How interprofessional collaboration between EPs and medical specialists
influences the patient flow in the presence of an AMU
A case study in a large non-academic Dutch hospital
MSc. Thesis Supply Chain Management Faculty of Economics and Business
University of Groningen February 11, 2019 Jildou Zwanenburg Student number: S2752018 E-mail: j.zwanenburg.1@student.rug.nl Supervisors:
Prof. dr. J.T. van der Vaart R.E. Gifford, MSc.
2 ABSTRACT
Worldwide, emergency departments suffer from overcrowding, negatively impacting patient satisfaction and length of stay. One of the factors that causes ED crowding is a lack of collaboration among staff. More specifically, Reiring (2018) found that the collaboration between emergency physicians (EPs) and medical specialists influences the ED patient flow. However, recently the context in which EPs and specialists collaborate has changed, as hospitals have started to implement Acute Medical Units (AMUs) to enhance the patient flow. Although the impact of the collaboration among EPs and specialists on the ED patient flow is studied by Reiring (2018), it remains unclear whether these findings also yield when an AMU is present. Consequently, this paper addresses the following question: How does the interprofessional collaboration between EPs and medical specialists influence the patient flow at the ED in the context of an acute medical unit (AMU)? To answer this question, a single case study is conducted at a large non-academic hospital. Findings show that there is a positive relation between the interprofessional collaboration among EPs and specialists and the ED patient flow, in the presence of an AMU. Moreover, the interprofessional collaboration among EPs and specialists indirectly influences the patient flow, by determining the impact of the AMU setting on the ED patient flow. Current agreements and a limited mutual understanding make that the full diagnosis is determined at the ED, causing longer waiting times for patients at the ED. Moreover, existing agreements do not specifically assign the responsibility for undifferentiated patients to a professional. This lack of clarity in the agreements induces admission problems, increasing waiting times for these undifferentiated patients. Therefore, when the interprofessional collaboration among EPs and specialists would be improved in terms of clear and revised admission policies, the AMU can be of greater value to the ED to a certain extent. Accordingly, this paper contributes to literature in two ways. Firstly, this paper enhances the understanding of the interprofessional collaboration among EPs and specialists in an AMU setting. Secondly, the paper presents how the interprofessional collaboration among EPs and specialists is perceived to impact the ED patient flow in the presence of an AMU.
Keywords: interprofessional collaboration, acute medical unit (AMU), ED patient flow.
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TABLE OF CONTENTS
ABSTRACT ... 2
1. INTRODUCTION... 4
2. THEORETICAL BACKGROUND ... 7
2.1 The Acute Medical Unit ... 7
2.2 The patient flow at the ED ... 9
2.3 Interprofessional collaboration ... 11
3. METHODOLOGY ... 14
3.1 Research design ... 14
3.2 Case selection and description ... 14
3.3 Data collection ... 15
3.4 Data analysis ... 17
4. RESULTS ... 19
4.1 Interprofessional collaboration impacting the ED patient flow ... 19
4.2 Interaction with the AMU... 21
4.3 The positive impact of the AMU setting on the ED patient flow ... 21
4.3.1 Faster and more efficient admission... 21
4.3.2 Reduce crowding at the ED ... 22
4.4 Experienced problems regarding the patient flow at the ED ... 22
4.4.1 (Dis)agreement on the division of diagnostic tasks among the ED and AMU. ... 22
4.4.2 Admission problems regarding undifferentiated patients. ... 24
4.5 Interprofessional collaboration determining the impact of the AMU setting ... 25
4.5.1 Agreements defining the interprofessional collaboration ... 25
4.5.2 Lack of mutual understanding among EPs and specialists ... 28
5. DISCUSSION ... 29
5.1 Interpretation of the results ... 29
5.2 Limitations ... 32
6. CONCLUSION ... 33
REFERENCES ... 35
APPENDIX A: INTERVIEW GUIDE... 43
APPENDIX B: CASE SPECIFIC DESCRIPTION OF THE ROLE OF THE EP ... 45
APPENDIX C: DESIGN AND PERFORMANCE OF THE AMU ... 46
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1. INTRODUCTION
“A patient has to wait for two hours in the ambulance before entering the emergency department”. This was recently published on the website of RTV Rijnmond, explaining that a Dutch emergency department (ED) suffered from crowding due to a poor patient outflow (RTV Rijnmond, 2018). Not only in the Netherlands, but worldwide EDs suffer from crowding (Pines & Bernstein, 2015). ED crowding is related to a prolonged length of stay (LOS), a delay in patient treatment and a higher in-hospital mortality rate (Bernstein et al., 2009). Therefore, hospitals try to mitigate crowding by advancing the patient flow (Jarvis, 2016). One of the causes for a delayed patient flow at the ED is a lack of collaboration among staff (van der Linden, de Beaufort, Meylaerts, van den Brand, & van der Linden, 2017). When focusing on the ED staff, in the majority of the Dutch EDs emergency physicians (EPs) are present along residents (Gaakeer, Veugelers, van Lieshout, Patka, & Huijsman, 2018). When EPs diagnose patients at the ED, it might be necessary to consult a medical specialist who has a specific level of expertise about a certain area of medicine (Lee, Woods, Bullard, Holroyd, & Rowe, 2008). However, if the specialist responds late to the consultation request, this slows down the patient flow (Lee, Woods, Bullard, Holroyd, & Rowe, 2008). Thus, collaboration between EPs and medical specialists is crucial as this impacts the ED patient flow. Currently, limited research is available regarding the collaboration between EPs and specialists (Thijssen, Giesen, & Wensing, 2012). Reiring (2018) was one of the first to investigate this and found a low relational integration between EPs and specialists for a Dutch hospital, subsequently impacting the patient flow. However, since the year 2000, Dutch hospitals have started to implement Acute Medical Units (AMUs) (van Galen et al., 2017). Therefore, the context in which EPs and specialists collaborate has changed in some hospitals.
