Variations in the patient care process at the emergency department: development and implications of an observational instrument

In this talk we discuss the development and implications of an observational instrument, designed to evaluate treatment routines at an Emergency Department (ED). The instrument divides all different types of activities a doctor can perform at an ED into eight categories. In 2010, a pilot study with the instrument was carried out at the ED of Leiden University Medical Center. All physician activities were registered on a minute-to-minute base by an independent observer. Ten doctors were observed during a total of 36 hours in which 42 patients were seen. Although emergency physicians were observed for a shorter period of time than internists, they saw more patients. Emergency physicians tended to have more patient contact time than internists, but both groups dedicated most of their time to documentation and had little communication with emergency department nurses. The average LOS of internal patients was significantly higher than for the patients of emergency physicians. By protocol, patients at the Emergency Department (ED) who are seen by emergency physicians are treated one by one, resulting in a more or less serial treatment routine. Physicians from other departments tend to see more patients at the same time (parallel treatment routine), and thus occupy more treatment rooms simultaneously. We suspect that the parallel treatment routine is related to a longer patient LOS and suboptimal ED logistics. In a succeeding study we will mathematically compare the advantages and disadvantages of serial and parallel treatment routines at the ED.