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Social Science & Medicine 71 (2010) 1997e2004

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Social Science & Medicine

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Integrated care in the emergency department: A complex adaptivesystems perspective

Peter Nugus a,*, Katherine Carroll b,David G. Hewett c, Alison Short a, Roberto Forero a, Jeffrey Braithwaite a

aUniversity of New South Wales, Sydney, NSW, AustraliabUniversity of Sydney, AustraliacUniversity of Queensland, Australia

a r t i c l e i n f o

Article history:Available online 15 September 2010

Keywords:AustraliaComplex adaptive systemsEmergency departmentsIntegrated careDiagnosisDischargeInterdepartmentalInterorganizational

* Corresponding author.E-mail address: p.nugus@unsw.edu.au (P. Nugus).

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.08.013

a b s t r a c t

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emer-gency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at theboundaries of the ED and other hospital departments and organizations whose services emergency clini-cians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, andpatients’ needs across this journey is challenging. The journey is usually accounted for in a linear waye asa “continuity of care” problem. In this paper, we instead conceptualize integrated care in the ED usinga complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which otherdepartments and units outside of the ED are integrated, and appropriately described, using CAS conceptsand language. One year of ethnographic research was conducted, combining observation and semi-struc-tured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CASapproach to be salient to analyzing integrated care in the ED because the processes of categorization,diagnosis and discharge are primarily about the linkages between services, and the communication andnegotiation required to enact those linkages, however imperfectly they occur in practice. Emergencyclinicians rapidly process large numbers of high-need patients, in a relatively efficient system of careinadequately explained by linearmodels. A CAS perspective exposes integrated care asmanagement of thepatient trajectory within porous, shifting and negotiable boundaries.

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Introduction

This paper adopts a complex adaptive systems (CAS) perspectiveto understand the interconnections across departments andservices in emergency department (ED) care. The ideal of achievingsuch interconnections has been labeled “integrated care” in policyand academic literature (e.g., Gröne & García-Barbero, 2001;Kodner & Spreeuwenberg, 2003). We argue that a CAS perspec-tive needs to be applied to understanding ED work, given thecentrality of inter and intra organizational work in the ED, andcomplexity theory’s language of, and focus on, spaces betweena system’s parts (Braithwaite, Debono, & Travaglia, 2009).

In response to the increasing fragmentation of care acrossprofessionals, services and health sectors, the concept of integratedcarehas received, in the past decade, increasing policyand academicattention. The concept of integrated care has been promoted by theWorld Health Organization (WHO) to represent the coordination ofcare across various professionals, services and health sectors (Gröne

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& García-Barbero, 2001). An important impetus for integrated carehasbeen theneed for continuityandcoordinationamongavarietyofprofessionals and services needed to help manage the co-morbid-ities of chronically ill and older patients (Leichsenring, 2004;Ouwens, Wollersheim, Hermes, Hulscherand, & Grol, 2005). Yet,little sociological attention has been paid to the integration of careacross formal organizational boundaries. It is timely to redress this(Gröne & García-Barbero, 2002; Kodner & Kyriacou, 2000; Nies,2004). The present study uses conceptual sociological tools exam-ining “boundary-work” (Allen, 2000; Hewett, Watson, Gallois,Ward, & Leggett, 2009a) and the “patient trajectory” (Strauss,Fagerhaugh, Suczek, & Wiener, 1985) to contribute an analysis ofnegotiation at the formal boundaries of the ED including the inter-connections between the ED and other departments and services.

The Emergency Department

The ED is an important and under-researched site of integratedcare in the hospital (Nugus & Braithwaite, 2010; Nugus, Bridges, &Braithwaite, 2009). The ED is the gate-keeper of the hospital’s

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differentiated services. It is also an important link between thecommunity (primary care) and the hospital (secondary and tertiarycare) (McCusker et al., 2001). In Australian public health care,patients access the ED for hospital admission, and are often dis-charged directly from the ED (Nugus & Braithwaite, 2010). Emer-gency clinicians manage patient trajectories as a response topatients arriving to the ED, constituting a uni-directional “flow”

from which patients are shifted through the process, dischargedfrom the ED or physically transferred to other departments in thehospital (Nugus & Braithwaite, 2010). The capacity to transferpatients to inpatient beds is influenced by processes within thehospital such as bed availability andmatching patients to particularinpatient units (Forero, et.al., 2004; Forero & Hillman, 2008). Thismakes the ED an important site for the study and practice of inte-grated care.

