 persons across healthcare settings and the rate ratio of ARI visits to non-ARI visits. We performed comparisons of these values by race/ethnicity, taking White persons as referent, using Poisson generalized estimating equations clustered within geographic regions. Results A total of 244,137 (6.5% of 3,745,135) hospitalizations, 237,873 (18% of 1,305,474) emergency visits, and 1,636,383 (5.7% of 28,941,645) ambulatory visits were associated with ARIs. We observed similar rates of ARI visits across race/ethnicity groups in all settings combined and in ambulatory settings, but higher rates of ARI hospitalization among Hispanic persons (IRR [95% CI]: 2.5 [1.7–3.7]) and higher rates of ARI emergency department visits among Black persons (2.5 [1.9–3.2]) (Figure). We also observed differences in the relative proportion of care received for ARI vs. other visits types by setting, for example with Black persons utilizing higher rates of hospital visits for ARI vs non-ARI care (2.2 [1.7–2.7]) but lower rates of ambulatory care for ARI (0.9 [0.7–0.96]). ARI Visits Per 100k Persons Conclusion Population rates of ARI visits and relative proportions of ARI vs. non ARI visits differed between racial/ethnic groups by setting. Understanding how utilization of care varies for ARI across settings can inform future monitoring efforts for health equity. Disclosures All Authors: No reported disclosures

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