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However, in order to realize these benefits Scott et al. (2009) and Suthers et al. (2012) state that factors in the local context of the AMU, such as the organization of the staff and the admission process, need to be tailored to the AMU setting. The reason for this is that factors in the local context might otherwise mitigate the improvements in the patient flow realized by the AMU setting (Scott et al., 2009; Suthers et al., 2012). Therefore, the implementation of the AMU has consequences for different healthcare professionals and wards, changing the current way of working (Hendrikx, van Kaam, & Landman, 2011). Although these studies indicate that factors in the local context will change or need to change when implementing an AMU, these factors are only mentioned in a very general way, lacking specificity and in-depth discussion. Therefore, it remains uninvestigated whether the AMU setting leads to a change in the collaboration among EPs and specialists in specific. As stated earlier, collaboration between EPs and specialists is indispensable to achieve a good patient flow. Nevertheless, most studies that investigate the patient flow mention that patient related factors (e.g. arrival time, patient characteristics) or ED related factors (e.g. ward layout, staffing levels) impact the ED patient flow. Therefore, it is unclear how the ED patient flow is impacted by the involvement of staff from various departments in ED practices. To conclude, it is unknown whether the AMU setting leads to a change in the interprofessional collaboration among EPs and specialists and whether this interprofessional collaboration influences the ED patient flow in the presence of an AMU.
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Reiring (2018) found a connection between relation integration and the patient flow, as barriers to relational integration are perceived to influence the patient flow. Some of these barriers found by Reiring (2018) are: specialists being unable to be available for the ED and a lack of trust among EPs and specialists. This study will build upon the research of Reiring (2018) by investigating the impact of the collaboration among EPs and specialists on the patient flow, but in a healthcare setting containing an AMU. As stated before, the interprofessional collaboration between EPs and specialists is studied. Green and Johnson (2015) define interprofessional collaboration as: “interprofessional collaboration occurs when two or more professions work together to achieve common goals and is often used as a means for solving a variety of problems and complex issues” (p.1). Accordingly, the aim of this research is to find an answer to the following question: How does the interprofessional collaboration between EPs and medical specialists influence the patient flow at the ED in the context of an acute medical unit (AMU)?
By answering the question above, this study contributes to literature in two ways. Firstly, this paper enhances the understanding of the interprofessional collaboration among EPs and specialists in an AMU setting. Secondly, the paper presents how the interprofessional collaboration among EPs and specialists is perceived to influence the ED patient flow in the presence of an AMU. Accordingly, this study provides hospitals with an insight into the impact of the interprofessional collaboration on the ED patient flow in an AMU setting. Therefore, this paper offers hospitals an opportunity to enhance the patient flow, avoiding the adverse events of crowding.
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2. THEORETICAL BACKGROUND
2.1 The Acute Medical Unit
Since this study focuses on an AMU setting, an understanding of the AMU is needed. There are multiple descriptions for an AMU, including acute medical assessment unit (AMAU) and acute assessment unit (AAU) (Scott et al., 2009). This study uses the Acute Medical Unit (AMU) description. An AMU is a hospital ward that provides care to acute patients from the emergency department or outpatient clinic for a limited period of time (Scott et al., 2009; van Galen et al., 2017). The maximum period of time that patients can stay at the AMU varies among hospitals, but most AMUs have a maximum length of stay between 24 and 72 hours (Reid et al., 2018; Scott et al., 2009). Moreover, AMUs do not only differ in the maximum length of stay, but are also heterogeneous in terms of their organization and staffing (Reid et al., 2016). In the Netherlands, this heterogeneity is caused by a lack of proper (national) guidelines. Consequently, AMUs vary among hospitals, showing differences in the location and number of beds (van Galen et al., 2017). Additionally, AMUs demonstrate variation regarding admission criteria (Reid et al., 2016). Despite this heterogeneity, the general aim shared by all AMUs is more timely assessment, diagnosis and treatment of patients (Hendrikx et al., 2011; Scott et al., 2009).
In the Netherlands, the implementation of AMUs started around the year 2000. The reason for Dutch hospitals to implement AMUs is the growing pressure experienced in the acute healthcare. This pressure is the result of changes in the policy of the Dutch healthcare system and the increase in emergency admissions caused by an aging population (van Galen et al., 2017). Subsequently, hospitals consider structural changes to optimize the evaluation, treatment and transfer of patients, in order to limit ED crowding. In this way, hospitals try to mitigate the negative effects of overcrowding, such as a long LOS and a high risk that medical errors occur (Scott et al., 2009). For clarification, Sinclair (2007) defines ED overcrowding as: “a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time” (p.491). To conclude, the implementation of the AMU is seen as a popular structural change, in order to limit crowding (Scott et al., 2009).
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AMU causes a reduction in the amount of ED patients waiting for admission to a ward. Next to enhancing the patient flow, an AMU has other advantages as well. According to Scott et al. (2009) and Hendrikx et al. (2011), an AMU has the potential to improve the quality of care. Moreover, an AMU might lead to a higher rate of patients discharged home within 48 hours (St Noble, Davies, & Bell, 2008). The benefits reported above indicate that an AMU setting can be beneficial, providing hospitals with incentives to establish an AMU. However, hospitals need to keep in mind that the design of the AMU determines the experienced benefits (Byrne & Silke, 2011). Moreover, de Almeida and Matthews (2016) state, based on the study of Ward, Potter, Ingham, Percival and Bell (2009), that the demand pressure experienced by the AMU has an influence on the quality of care and patient flow. Therefore, Suthers et al. (2012) stress that hospitals need to consider factors that may mitigate the improvements in the patient flow realized by the AMU setting. More specifically, this means that admission policies, the organization of the staff, the governance structure and other aspects of the local context need to be tailored to the AMU setting, as these factors determine the operational success of the AMU (Scott et al., 2009).
