Emergency Department access and flow: Complex systems need complex approaches

Abstract

Hospital access block, often referred to as Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving healthcare systems. 1 The multiple, dynamic, and interdependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems (CASs) analysis and approach. Complex adaptive systems differ from simple systems in the number of components, the degree of interconnectedness between and among those components, and the certainty of a working solutions. Complicated systems lie some place in the middle but would still operate with predictable and controllable characteristics. While this categorization itself may be an oversimplification, it is clear that simple/complicated systems have different properties (linear cause-and-effect, predictable outcomes), and behave differently than complex systems (non-linear and difficult to predict). 2-4 These different properties have a significant impact on problem formulation and solving. In fact, not recognizing how complex systems behave has limited attempts at health system "transformation" 5 and complex issues management. 6 For example, our approach to the opioid crisis 7 and the obesity crisis 8 started with siloed and doomed-to-fail linear approaches but have now recognized the complexity of the problem. 9 This suggests that we need to shift our mindsets, and improve our systems thinking, as we address the health system problems that have proven resistant to conventional approaches. These shifts in thinking may significantly impact a Health System's approach to ED access block. 10 Understanding the number of components and degree of inter-dependencies in the system may bring to the fore previously under-emphasized, or even unrealized, strategies and solutions.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

“…Although there has been previous work that has noted the need to study EDs as complex adaptive systems [54,71,72], there has been very limited empirical research that conceptualizes EDs as CAS. Of note, in a study by Nugus et al [73], the authors examine how emergency clinicians manage dynamic boundaries between the ED and other hospital departments and organizations in striving to integrate care and meet the patient's needs.…”

Want improved quality? Improve your systems

“…Focussing on improvements of organization is key to achieving the most effective running of emergency departments. Petrie and Comber 22 allude to polarity management as a way to successfully manage competing demands on the system.…”

Inter hospital external validation of interpretable machine learning based triage score for the emergency department using common data model

“…Emergency department (ED) is complex and need urgent judgement for the better triage 1 , 2 . In order to determine the patient’s condition quickly, Korea Triage Acuity Scale (KTAS), New Early Warning Score and Modified Early Warning Score have been developed by expertise 3 , 4 .…”