ED patients progress through a series of stages. Senioremergency nurses (and sometimes senior doctors) “triage”presenting patients into a category using scales depending onthe urgency of their condition e from the most to the leasturgent (ACEM, 2000). Emergency clinicians who, for the purposeof our study, are nurses and doctors, stabilize patients, anddiagnose their conditions and execute a treatment plan. Thisinvolves determining and organizing the patient trajectory(Nugus et al., 2009). This implies a role for emergency cliniciansin coordinating various professionals and services in the care ofemergency patients in order for admission to the hospital or innegotiating and organizing discharge from the ED.

Chain reasoning in conceptualizing care in the ED

Most literature on integrated care, and on the performance ofEDs (e.g., Campbell & Zalenski, 2006; Christensen et al., 2004), hastended to conceptualize care via a linear patient trajectory, or ata fixed point in a patient’s care trajectory. This reflects a continuity-of-care perspective which characterizes care in a chain (Henrardet al., 2006; Paquette-Warren, Vingilis, Greenslade, & Newnam,2006). This is not surprising because health policy tends to privi-lege linear notions of efficiency which seem relatively easy tomeasure (White & Willis, 2002). A review article by Hearld,Alexander, Fraser, and Jiang (2008) found that most researchersof health services examine quality of care in a linear fashion, forexample, drawing direct links between hospital structure (such as,hospital size) and quality care through indicators, rather thanfocusing also on the processes of achieving quality improvement,such as coordination among professional groups (Hearld et al.,2008). Similarly, policy-makers have tended to approach healthsystems performance from a linear perspective, such as privilegingclinical outcome indicators rather than complex processes, and, inthe case of EDs, efficiency over quality of care (Nugus & Braithwaite,2010).

Yet, the patient trajectory can be conceived in both linear andcomplex ways. Depending on the perceiver’s standpoint, aspects oflinearity and non-linearity can be seen in systems and sub-systems.Linearity is an important way of thinking about health systems.Within indeterminable complexity there are well-worn and map-able paths that patients follow (e.g., Long, Iedema, & Lee, 2007). Yeta focus on linearity to the exclusion of complexity privileges somefeatures of the system over others, andmay reflect an unnecessarilymechanistic and reductionist view that parts of a health careservice, or system, can be isolated from other parts (Morgan, 1997).It ignores the relational work enacted by clinicians in connectingthese parts. The benefit of a CAS perspective is that it incorporatesboth linearity and non-linearity. In this way, a CAS perspectiveforegrounds the nuances and dynamism of the integrative work ofemergency clinicians. We argue that a linear perspective alone,

despite its appeal, is insufficient to account for the care that needsto be delivered to ED patients.

Complex adaptive systems: porous boundaries and relationshipsbetween parts

The concept of a CAS stems from complexity theory and takesa dynamical systems approach to groups of both human andnonhuman agents (Urry, 2003). A CAS is “an entity composed ofmany different parts that are interconnected in away that gives thewhole capabilities that the parts don’t have on their own” (Letiche,2008, 127). For example, nursing homes have been studied ascomplex adaptive systems in which the combination of manage-ment practices and organizational processes were shown tocorrelate with patient outcomes (Anderson, Issel, & McDaniel,2003). Academic medical centres have many different specializa-tions, agencies and providers which, as a collective whole, provideservices to patients, the sum of which is much greater than could beachieved by the individual parts alone (Letiche, 2008). A key featureof CAS is that individual parts are adaptive, responding to changesand demands of the environment, and are also highly interactive(Urry, 2003).

In terms of the function of a complex adaptive healthcaresystem as a whole, the boundaries within and across sub-systemsare seen as porous and negotiable rather than fixed, reflectinginterdependence within and across a system’s external environ-ment (Hurst & Zimmerman, 1994). The porous boundariessurrounding a complex system mean that it is inherently interac-tive with other systems that collectively constitute the environ-ment of the CAS (Cilliers, 2001).

The study of relationships and interaction is germane to soci-ology. A fundamental sociological insight, applied to healthresearch, is that actors are part of an interdependent web. Symbolicinteractionist research shows that systems, parts of systems andactors are mutually influencing (Barnes, 2001; Nugus, 2008). Largersocial structures set the terms of interaction in ways often unbe-known to actors (Katovich & Maines, 2003). Actors both reflect andamend social structures as they negotiate, in interaction, the defi-nition of the situation (Vryan, Adler, & Adler, 2003).