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condition of the patients, in order to make a treatment plan (de Almeida & Matthews, 2016). After admission at the AMU, between 45% to 55% of the patients are discharged. The remaining patients are still admitted to the ward of their specialism (Hendrikx et al., 2011).
FIGURE 1
Changes in the patient flow when an AMU is implemented
(Source: van Galen et al., 2017).
2.2 The patient flow at the ED
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patient flow, like: patient characteristics, management practices and arrival time of the patient (Yoon, Steiner, & Reinhardt, 2003). Moreover, Jarvis (2016) states, based on the study of Asplund et al. (2010), that factors impacting the ED patient flow can be classified into factors external or internal to the ED. Here, external factors represent a lack of inpatient bed availability and fluctuations in patient demand for acute care. Examples of factors internal to the ED are the layout of the ward and the number of employees staffed at the ED (Jarvis, 2016). Some of the factors stated by Jarvis (2016) are also mentioned by Asplin et al. (2003), who explain that the throughput of the ED is determined by: the ED layout, ED staffing levels, the use of diagnostic testing at the ED and accessibility of medical information (Asplin et al., 2003).
Although the studies above indicate important factors that impact the ED patient flow, these studies mostly mention factors that are associated with the ED itself or factors that are patient related (e.g. patient characteristics, patient arrival time). Therefore, it is unknown how the patient flow is impacted by the involvement of staff from various departments in ED practices. As stated earlier, a well-functioning patient flow is important, to avoid the adverse events of crowding. Accordingly, this study focuses on investigating how the interprofessional collaboration among EPs and specialists influences the ED patient flow, in an AMU setting. Concerning the role of the EP, it should be mentioned that the staffing of the ED varies among hospitals. However, in 85% of the EDs in the Netherlands, EPs are present next to residents (Gaakeer et al., 2018). EPs have a broad range of knowledge and are able to treat all incoming patients at the ED, independent of the patient’s age or complaint (physical or psychological) (Nederlandse Vereniging voor Spoedeisende Hulp Artsen, 2018). Thus, an EP or resident diagnoses an incoming patient at the ED (van der Linden et al., 2017). When the EP diagnoses an incoming patient, a medical specialist who is available in the hospital or on-call might be consulted (van der Linden et al., 2017). Consultation is a frequently occurring process at the ED, whereby EPs request other specialists to contribute to the care of the patient at the ED (Woods et al., 2008). During this consultation, the EP remains responsible for the care of the patient (Lee et al., 2008). According to Nugus et al. (2010) there are three reasons why an EP consults a medical specialist: to confirm the decision to discharge the patient, to ask whether the medical specialist agrees with the determined diagnosis and treatment, or to convince the medical specialist to admit the patient.
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delayed response of the specialist to a consultation request slows down the patient flow (Brick et al., 2014; Lee et al., 2008). A delay in the response of the specialist might occur when the specialist and EP have different priorities (Lee et al., 2008). Moreover, a limited availability and accessibility of the specialist leads to a delay in consultation response time (Lee et al., 2008; Woods et al., 2008). Additionally, problems in the consultation process might arise due to a lack of effective communication (Kessler, Kutka, & Badillo, 2012).
2.3 Interprofessional collaboration
From section 2.2 it becomes clear that consultation influences the patient flow, whereby a lack of communication and collaboration among professionals delays the patient flow (van der Linden et al., 2017). Therefore, Kessler, Kutka and Badillo (2012) state that collaboration is a key skill needed to achieve a good communication during consultation. Accordingly, the focus of this study is on the interprofessional collaboration between EPs and medical specialists. Ellinger, Keller and Hansen (2006) state, based on the study of Mintzberg, Jorgensen, Dougherty and Westley (1996), that interprofessional collaboration is an informal communicative process, which is determined by the ability in which people trust others and appreciate the knowledge that others possess. More specifically, interprofessional collaboration takes place when professionals from different backgrounds and professional cultures work together (Morgan, Pullon, & McKinlay, 2015). Additionally, interprofessional collaboration is characterized by interdependency (Fang, Feng, & Xu, 2018). When focusing on the factors that determine the collaboration, Barratt (2004) mentions that trust, communication and commitment are, among others, important aspects of the collaboration in the supply chain. This is also stated by Kahn and Mentzer (1998), who indicate that the achievement of collective goals, mutual understanding and sharing of resources are important facets of collaboration. Based on these studies, interprofessional collaboration is conceptualized here in terms of: trust, mutual understanding, communication, and commitment.
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(MacDonald et al., 2010). In order to develop a mutual understanding, communication is needed (Fang et al., 2018; Simatupang, Sandroto, & Lubis, 2004). Moreover, communication is important for building trust among parties (Fang et al., 2018; Hakanen & Soudunsaari, 2012). Thus, EPs and specialists need to build mutual understanding and trust, by putting time and effort in communication. This means that both parties need to commit resources (e.g. time) to the interprofessional collaboration, in order to make it successful (Barratt, 2004; Green & Johnson, 2015).
