Patient safety/original research
The Safety of Emergency Care Systems: Results of a Survey of Clinicians in 65 US Emergency Departments

https://doi.org/10.1016/j.annemergmed.2008.10.007Get rights and content

Study objective

Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety.

Methods

This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination.

Results

Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour.

Conclusion

Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.

Introduction

Emergency medical clinicians care for complex, high-acuity patients with diverse, potentially life-threatening conditions, who arrive at unpredictable times and in unpredictable numbers. Recent trends have added to the inherent difficulty of providing care in emergency departments (EDs). From 1993 to 2003, the number of visits to US EDs increased by 26%, whereas the number of EDs decreased by 9%.1, 2 The Institute of Medicine (IOM) has concluded that US EDs are currently “at the breaking point.”3

To provide safe care under such challenging circumstances, it is especially important that EDs be designed, managed, and supported in ways that are conducive to patient safety. The literature on patient safety indicates that the implementation of reliable systems is the most fundamental requirement for safe care.4, 5, 6, 7, 8, 9, 10, 11, 12, 13 A firm understanding of human factors, defined by the IOM as the “interrelationships between humans, the tools they use, and the environment in which they live and work” should ground the design of ED systems.4 Among the factors contributing to safety are appropriate and properly maintained equipment, well-designed physical environments, adequate staff with appropriate skills, effective teamwork, and organizational supports for safety, including a culture of safety exemplified by leadership support for safety improvement and tolerance of human limitations.8

The purpose of this study was to assess the extent to which systems that facilitate safe care currently exist in US EDs. A basic tenet of quality and safety theory is that personnel involved in daily work are often best informed to identify problems that threaten quality and safety in the workplace.14, 15, 16, 17, 18 Therefore, we surveyed health care personnel in 69 US EDs about their perceptions of the performance of systems vital to the provision of safe care. According to previous work on the state of US EDs and the prevalence of safety problems in EDs,19, 20, 21, 22, 23, 24, 25, 26 we hypothesized that reports of ED personnel would reveal multiple opportunities to improve ED systems in ways that might contribute to safety of care.

Section snippets

Materials and Methods

According to the safety literature and input from the investigators, we developed a questionnaire to assess the status of critical systems in the ED (eg, physical environment, equipment). This questionnaire was further refined through detailed interviews with key informants and focus groups of ED personnel from 3 other EDs. Key informants consisted of ED chairpersons, medical directors, nurse managers, administrators, physicians, and nurses. Interviews explored specific clinical processes and

Results

The final analytic sample included 65 EDs and 3,562 respondents. The majority of EDs cared for both adults and children (80%), half had visit volumes of more than 60,000 patients per year (49%), 75% were classified as emergency medicine residency–affiliated EDs (Table 1), and all were urban. The majority of respondents were men (61%), younger than 40 years (57%), and white (81%) (Table 2).

ED clinicians reported that the size of the ED was often not large enough to meet the needs of patients

Limitations

Several issues merit consideration in the interpretation of our study. The results of this study may not be generalizable to all US EDs, because the facilities that participated in this study tended to be larger, were more urban, and were more likely to be affiliated with an emergency medicine training program than the typical US ED.33 It is also possible that the institutions that participated in the study were more interested in and more aware of concerns surrounding patients safety than the

Discussion

To our knowledge, this is the first study to intensively examine clinician perceptions of systemic supports for safety in a large sample of US EDs, using factors identified from the safety literature and a well-designed, validated survey instrument. Survey respondents commonly reported problems in the areas of the physical environment, staffing, inpatient coordination, and information coordination and consultation. The state of equipment, triage and monitoring, teamwork, nursing, and safety

References (45)

  • Crossing the Quality Chasm: A New Health System for the 21st Century

    (2001)
  • L.L. Leape

    Error in medicine

    JAMA

    (1994)
  • M.S. Bognor

    Human Error in Medicine

    (1994)
  • P.L. Spath

    Reducing errors through work system improvements

  • J. Reason

    Human Error

    (1990)
  • J.T. Reason

    Foreword

  • J.T. Reason

    Managing the Risks of Organizational Accidents

    (1997)
  • J. Reason

    Human error: models and management

    BMJ

    (2000)
  • C. Vincent et al.

    Errors conference: executive summary

    Acad Emerg Med.

    (2000)
  • W.E. Deming

    Out of the Crisis

    (1986)
  • D.M. Berwick et al.

    Curing Health Care: New Strategies for Quality Improvement

    (1990)
  • J.M. Juran

    Juran on Leadership for Quality: An Executive Handbook

    (1989)
  • Cited by (55)

    • Frontline barriers to effective paramedic and emergency nursing STEMI management: clinician perspectives

      2020, Australasian Emergency Care
      Citation Excerpt :

      These findings align with results from the Rajabali et al., study that concluded ‘protocol and process’ varied by professional groups [14]. The Magid et al. study had suggested the reworking of processes of care would improve flow of information [15]. Our results could also be explained by the distinctively different organisational environments these professionals operate within; paramedics function under one unified structure, Emergency nurses operate within larger heterogenic organisational structures.

    View all citing articles on Scopus

    Provide feedback on this article at the journal's Web site, www.annemergmed.com.

    Supervising editor: Robert L. Wears, MD, MS

    Author contributions: All authors take responsibility for the accuracy of the paper. DJM takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This project was supported by grant number 5 R01 HS013099 from the Agency for Healthcare Research and Quality. The Agency for Healthcare Research and Quality had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the article. All of the authors have participated sufficiently in the work to take public responsibility for the content and have no financial arrangement with a company that makes a product or makes a competing product discussed in the article.

    Reprints not available from the authors.

    Publication date: Available online December 3, 2008.

    View full text