Influences from within and across systems and sub-systems ofhealth services require staff to coordinate their care activities. Strausset al. (1985) introduced the notion of the “patient trajectory” toexpress the dynamic role that staff play in negotiating social struc-tures to deliver care andmove patients through a service. Staff need toactively resolve unanticipated and relatively unpredictable contin-gencies, through a set compromises that “gets [sic] the job done”,given that work occurs in an open system for which formal, globalrules do not always apply (Gerson & Star, 1986, 166). Such coordina-tion is complicated by the distribution of tasks among mutuallydependent but semi-autonomous staff members who have their owntasks, goals and contingencies to resolve (Allen, Griffiths, & Lyne,2004, Goorman & Berg, 2000; Schmidt & Bannon, 1992).

Coordination, then, foreshadows the need for “boundary-work”across professionals in different roles (Allen, 2000) and organiza-tional units (Carmel, 2006). For instance, Allen (2000) demon-strated how occupational demarcation occurs through negotiationof clinicians in the context of the influence of occupationalmanagers. Carmel (2006) highlighted the way intensive careclinicians accomplish a distinctive organizational boundary of theintensive care unit from the rest of the hospital. Similarly, inter-dependent work across units is germane to the ED because emer-gency clinicians categorize patients in terms of their worthiness foremergency care and their potential transfer out of the ED to otherservices or departments (Dingwall & Murray, 1983; Dixon-Woodset al., 2006; Hughes, 1989; Jeffrey, 1979). The way patients are

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categorized in the ED is a response to pressures from and expec-tations of staff inside the hospital (Dodier & Camus, 1998; Vassy,2001).

By focusing on the negotiation between departments andservices through a CAS approach, our study reconceptualizes andadvances research on the communication between organizations(e.g., Dooley & Zimmerman, 2003). To extend sociological notionsof boundary-work and patient trajectory, a CAS perspectiveprovides concepts and a specific language for the relationshipsbetween parts, rather than focusing on the departments andservices on either side of boundaries, and is yet to be expoundedempirically in the relation to the ED. Such an ambition is capturedin Kodner and Spreeuwenberg’s notion of integrated care as“organic, differentiated care”, which is a conceptual context for thepresent study. This complexity-informed notion of integrated careplaces a premium on researching communication and relationshipsbetween components of a system, between systems, and betweensystems and their environment (Hewett, Watson, Gallois, Ward, &Legget, 2009b).

Aims of the present study

This paper has two interrelated aims. It aims, firstly, to accountfor the interconnections across departments and services in EDwork. The second aim is to extend the field of the study of inte-grated care, and sociological understandings of health services,using a CAS approach. This study uses key CAS concepts to expandthe traditional and dominant languages and concepts of linearityin healthcare understanding, such as continuity-of-care, andsociological notions of boundary-work and patient trajectory. Weargue that CAS concepts and language augment our under-standing of interdependent social processes at work in healthorganizations.

Methods

We learn more about a system, such as an ED, a hospital, ora broader health system, from seeing how phenomena emerge insitu and in real time (Begun, Zimmerman, & Dooley, 2003).Ethnographic methods were chosen to illuminate the processes ofwork in real time and place, as well as to apprehend socialstructuring (Nugus & Forero, forthcoming). The current studyexplores the care coordination processes and decisions made byclinicians in the EDs of two tertiary referral hospitals in Sydney,Australia. The study is part of a larger sociological research projecton the organizational work of emergency clinicians. Data weregenerated through ethnographic observation by accompanyingjunior, mid-ranked and senior emergency nurses and emergencydoctors, chosen in conjunction with the heads of department andsenior nurse manager, for two full shifts each across the two EDs(comprising approximately 110 h of observation accompanyingparticular clinicians, and generating approximately 800 pages offield notes) over a full year. This included attendance at 24 wardrounds and 24 nurse handovers. The words and actions of theclinicians observed were documented in handwritten field notesacross these shifts. Fifty-six semi-structured interviews wereconducted with emergency doctors and nurses that were alsodocumented in and transcribed from field notes. Interviewparticipants were approached and recruited by the observingresearcher during observations. The first-listed author conductedthe field work.

Interview and observational field note excerpts were codedaccording to the primary participant being observed or recorded:such as senior doctor (staff specialist) (SD), junior doctor (intern, inthe case of the present study) (JD), Team Coordinator (Nursing Unit

Manager) (TC) or senior nurse (SN). Codes also indicated whetherthe data were derived from Hospital A or Hospital B. Names ofparticipants were changed to protect their identities. The researchwas conducted in 2005, and human research ethics approval wassecured from the University of New South Wales Human ResearchEthics Committee and the HRE Committees of the two hospitals inwhich the research was conducted.

Staff in each department were informed of the project and theobserving researcher on each occasion introduced himself andrequested permission to document their talk. ED staff wereinformed that they could request not to be observed or for their talknot to be recorded.