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3. METHODOLOGY
3.1 Research design
The research question addressed within this study is: How does the interprofessional collaboration between EPs and medical specialists influence the patient flow at the ED in the context of an acute medical unit (AMU)? In order to find an answer to this question, a single case study has been conducted. The reason for applying a case study is that there is a limited amount of literature available regarding the collaboration between EPs and medical specialists and the influence of this collaboration on the patient flow. Therefore, a case study is suitable as an important aspect of the case study methodology is to describe and explore an unstudied situation and subsequently contribute to theory development (Eisenhardt, 1989). A case study is furthermore appropriate as this method allows the use of multiple data sources, such as observations, interviews and documentation (Rowley, 2002).
This study focuses on a single case, in order to gain a deep understanding about the subject under investigation (Dyer & Wilkins, 1991). Here, the subject under investigation is the collaborative relationship between EPs and medical specialists. Additionally, a single case is powerful in the early stage of theory development and is therefore seen as a suitable research method for this study (Karlsson, 2016). Also, the limited resource availability has been kept in mind during the selection of a research method. Since case study research requires a significant amount of time and resources (e.g. money) to achieve in-depth data, a single case has been studied (Rowley, 2002).
3.2 Case selection and description
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The hospital that is selected based on the criteria described above is considered as a representative sample for the population. The aim was to select a large non-academic hospital with an AMU. The hospital that is selected has a capacity of more than 500 beds, and is therefore one of the largest non-academic hospitals in the Netherlands. Additionally, the hospital has over 300 medical specialists, covering nearly all medical specialisms1. Further, the hospital implemented an AMU five years ago. Based on these characteristics, the selected case is a representative sample of the population.
When focusing on the selected case, the hospital has an AMU in which unplanned admissions of acute patients from the ED and outpatient clinic take place 24/7. The maximum designated period that a patient can stay at the AMU is 48 hours. Within the 48 hours that the acute patient is at the AMU, the patient is diagnosed and a treatment plan is prepared. Therefore, the medical specialist visits the AMU regularly, to determine the treatment and to communicate with the patient about this treatment. Additionally, during the visits at the AMU, the medical specialist explains to the patient whether it is appropriate to discharge the patient, to admit the patient to a ward, or to transfer the patient to an external facility1.
3.3 Data collection
Within this study, primary data was collected by means of semi-structured interviews with EPs and medical specialists. In addition, an operational leader of the AMU was interviewed, to gain a better understanding of the functioning of the AMU for this specific case. Semi-structured interviews are seen as suitable in this study, because this method provides the flexibility to the interviewer to validate the meaning of the respondent’s answer, by giving the interviewer the option to use follow-up questions based on the participant’s responses. This is also called “probing” (Doody & Noonan, 2013; Holloway & Wheeler, 2010). Further, semi-structured interviews are useful to explore opinions and perceptions of respondents concerning sensitive issues (Barriball & While, 1994). Table 1 provides an overview of the characteristics of the interviewees. In total, twelve semi-structured interviews were conducted, with an average duration of 40 minutes per interview. The majority of the interviews were conducted face-to-face. However, due to time limitations of the respondents, three interviews were conducted by phone. After conducting twelve interviews, data saturation was experienced. More specifically,
1 Source: The website of the hospital under investigation. For anonymity reasons, this source is not mentioned in
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diminishing returns were experienced during the data collection, as the last interviews did not lead to a lot of new information anymore (Mason, 2010). The interview guide that was used for the interviews is shown in Appendix A. All the interviewees were asked the same questions, to enhance the reliability of the data (Karlsson, 2016).
TABLE 1
Characteristics of the interviewees
Interviewee Gender Profession Specialism (in case of medical specialist)
Interviewee 1 M Emergency physician - Interviewee 2 M Emergency physician - Interviewee 3 F Emergency physician - Interviewee 4 F Emergency physician - Interviewee 5 F Emergency physician - Interviewee 6 F Emergency physician -
Interviewee 7 M Medical specialist Oncological surgeon Interviewee 8 M Medical specialist Trauma surgeon Interviewee 9 M Medical specialist Gastroenterologist Interviewee 10 F Medical specialist Internist nephrologist Interviewee 11 M Medical specialist Orthopedic surgeon Interviewee 12 M Operational leader AMU
Regarding the conduction of the interviews, the informed consent was addressed first. Thus, it is was explained to the interviewees how the interview results would be used and the interviewees were informed that the interview outcomes would be processed anonymously. Additionally, permission for the recording of the interviews was requested, to ensure an accurate transcription of the interviews (Karlsson, 2016). Concerning the location, the interviews were conducted at the hospital, at a place that was comfortable to the interviewees and provided sufficient privacy (Bolderston, 2012).
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meetings, the outflow of patients from the AMU to the normal wards is discussed. Next to primary data, secondary data was collected in the form of a recent work conference report and documentation on the website of the hospital. Regarding the conference report, once in a while the hospital organizes meetings in which specialists, residents, emergency physicians, managers and other staff members participate. During these meetings, current problems that are experienced by the participants are discussed. Based on these discussions, steps are undertaken to investigate certain issues further. Therefore, the conference report summarizes the outcomes of the issues that are discussed and investigated more in-depth. To conclude, multiple data sources were used in this study, in order to ensure data triangulation and to enhance construct validity (Meyer, 2001).
3.4 Data analysis
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19 4. RESULTS
This chapter discusses the outcomes of the data collected through interviews, observations and documentations. First, it is described when EPs and specialists collaborate and how this impacts the patient flow. Subsequently, the influence of the AMU on the patient flow will be discussed and it is explained that the current interprofessional collaboration determines the impact of the AMU setting on the patient flow.
