Interprofessional barriers in patient flow management: an interview study of the views of emergency department staff involved in patient admissions

ABSTRACT

Patient flow in emergency departments (EDs) is notoriously difficult to manage efficiently. While much of the attention has focused on the procedures, protocols and pathways in which patients receive their first hours of care, less attention has been paid to the relational factors that make it happen. Our study is the first, to our knowledge, to consider the role of interprofessional barriers, defined as suboptimal ways of working, as perceived by ED staff in patient flow management. Drawing on 19 interviews with hospital staff in an acute tertiary trauma center hospital in England, we established three flow-related types of interprofessional barriers: ED teamwork barriers, performance-driven coordination barriers, and referral-related collaborative barriers. Knotworking was recognized as a form of interactions and asset to teamworking, coordination, and collaboration. Identifying processes such as chasing, escalating, and advocating enabled our investigation to highlight a very complex set of interprofessional interactions, and signpost what the suboptimal practices of flow management are. Our analysis holds promise for hospitals beyond the National Health Service in England.

KEYWORDS:

• Patient flow
• interprofessional barriers
• knotworking
• emergency admissions

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Funding

This work was supported by King’s College London [Interdisciplinary award ‘King’s together’].

Notes on contributors

Olga Boiko

Dr Olga Boiko is a Research Fellow at London School of Hygiene and Tropical Medicine with specialism in medical sociology and health services research. She has been involved in a wide range of quality improvement, implementation and evaluation studies, and currently explores the evolution of integrated care systems in the UK NHS.

Matthew Edwards

Matthew Edwards is a Consultant in Emergency Medicine and Paediatric Emergency Medicine based at Kings College Hospital NHS Trust and pre-hospital HEMS physician for Air Ambulance Kent Surrey and Sussex. He previously held a NIHR Academic Clinical Fellow position at King's College London and served as emergency department liaison for the King's Together research team.

Steffen Zschaler

Dr Steffen Zschaler is a Senior Lecturer at King’s College London, where he focuses on software engineering, especially on the development of modelling languages and tools for supporting the collaboration between domain experts and software engineers in software development. He is interested in developing modelling approaches for simulation-based exploration of patient flow and workflow in emergency departments as a means of making EDs safer and more efficient.

Simon Miles

Dr Simon Miles is a Reader in Computer Science at King's College London and Director of the Centre for Urban Science and Progress London (CUSP London). His research expertise is in agent-based systems, a branch of artificial intelligence, and data provenance, tracking the history of data so as to determine its reliability, which he applies within health informatics and other domains.

Anne Marie Rafferty

Professor Anne Marie Rafferty is President of the Royal College of Nursing and Professor of Nursing Policy, King’s College, London. She is Co-Director of the NIHR Health and Social Care Workforce Policy Research Unit at King’s College London and a leading expert in healthcare workforce policy; nursing policy and the history of medicine and nursing.