For the current study, we analyzed those parts of the tran-scripts and fieldnotes that concerned decisions about patientadmission or discharge, and interactions between emergencyclinicians and clinicians from other departments in the hospital ororganizations outside the hospital. These parts of the transcriptswere coded and themed manually, through “line-by-line” coding.Specifically, themes were derived from the data by iterativelycomparing and contrasting potential explanations for externalrelations from the ED until all themes were incorporated orexplained (Glaser, 1992). We exemplify such themes in the dataexcerpts provided. Line-by-line coding of data, drawn from botha purposive and systematic sample of activity in the ED, showedthe dominant and continual engagement with, and the context of,external departments and services, as a core and virtually exclu-sive activity of emergency clinicians. Therefore, CAS principleswere found post hoc to be most appropriate for articulating thethemes because they reflect, and assist in the analysis of, thecontinual engagement with shifting boundaries that need to beconstantly negotiated.

Findings

The role of emergency clinicians was to treat all presenting,undifferentiated patients who had reversible conditions. Patientspresenting directly to the ED were triaged, that is, patients werecategorized according to the relative urgency of their condition.Patients brought in by ambulance or rescue service were pro-cessed through the ambulance bay. Through diagnosis, emergencydoctors organized a patient’s history, symptoms, signs, and testresults into a symbolically recognizable form to which particulartreatment (clinical) and motional (organizational) options areattached.

Throughout the 24ward rounds observed, it was clear that therewere three key organizational questions implicitly, and sometimesexplicitly, asked by clinicians of each ED patient beyond clinicalquestions of assessment, diagnosis and treatment alone. Thesequestions were found, post hoc, to underpin the complex organi-zational labour of emergency clinicians and were as follows: Canthis patient be discharged, or does the patient need to come intothe hospital? If he or she needs inpatient admission, where andunder whose management is the patient going, and when? If theycan be discharged, how can we discharge them efficiently andsafely? The first question is a “fork”, providing two straightforwardoptions. The second and third questions, as prongs of the fork,represent mutually exclusive pathways,

We present our findings according to these central questionsthat govern ED work. The first section explores the relationshipbetween patient categorization and the “admission-dischargeconjunction” that characterizes ED work. The second sectionfocuses on specific interactions, between emergency clinicians andclinicians from other hospital departments, and their culturalsignificance. The third section examines the relationship betweenthe “discharge imperative” and patients’ needs.

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Can they be discharged or do they need to be admitted?Categorization and the “admissionedischarge conjunction”

The “admission-discharge conjunction” is the categorization ofthe admission or discharge status of ED patients, and is theprimary goal of the initial ED diagnostic assessment. Duringa ward round, emergency doctors were debating which inpatientmedical or surgical teams to engage for potential inpatientadmission of a particular patient. Highlighting the significance oforganizational boundaries in categorization, an emergency staffspecialist concluded the discussion by stating: “He needs to comein under someone” (MDA2: 30). Accordingly, work inside the EDdisplays its “bounded complexity” e that is, the porous andnegotiable boundaries between the external and internal worldsof the ED.

The interdepartmental role of the ED, and the influence on EDwork of other departments and organizations outside the hospital,is evident in the following unabridged comment by a Team Coor-dinator (TC):

“The Bed Manager’s close to tears. But if we have to admit, wehave to. We have a duty to accept patients from other hospitals.The ambos [ambulance officers] are great. We’re a big hospitalso we have to admit them here. The problem is they can’t staffthe wards properly.” (TCB1: 9).

The significance of this comment is its demonstration of theporous boundaries of the ED, and its connections with otherhospital wards and hospitals in the city. It conveys what is calledthe “spatial reach” (Carroll, 2009) that the ED has to an entirelocal community, the influence that community has on ED work,and hence the need to manage those boundaries throughnegotiation.

External liaison most commonly occurred with three groups:General Practitioners (GPs: called family doctors or primary carephysicians in some countries) and community health services;inpatient doctors; and inpatient nurses. As an example of externalliaison, emergency specialists interacted frequently with GPs aboutpatients who were to be discharged. Staff specialists preferred GPsto contact them rather thanmerely send their patients to the ED. Anemergency specialist gave a GP the following telephone advice:

[Staff specialist] takes call. Typing on computer. “Hello. Hi ‘Don’.(Pause.) . Occult blood positive . (clinical talk) . Have youreferred them to ambulatory care? She’d be a great patient forthem. I’ll give you the number. It’s ‘26847’. Do [the test] and dosay you’re a [General Practitioner], you want to use ambulatorycare and if there’s a problem they can ring me” (SDA1: 19).