4.1 Interprofessional collaboration impacting the ED patient flow
Within the current setting, EPs and medical specialists collaborate in multiple ways. First, collaboration between EPs and specialists happens in interdisciplinary teams, such as the trauma team. Second, collaboration occurs when the EP requests a consult or asks the permission of the specialist to admit a patient. This is done both by phone and face-to-face. Third, collaboration takes place on a higher-level, during meetings. However, these meetings are not institutionalized and take place ad hoc, when problems are experienced.
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“Trust is the utmost important thing in medicine. With this I mean trust on each other's knowledge and each other’s efforts.” – MS 2
“I really think that if you know the people and they trust you, things go a lot smoother.” – EP2
Moreover, interviewees state that trust makes things easier. If specialists are more familiar with the EPs and have more trust in their competences, the communication among the two groups is better, resulting in an improved patient flow. Third, communication in general is also noticed as factor impacting the patient flow. When there is a good and effective communication among the two professions, a treatment plan can be made more quickly. Last, commitment is an important aspect of the collaboration that impacts the ED patient flow. When specialists are able to commit sufficient time to the ED, meaning that the EP can easily reach the specialist to request a consultation, this leads to a better functioning patient flow. Although specialisms are easy to reach in general, some problems are experienced regarding the reachability of the surgeons. When the surgeon is in the operating room, the EP cannot reach the surgeon. Consequently, the EP is not able to request permission to admit a patient and the patient needs to wait at the ED until this permission is gained.
“There are a few specialties, especially surgery, that are very difficult to reach during the working day, because they are all in the operating room or not available because they are busy somewhere else. Then you need to wait for a long time before you for instance can speak with a surgeon. This is quite frustrating, because waiting for 1 or 2 hours just to get to speak to someone is not good for your patient flow.” – EP 2
Surgeons acknowledge this problem and indicate that they would like to have more time available to support the ED. Currently, surgeons have a dual role, being present at the outpatient clinic or the operating theater. This dual role makes it difficult for the specialist to be fully committed to the ED.
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The role of the EPs is limited to the ED, as EPs have no formal role in the processes within the AMU. As soon as the patient leaves the ED, the formal responsibility for the care of the patient is transferred to the attending medical specialist (for a more extensive description of the role of the EP, see Appendix B). Although the formal responsibility is transferred to the specialist, in practice the resident at the AMU takes care of the patient. The reason for this is that just like the EP, the medical specialist has a limited involvement with the AMU. Here, the exact involvement of the specialist with the AMU differs among specialisms. For internal medicine and gastroenterology, a specialist is supervising the resident at the AMU and does a ward round at the AMU in the morning. However, in the case of surgery, the resident does the ward round and the specialist almost never visits the AMU. This means that the surgeon only visits the AMU on a consultation basis, when the resident has requested the specialist to have a look at the patient at the AMU in person. In Appendix C, the design and performance of the AMU are discussed further.
4.3 The positive impact of the AMU setting on the ED patient flow
The presence of the AMU has some positive effects on the ED patient flow. These effects will be discussed below.
4.3.1 Faster and more efficient admission. Now with the AMU in place, admissions are done
faster and more efficiently. Previously, the normal wards picked up patients from the ED, but these wards were very busy and had limited staffing levels. Therefore, it was hard for these wards to collect patients from the ED in a timely manner. Nowadays, picking up patients from the ED is mostly done by the AMU, which has sufficient staff to collect patients within 15 minutes. Therefore, patients are now collected faster from the ED. This is not only beneficial for the patient flow, but also for the normal wards as it creates rest at these wards and reduces the workload of the staff. Additionally, another advantage of the AMU setting is that there is less confusion, as most patients go to the AMU. Consequently, there is less “calling around” to find a free bed and fewer discussion regarding which ward the patient should go to.
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4.3.2 Reduce crowding at the ED. Next to the increased efficiency in the admission process of
patients, another benefit of the AMU setting is that crowding at the ED can be reduced. When it is almost sure that a patient belongs to a certain specialism, the EP explains to the specialist that more diagnostics needs to be done at the AMU, to create space at the ED. Thus, the specialist is responsible for conducting additional diagnostics at the AMU. Normally, these diagnostics would have been done at the ED, before admitting the patient. In this way the AMU functions as a buffer, absorbing the overflow of the ED. However, this way of working is not described in formal agreements and only happens when it is crowded at the ED. Moreover, respondents indicate that it is not always possible to reduce crowding at the ED, as the AMU is sometimes crowded as well.
4.4 Experienced problems regarding the patient flow at the ED
Although the AMU setting has a positive impact on the ED patient flow, the benefits of the AMU are not fully utilized by the hospital, according to some respondents. There are multiple reasons for this, which will now be discussed.
4.4.1 (Dis)agreement on the division of diagnostic tasks among the ED and AMU. Currently,
the ED determines the specialism for which the patient will be admitted and the EP needs the permission of an attending specialist to admit the patient in the name of this specialist. In order to identify the specialism to which the patient belongs, the EP needs to diagnose the patient and therefore diagnostics, among which CT-scans and X-rays, are performed. EPs have the feeling that this is valued by the specialists.
“They are glad with our broad view on things and a complete package of care when we are done with our patients.” – EP 2
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the waiting time at the ED can be reduced, by indicating that part of the diagnostics or waiting for the (results of) diagnostics can be done at the AMU.
“The idea is that you just see the emergency department as a kind of triage unit in which you decide if the patient is going to be admitted or not. The definitive diagnosis of the patient is less important for admission, it is just that you know that this patient will be admitted, even though the diagnosis is not really clear already. So, instead of waiting for a CT-scan in the ED, you wait for the CT-scan in the AMU. However, not everybody is really into that already.” – EP 2
Multiple specialists share the opinion of the EPs, acknowledging that long waiting times at the ED might occur when all the diagnostics are conducted at the ED to get a clear diagnosis.