In this instance, the emergency specialist assisted the GP tonegotiate their path through particular services. In helping tointegrate community services, such as those of the GP, the emer-gency specialist lent the GP his positional authority within thehospital.

The categorizationwork of emergency clinicians makes EDworkfundamentally interdepartmental and interorganizational. Thefollowing excerpt shows, in a continual stream of interaction, theinfluence of the quality of the departmental flow on emergencyclinicians’work. The excerpt commenceswith the TC and the seniorstaff specialist negotiating whether the department should staygreen or “go orange”. EDs in Sydney determined their status asgreen, amber (orange) or red. Code green indicates that the ED istaking ambulance patients, code amber indicates that ambulancesshould avoid a particular ED in preference for another ED, ifpossible, and code red shows that the ED is only available toambulances for trauma, such as from motor vehicle accidents.

TC: “I want to stay green”. Senior staff specialist: “I reckon weshould go orange . Mmm e I’d like orange. It’d give us somebreathing space”. TC: “I’ll call the ADON [After-hours Director ofNursing] and you call the Bed Manager. [The ambulance-basedemergency] phone [rings]. [TC1 had come onto shift andanswered phone]. TC1 and staff specialist look at each other.TC2: “MVA [motor vehicle accident]. Probably needs intuba-tion”. TC1 then puts out the trauma alert. TC1: “Let’s go orange”.TC2: (callover): “Trauma team in resus please. Trauma team inresus. The department is orange for 2 h”. Bed Manager: “I’ll fillout the form” (TCA2: 18e19).

Thus, emergency clinicians work continually in the spacesbetween departments, services and organizations. The need tocontinually negotiate and prioritize demands from other depart-ments and organizations shows that patient care in the ED is aboutmanaging perennially negotiable organizational boundaries.

Under whom should they be admitted? Interdepartmental andinterorganizational communication

The open access of the ED limits the ability of emergencyclinicians to plan for the future. Emergency clinicians claimed tohave discerned relatively consistent, and therefore predictable,patterns of patient attendance to the ED. However, this did notguarantee desired responses by other departments about thosepatients, emphasizing the significance of interdepartmentalnegotiation for the work of emergency clinicians. Sometimes, innegotiation, emergency clinicians sought to transfer the conse-quences of categorization, reflecting the intergroup dynamic in thenegotiated order of the hospital (Hewett et al., 2009a,b). Forexample, an emergency registrar (known as a resident in the USand a house officer in the UK) said to an obstetrics and gynae-cology registrar: “If you’re not happy for her to go home, I can giveher to you” (MDA2: 33).

Most of the specialties with which emergency cliniciansengaged corresponded to specific wards in the hospital. When aninpatient medical team had admitted a patient, the TC and nursesarranged for the transfer of the patient to the assigned ward.When no beds were available, they remained “boarding” in theED as “outliers”. Within the hospital, emergency doctors engageddoctors from inpatient teams for one of three reasons. First, anemergency doctor might liaise with a doctor from a particularinpatient team to confirm their decision to discharge the patient.Second, emergency clinicians sometimes engage the opinion ofinpatient team doctors to seek their opinion on the diagnosis andtreatment of the patient, i.e. to “review” a patient or doa “consult”. The third reason for engaging an inpatient teamdoctor in the care of an ED patient was to seek to persuade themto admit the patient. The intention was for an inpatient doctorfrom a particular medical or surgical team to accept medicalresponsibility, either solely or jointly with a doctor from anotherteam, for the care of the patient, and for the patient to bephysically transported to the ward corresponding with theadmitting medical specialty, or to a general ward in the hospital.Emergency doctors sometimes contacted inpatient doctors foreach of these reasons, in progressive stages. Discussion ofa potentially dischargeable patient might lead to review andsubsequent admission.

Most communication events between emergency clinicians andclinicians from other departments observed during the fieldresearch were relatively amicable and free from overt conflict.Frustration was expressed about ward nurses not acceptingpatients when emergency nurses are ready to send them “up”. Forinstance, two junior emergency nurses explained their perception

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of the relationship between emergency nurses and nurses in twoparticular departments:

Junior nurse 1: “[Names two departments] don’t like ED. Wegive them patients and we push them and they say they’re notready. They’re busy.” Junior nurse 2: “But we don’t have theluxury of saying, ‘Not yet e just wait there’ to the ambulancesthat back up”. Junior nurse 1: “They couldn’t say, ‘Hold off’ atGallipoli [reference to a famous battle in World War One]”(JNA1: 8e9).

In terms of the engagement of emergency doctors with doctorsfrom inpatient teams, patients in the ED could effectively bedivided into three categories that integrate the external environ-ment. The first group of patients reflects those whose symptoms,histories and test results have been organized into a diagnosis andfor whom treatment is expected to result in their discharge fromthe ED without input from inpatient teams. The second groupcomprises those who are under review by one or more inpatientteams. These patients are under the medical care of emergencydoctors or under joint care by emergency doctors and an inpatientteam. They might or might not have a diagnosis. If they havea diagnosis, emergency doctors determine, sometimes inconjunction with doctors from one or more inpatient teams, thatthey did not require hospitalization. Patients require hospitaliza-tion if doctors deem that they need to stay in the hospital for morethan 24 h. The third group of patients concerns those patientswhose conditions have been attributed to diagnoses and who areunder the medical care of an inpatient team or teams but for whomthere are insufficient beds on the wards corresponding to themedical team or teams under whom they have been admitted(i.e. “outliers”). This highlights that the common feature of many EDpatients is the engagement of inpatient clinicians; emergencyclinicians liaise with inpatient clinicians even regarding patientswho will not be admitted. Thus, the structural location ofa department at the boundary of a complex organization impelsthem to manage interdepartmental and interorganizational rela-tionships (Hyde, 2006).

How can we discharge them safely? Patients’ needs beyond the ED

Because emergency clinicians sought, where possible, dischargefor the patient from the ED, they were committed to engaging withthe personal and non-clinical circumstances of patients in clinicaland transfer decisions. This was especially the case for emergencyclinicians in senior roles. The following excerpt from fieldnotesdemonstrates the clinical, organizational and personal boundariesthat senior emergency clinicians traverse in providing care to EDpatients:

‘Natalie’ [a nurse] is trying to find a social worker for twoteenagers e in shock over car accident involving mother. Pages[social worker] and waits for [them]. Comforting son: “It’salright to be scared, love”. Social worker rings. ‘Natalie’: “Wethought she was hyperventilating . She’s on lots of drugs .She’s intubated. There’s a young boy. two of them. and thedaughter . We let them stay outside in case she arrests . Theson’s really, really shocked. He needs you. The daughter thinksshe’s got to hold it together . Yes, she’ll have to go to ICU . Idon’t knowmuch else. but I’ll keep you informed” (SNB2: 27).

The prospect of discharge required emergency clinicians toconnect with the world of patients beyond the clinical conditionthat was also dealt with on presentation to the ED. Thus, whatmight be called the “discharge imperative”, as a structural influenceon the behavior of emergency clinicians, allowed a mutuality ofinterests between the organization, patients and clinicians, and the

prospect of integrated care in a differentiated organization. Indetermining priorities of admission and discharge, emergencyspecialists, for instance, or doctors presenting patients during wardrounds, exhibited knowledge of the personal circumstances ofpatients. An emergency specialist, speaking about an anotherpatient, said to an intern:

You can’t discharge her. She’s got two flights of stairs [at home](SDA1: 21).

Therefore, emergency specialists helped junior doctors tounderstand the challenge of discharging patients if they believedthat the home or personal circumstances presented difficulties.This shows the crucial role of emergency clinicians in dischargeplanning, and their focus on the relationship between the ED andits external environment, including knowledge of other servicesand the day-to-day lives of patients. Sometimes, staff used the term“social admission” when the doctors were discussing a jointadmission between two or more medical or surgical teams. Ina field interview after the observation, the registrar explained to theobserving researcher: “Sometimes admissions are just to look afterthe patient; sometimes joint admissions are social admissions”(MDB1: 14). The discharge imperative of the ED thus was patient-centred to the extent that it meant taking the patient’s personal,non-clinical circumstances into account in making dischargedecisions.

Senior emergency clinicians initiated interaction to engage thepersonal, non-clinical circumstances of patients, beyond theimmediate clinical care being delivered in the ED, as an influentialfactor in determining patient trajectories. During observations,a senior emergency nurse articulated the simultaneous engage-ment with clinical, personal, legal, and interdepartmental aspectsof ED work, as well as managing the future workload of thedepartment:

“Sometimes we get a cardiology review to play it safe. Often it’schest pain.We’re less likely to have litigation. We get it just torule it out. If they seem to have psych [psychiatric] issues we getPsych [Psychiatry] to admit them which at least means they’rein. Then we get a cardio [cardiology] review . Often we don’twant to send patients home. If they shouldn’t be sent homethey’ll just bounce back. There’s . the litigation threat. Plus wewant to provide the best service for the patient . Nurses canalso get charged if they don’t get [ie, take a reading of] bloodalcohol levels. We’ve got new equipment for that. That’s why Ismell a rat with that lady. We’ve got to work out the story, see ifshe’s lying, see if it really was a suicide attempt and seewhat thesocial situation is e what’s going on .” (SNB1: 14).