“Sometimes they do diagnostic maneuvers at the ED, which takes time. This could also be done on the AMU. Sometimes a patient waits for hours on the ED, because they wait for a CT-scan. I think that in these cases, it would be better to have earlier contact with the surgeons. The patient has to go to the hospital anyhow, the patient has to go to the AMU anyhow. Then, it would be better to transfer the patient to the AMU already and that they say to us “you take care for the CT-scan and you look to the results”. Now, they keep patients at the ED till the diagnosis is worked out. So, sometimes patients stay for eight hours or ten hours at the ED. Then, the ED functions like an AMU.” – MS 1
Thus, various specialists share the opinion of the EPs that the AMU can be utilized more, by finishing diagnostics at the AMU and let patients wait for the results over there. However, not all specialists think that this is a good idea. One specialist states that the diagnostics needs to be done at the ED, to determine the medical policy and specialism of the patient. This specialist explicitly emphasizes that only diagnostics that do not influence the medical policy can be conducted at the AMU.
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Additionally, another specialist indicates that when the ED would be able to transfer patients faster to the AMU, this will only move problems.
“Of course, if the ED can transfer patients to the AMU in an easy fashion, then soon it will get stuffed at the AMU. The problem is moved one step further. Where usually the ED used to be crowded, now they can say after two hours “go to the AMU, they will take care of it”. Then, the problem is only moved, because it is also impossible sometimes to fix a problem within 48 hours.” – MS 2
4.4.2 Admission problems regarding undifferentiated patients. Next to the fact that it might
take long to finish the diagnosis at the ED, admission problems are experienced regarding certain patient categories that are undifferentiated. Undifferentiated patients are patients with vague complaints, that do not clearly belong to a specific specialism. Although the majority of patients can be assigned properly to a specialism, the amount of undifferentiated patients is still considerable. Therefore, the hospital under study is currently investigating the exact amount of undifferentiated patients at the ED. With regard to the undifferentiated patients, multiple EPs mention that it is sometimes a discussion for which specialism these patients need to be admitted. This means that EPs experience difficulties in finding a specialist willing to admit the patient. As a result, multiple diagnostics are executed at the ED, in order to get a diagnosis for these undifferentiated patients.
“The thing is that you have certain patient categories who are undifferentiated. For example, abdominal pain. That's a really complex category. It can be either really surgical, but it can also be urological. For women it can be gynecological, or it can be even more geriatric internal medicine. The discussion shouldn’t be “for which specialism is this patient”. It should be more about acknowledging that the patient needs admission. It shouldn't be a discussion like “No, I want to make sure it's really urological”, for example. Like, “I'm not sure whether it is kidney stones or not, so I'm not going to take this patient”. The result is that we are doing a lot of diagnostics here at the ED, to get the diagnosis. When you see that from a patient perspective, they are lying here for hours.” – EP 5
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“I think that we as internists face some problems regarding the fact that there are patients with unclear complaints at the ED. Then, the ED consults multiple specialisms, which takes a long time sometimes. At the end, when all specialists say “the problem in my area is not so big”, the internist is chosen as main practitioner. That’s not very good care. In my opinion, also the undifferentiated patients should be admitted earlier to the AMU, to do more diagnostics over there.” – MS 4.
Next to the interviews, the admission problem with regard to the undifferentiated patients is also addressed in the conference report. Within the report, it is acknowledged that EPs face difficulties regarding the admission of patients without a clear diagnosis. The report explains that specialists are not eager to approve the admission of undifferentiated patients for the following reasons. First, it can be the case that specialists face capacity problems concerning their specialism. Second, the medical specialist might lack knowledge or possesses too much specialized knowledge2. From the report it follows that the current situation regarding the admission of undifferentiated patients causes long lead times and a lengthy diagnosis, negatively impacting the quality of care2.
4.5 Interprofessional collaboration determining the impact of the AMU setting
Although section 4.3 describes how the AMU setting enhances the patient flow, respondents indicate that the benefits of the AMU are not fully utilized. More specifically, determining a clear diagnosis at the ED leads to longer waiting times, especially for undifferentiated patients. Here, the interprofessional collaboration between EPs and specialists influences the lead time at the ED, by determining the impact of the AMU on the patient flow. The underlying reasons for this will now be discussed.
4.5.1 Agreements defining the interprofessional collaboration. First of all, the agreements
among EPs and specialists play a role, impacting the waiting time at the ED. These agreements demonstrate that EPs have a limited power. EPs can make a medical policy indicating the treatment of the patient, but are not able to admit the patient to the AMU. Since there is not a general doctor responsible for the care of the patients at the AMU, the EP needs the approval of an attending medical specialist to admit the patient to the AMU. Before approving the admission, medical specialists want to have a diagnosis, as specialists want to make sure that
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the patient belongs to their specialism before taking over the responsibility for the care of the patient. In this way, specialists try to avoid that a patient is admitted for the wrong specialism, as this leads to an additional handover among specialists. To clarify, if a specialist approves the admission of a patient that does not belong to his or her own specialism, the specialist in whose name the patient is admitted has to involve a different specialism and needs to ask this specialism if they can take over the patient. This extra handover is experienced as inefficient and time consuming by specialists. Thus, as specialists need to approve the admission, the power of the specialists leads to the fact that EPs need to consult multiple specialisms and do several diagnostic tests, especially for patients with vague complaints, to determine the diagnosis. Consequently, EPs would like to have the power to admit patients to the AMU, in order to manage the ED patient flow.