The imperative the nurse expressed to discharge patients safelyevinces the centrality of the dischargeeadmission conjunction inED work. Experience enabled the senior emergency nurse toreconcile the clinical conditions of patients, the engagement ofinpatient teams in diagnostic processes, and the transfer of patientsto fulfil their professional and perceived legal responsibilities.

When emergency specialists found the opportunity to treat andorganize care for their patients, they adroitly referred to and inte-grated their patients’ personal non-clinical circumstances inengaging multidisciplinary care. Emergency specialists were effi-cient in and adept at engaging appropriate services such as the PostAcute Care Services Team and Hospital in the Home program. Anemergency specialist looked at the fracture of a child on an x-rayand obviously became concerned for the child’s safety, then said:“I’m calling [the Department of Community Services]” (SDA1: 21).The crucial roles and expertise of senior emergency clinicians wereengaged to organize holistic, integrated multidisciplinary.

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The focus on discharge illuminates the under-recognizedengagement of emergency clinicians with the personal, non-clinicalcircumstances of the lives of ED patients beyond the hospital. Emer-gency clinicians take into account non-clinical aspects of patient care,such as the adequacyof their living arrangements, because of concernfor patients, desire to manage workload by avoiding their re-presentation, and fear of litigation. The emphasis on, and preferencefor, discharge, requires emergency clinicians to account systemati-cally for the ED’s external environment in the day-to-daywork insidethe ED, and the relationship between the ED and broader systems.

Discussion and conclusion

Three questions frame, inform and underlie what emergencyclinicians do. These are: Can the patient be discharged, or do theyneed to come into the hospital? If they need inpatient admission,where and under whose management is the patient going, andwhen? If they can be discharged, how can we discharge themefficiently and safely? The first question is a fork in the patient’spathway. The second and third questions flow as prongs of the fork,representating mutually exclusive pathways. This is a straightfor-ward algorithm. Yet, it belies the degree of agency required ofemergency clinicians and the complexity of their work and thesystems they inhabit. In answering and operationalizing thesequestions, emergency clinicians work beyond the narrow focus oftheir reputation to “meet, treat and street” patients (Campbell &Zalenski, 2006), and beyond a linear approach to ED care. Rather,negotiating a solution to these questions requires sophisticated,tacitly held understandings of how to manage system complexityand how to integrate care holistically.

Ethnography exposed the real-time-and-space dynamics ofrelationships. We showed that managing the patient trajectorythrough the process of patient categorization, including diagnosisand patient “work up”, is inextricably tied to the relationshipbetween the ED and its external environment. We can see that thedifferentiation of services provided by particular inpatient depart-ments is crucial in decisions about admission and discharge.Admission and discharge decisions require: benchmarking ofpatients’ needs for specialized treatment against the ability of thehospital to provide for those needs; determining the current andfuture capacity of the ED e requiring efficient flow through thedepartment; and weighing up the risk to patients and staff ofpatient readmission. The means for achieving mutually compatibleinterests of patients and the organization are built into thedischarge process, even though this partially concerns fear of liti-gation, and even if it does not always happen perfectly in practice.The imperative to discharge invariably draws emergency cliniciansinto the “real world” personal, non-clinical circumstances of EDpatients and requires emergency clinicians to engage with multi-disciplinary care services to be able to discharge patients.

Although much past literature on integrated care in the EDfocused on linear processes, what needs to be more fullyacknowledged is that ED work is fundamentally about dynamicalprocesses. It is overly simplifying to describe work in the ED withreference to terms suggestive of linearity such as continuum ofcare. EDs are instead more usefully seen as complex adaptivesystems comprising multiple dynamic networks of multiple agentsacting and reacting in real time. Behaviors are emergent, highlydispersed and decentralized.

Seen this way, ourwork gives empirical substance to Kodner andSpreeuwenberg’s (2003) complexity-aligned conception of inte-grated care as “organic” and “differentiated” care.We found that thedifferentiation of the hospital is the reference point for admis-sionedischarge decisions. The integrative function of the dischargeprocess was to combine the interests of mutual stakeholders,

through the structural location of emergency clinicians between theshifting boundaries of other departments and services.