“Agreements can be improved, that we as EPs can decide that a patient is going to be admitted.” – EP 5
Regarding the undifferentiated patients, EPs suggest that it would be of added value to have some undifferentiated beds at the AMU. Additionally, a person that is responsible for the care of the patients at these undifferentiated beds needs to be assigned. In this way, patients can wait for their results in the AMU and a definitive diagnosis can be determined over there. In order to realize this, EPs indicate that agreements should be adjusted.
“I think you have to make work agreements for those undifferentiated patients, that we for example agree that all those undifferentiated patients go to internal medicine or all go to the surgeons. I think that would be the solution.” – EP 5
Multiple specialists agree that the admission of undifferentiated patients can be improved, by adjusting the agreements. Medical specialist 1 shares the opinion of EP 5, indicating that the responsibility for the care of the patient should be transferred earlier from the EP to the specialist.
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patient will lose his emergency doctor anyhow. You can say that EPs stay for two hours responsible on the AMU, but then you better give the responsibility early to a surgeon or neurologist or someone else. If then the diagnosis may change because of the CT-scan, then that doctor says to another doctor, “it’s your problem”.” – MS 1
Also, medical specialist 2 and the operational leader of the AMU indicate that the agreements among EPs and specialists can be improved, but have a different opinion about how these agreements should be adjusted. These respondents explain that EPs could be responsible for a longer period of time, in order to finish the diagnostics at the AMU and to make sure that the medical policy determined at the ED is conducted at the AMU.
“It would be ideal if the emergency physicians still had something to say about what happens at the AMU. If he's stretches his responsibility to the AMU, maybe together with an intensive care doctor, then he can finish his job over there.” – MS 2
“We are thinking about making the EP responsible for the medical policy during the first 24 hours at the AMU. Now, most patients are admitted in the afternoon and evening. During that time an EP is available, but an internist or surgeon is for example not available. As a consequence, continuity in the policy is missing. What happens if someone needs an operation during that night? In that case, there is not that much back up. So, we would like to see that the policy made at the ED is also conducted during the evening and night, that there is someone responsible for these patients. Now, on paper, they (the specialists) are responsible, but in practice an internist or surgeon does never drop by the AMU in the evening or night.” – OL 1
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4.5.2 Lack of mutual understanding among EPs and specialists. Another reason for finishing
the diagnosis at the ED and having difficulties in admitting undifferentiated patients, is a lack of mutual understanding. One medical specialist indicates that, in his opinion, it is not time consuming to do the full diagnostics at the ED, as long as EPs work efficiently and focus on one task at the time.
“If it’s for trauma, the diagnostics can be finished within 1 hour, depending on how crowded it is at the ED. The work can be done in 1 hour, everything like a CT-scan and X-ray can be done in that time.” – MS 5
However, EPs explain that patients might wait for hours at the ED, before a CT-scan can be conducted. Additionally, EPs have the feeling that medical specialists have a limited understanding of the process at the ED, stating that specialists do not fully understand why it takes so long to diagnose the patient.
“I would suggest that the medical specialists come to the ED and talk to us as EPs. In this way, they would also see the crowding of the ED and understand how the process is working, because I think at the moment there is a lack of that. I think they don't quite understand why it takes so long before they will go to the ward.” – EP 3
The perception of EPs that specialists have a lack of understanding regarding the process at the ED is confirmed by medical specialist 5, who indicates not to be aware of the challenges at the ED.
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5. DISCUSSION
5.1 Interpretation of the results
This study aimed to investigate the impact of the interprofessional collaboration among EPs and medical specialists on the ED patient flow, in the presence of an AMU. Regarding the interprofessional collaboration, Kahn and Mentzer (1998) and Barratt (2004) state that trust, communication, mutual understanding and commitment are key aspects of collaboration. In this study, respondents acknowledge that all these aspects are important elements of the collaboration among EPs and specialists. With respect to trust, competence trust as identified by Sako (1992) was mentioned specifically, since interviewees described trust in terms of having confidence in each other’s knowledge and abilities. Respondents state that competence trust facilitates a better communication, leading to an enhanced patient flow. Also, communication on itself is mentioned to impact the patient flow, as a better communication makes it possible to make a treatment plan in a quicker way. Concerning the aspects mutual understanding and commitment, it was found that these aspects are not optimal, causing longer lead times at the ED. Some specialists are not aware of the challenges at the ED and the waiting times for diagnostics. Consequently, these specialists find it obvious that a diagnosis is determined at the ED, leading to patients waiting for (the results of) diagnostics at the ED. As stated before, in order to admit the patient, the EP needs the permission of an attending specialist. However, when the actor that holds the power is not aware of his position and impact on integration efforts, this may lead to ineffectiveness in the supply chain (Benton & Maloni, 2005; Maloni & Benton, 2000). Thus, some of the specialists do not fully see what the impact of their power is with regard to the challenges at the ED, leading to ineffectiveness in the supply chain. This shows that it is important for actors to have sufficient mutual understanding of each other’s business processes, to avoid a silo mentality (Barratt, 2004; Ellinger et al., 2006). Moreover, the commitment of the specialism surgery is not optimal. Sometimes EPs are not able to reach a surgeon for consultation. Here, a limited availability of specialists delays the patient flow (Lee et al., 2008). From the above it follows that the interprofessional collaboration among EPs and specialists impacts the ED patient flow, showing that the findings of Reiring (2018) also yield in a healthcare setting with an AMU.