As famously captured by Strauss et al. (1985), care does notalways follow linear, predictable rules, but enacted rules thatchange under varying circumstances (Strauss, Schatzman, Ehrlich,Bucher, & Sabshin, 1963). An ED, like a hospital, is the sum of itsmicro, meso and macro interactions. These include interpersonalrelationships, negotiations between individuals, interactivitybetween individual actions and policy, and the continual negotia-tion of practice that occurs within a shifting milieu of changingstructural influences, such as professional training and organiza-tional targets. Such targets include the 4-h rule, bywhich EDs in theUK have been expected to transfer ED patients within 4 h of beingseen by a doctor (Hughes, 1989). Relationships and endogenousfactors both reflect and create dynamic structures.

This makes for a complex system whose boundary-work isunpredictable, and changing from moment to moment. This alsomeans, from a policy perspective, that abstracted numbers toevaluate EDs (e.g., “the average waiting time is 2 h”) cannotadequately deal with the dynamic quality of care ED patients need.The external environment is intimately connected to the categori-zation and diagnosis of the conditions of ED patients; interde-partmental and interorganizational work are central features of EDwork. ED work also involves taking account the broader system ofthe personal circumstances of patients. This reflects the notion ofintegrated care which has emerged as a significant health policyimperative deserving of more sociological attention. The notion ofintegrated care captures the imperative to coordinate care, notmerely in a linear fashion, with reference to a range of specializedand professional services around the temporal and spatial needs ofpatients (Gröne & García-Barbero, 2002; Kodner & Kyriacou, 2000;Nies, 2004).

A CAS perspective advances social scientific accounts of healthcare, particularly notions of boundary-work and the patienttrajectory, by locating ED work in the constantly shifting spacesbetween departments and services, rather than referring toboundaries with a primary focus on departments and services oneither side of those boundaries. It is well suited to examining theinteractions of parts “between” systems rather than merely “on”the boundary of two services or units in an organization. A CASperspective holds that there are boundaries everywhere to distin-guish the system under observation. These boundaries are notnecessarily naturally-occurring but are foregrounded by theresearcher to understand the system and its dynamics (Heylighen,Cilliers, & Gershenson, 2007). A CAS perspective uniquely accountsfor the dynamism of patient trajectories. The process by whicha person, artefact or information follows a path is continuallyrecalculated as the circumstances change (Urry, 2003). Thus noactivity occurs in isolation. The movement of a person, artefact orinformation influences system behavior, just as system behaviorinfluences them. As such, integrated care is managing the patienttrajectory in the porous, shifting and negotiable boundaries ofhealth services.

The study elaborated the elasticized boundaries of the ED thatnecessitate a dynamic relationship between parts (Cilliers, 2001).Integrated care in the ED is deliverable through focusing on rela-tionships between constituent components of services as part of anorganic whole (Kodner & Spreeuwenberg, 2003). Therefore, ulti-mately, integrated care in the ED can be illuminated through theconcepts and language of complex systems e beyond “continuity-of-care” e to articulate the work of emergency clinicians. Thesignificance of the boundary-work (Allen, 2000; Carmel, 2006;Hewett et al., 2009a,b) of emergency clinicians was recognizablethrough a CAS perspective that focuses on interactive systemscomponents, rather than parts in isolation.

P. Nugus et al. / Social Science & Medicine 71 (2010) 1997e2004 2003

Educators, researchers and policy-makers ought to recognizeand account for the integrative care that emergency clinicianscurrently undertake, perhaps unbeknown to themselves andothers. This will help give integrated care symbolic authority andthe expectation that it will be delivered systematically, rather thanon an ad hoc basis. For example, training of emergency cliniciansneeds to focus on integrated care, including information about, andtraining in negotiating with, clinicians in other roles, and organi-zations outside the ED. These ought to be incorporated intoprofessional education and accreditation of emergency clinicians.

Both linearity and complexity are critical to researchers’understanding of health service delivery, and a CAS perspective isneeded to account for dynamical interaction and communicationbetween parts of a system. Therefore, evaluation of the perfor-mance of EDs must include the context of work between systemparts rather than be abstracted from their context. Numbers needalways to be seen in context to achieve “embedded” accountabilityrather than “abstracted” accountability (Hor et al., 2010). It behovespolicy-makers to engagewith the complexity of local practice. Theyneed to experiment with methods that engage practice complexity(Iedema & Carroll, 2010). Methods and models that take account ofcomplexity (Anderson et al., 2003) must also be applied to the EDand other parts of health systems if they are to be unshackled fromtraditional ways of categorizing and framing them.

Acknowledgement

We wish to acknowledge and thank the clinical staff who wereparticipants in this study

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