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arranged that a specialist is doing a ward round at the AMU. This change in the role of the specialist is also mentioned by Hendrikx, van Kaam and Landman (2011). Since the AMU is located close to the ED, specialists are more often in the physical proximity of the EPs. Nevertheless, the collaboration among EPs and specialists did not change. This is contradictory to earlier findings of Leenders and Wierenga (2002), who state that the physical proximity among different functions has a positive influence on the collaboration between these functions. This study confirms that a closer physical proximity has no uniform beneficial effect on the collaboration among actors (Kahn & McDonough, 1997; Rashid, 2013).
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patients presented at the ED with unclear complaints is roughly between 13.5% to 23%. More specifically, the study of Sauter et al. (2018) shows that 23% of the ED patients have non-specific complaints and indicates that of all of these patients with non-non-specific complaints, 30% have an unclear diagnosis at the end of their ED stay. Moreover, the study of Nemec et al. (2010) found that a definitive diagnosis cannot be established for 13.5% of the ED patients, as these patients have unclear complaints. Although it seems that the amount of undifferentiated patients at the ED is not very large, in the future the admission difficulties for undifferentiated patients will become more problematic. The reason for this is that the amount of patients presented at the ED without specific complaints is increasing over the years, making the diagnostic process at the ED more complex (Schouten, Dekker, & Diepeveen, 2013; Wachelder et al., 2017).
When considering the admission of patients in general, EPs have the opinion that patients could go faster to the AMU, to finish diagnostics at the AMU. Although most of the specialists agree that patients should go faster to the AMU, specialists also want that diagnostics is finished at the ED, before approving the admission. The reason for this is that after the conduction of certain diagnostics, the patient’s diagnosis might change. Here, specialists want to avoid that a patient is admitted for the wrong specialism, as this leads to an extra handover among specialists. This extra handover is experienced as inefficient and time consuming. Moreover, poor communication during the handover might lead to: a delay in the treatment of the patient, repetition of diagnostics and medication errors (Jorm, White, & Kaneen, 2009). To conclude, specialists want to avoid that they approve the admission of a patient that does not belong to their specialism. Consequently, EPs need to conduct and finish diagnostics at the ED, to determine a diagnosis. Here, agreements lead to functional friction among the parties and lack an overall process focus (Barratt, 2004). When EPs would be empowered to admit patients to the AMU for a particular specialism, the patient flow can be enhanced (Kang et al., 2014). However, this might lead to conflicts when the specialist thinks that the patient belongs to a different specialism (Kang et al., 2014).
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patient needs to stay for a longer period of time, the patient is transferred from the AMU to the ward of the specialism. However, from the observations it appeared that the AMU faces outflow problems to the normal wards, as these wards do not have sufficient capacity to take over the patients from the AMU. This problem especially exists during the winter period, when the hospital admits a large amount of patients (in Appendix C this outflow problem is described in more detail). According to Hopp and Spearman (2001), capacity utilization determines the patient flow performance. Therefore, it is necessary that every stage in the process has sufficient capacity to handle the inflow of patients from the previous stage. The reason for this is that when capacity is matched closely with demand, a high utilization rate will be achieved, resulting in longer waiting times (Hopp, 2008). Here, the process with the highest utilization rate is called the “bottleneck” (Hopp, 2008). Kreindler (2017), who applies the theory of constraints of Goldratt and Cox (1984), states that a bottleneck will move if the successive steps in the process are not aligned with the changes made in the previous process step. Thus, when the outflow problems experienced by the AMU in the case studied will not be resolved, a faster inflow of patients from the ED to the AMU will only move the bottleneck in the process. In this way, the utilization rate of the AMU will increase, making the AMU the bottleneck. Consequently, a faster inflow of patients from the ED to the AMU might not always be realizable and desirable (especially during the winter period), as this leads to crowding at the AMU.
5.2 Limitations
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6. CONCLUSION
The aim of this study was to find an answer to the research question: How does the interprofessional collaboration between EPs and medical specialists influence the patient flow at the ED in the context of an acute medical unit (AMU)? The results from the case study show that there is a positive relation between the interprofessional collaboration among EPs and medical specialists and the ED patient flow. Accordingly, this study contributes to the establishment of literature on the impact that collaboration among EPs and specialists has on the ED patient flow, showing that the findings of Reiring (2018) also yield in a healthcare setting with an AMU. More specifically, it was found that competence trust, communication, commitment and mutual understanding are important aspects of the interprofessional collaboration among EPs and specialists, subsequently impacting the ED patient flow. Within the case studied, mutual understanding and commitment (availability) of the specialism surgery were not optimal, delaying the ED patient flow.
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collaboration not only directly impacts the patient flow, but also indirectly influences the patient flow by determining the impact of the AMU setting on the ED patient flow.
For managerial purposes, the ED patient flow can be further improved when EPs and specialists enhance the clarity in the admission policies, by agreeing on who should be responsible for the undifferentiated patients. Regarding the admission of patients in general, EPs and specialists need to agree on when the patient should be admitted to the AMU. Therefore, the mutual understanding among both parties should be enhanced and EPs need to make clear that waiting times for diagnostics can be lengthy. One way in which the mutual understanding can be improved is by having recurring meetings between EPs and specialists, instead of ad hoc meetings (Fang et al., 2018). Based on an enhanced mutual understanding, EPs and specialists can for example create a rule that patients need to leave the ED within 3 hours, even when diagnostics is not finished, to limit ED crowding (Hendrikx et al., 2011). However, when adjusting the agreements, the throughput of the AMU should be considered, in order to avoid crowding at the AMU. Thus, when the interprofessional collaboration among EPs and specialists would be improved in terms of clear and revised admission policies, the AMU can be of greater value to the ED to a certain extent.
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