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Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.Copyright © 2021 Australasian College for Emergency Medicine

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.Copyright © 2021 Australasian College for Emergency Medicine

Background: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. Methods: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. Results: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. Conclusion: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff's experiences.

Objective: To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. Methods: A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and ‘left at own risk’ (including ‘did not wait for assessment’). Results: Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED reattendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). Conclusion: ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine Objective: Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four-Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. Methods: A longitudinal cohort study of a population-wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2–4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. Results: There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age-standardised mortality was decreasing before the intervention. Post-intervention, WA had a significant reduction in mortality rate of −0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta-regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. Conclusions: The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long-term effects of the policy.

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine. Objective: To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. Methods: A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and ‘left at own risk’ (including ‘did not wait for assessment’). Results: Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED reattendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). Conclusion: ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

Background: In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. Methods: A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. Findings: There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. Conclusions: The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing re

Background: The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments. Methods: We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015-2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study, Results: We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement. Conclusion: Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance

BACKGROUND: To investigate the impact of presenting to an Emergency Department (ED) during pregnancy on postnatal depression (PND) in women in New South Wales (NSW), Australia.

BACKGROUND: To investigate the impact of presenting to an Emergency Department (ED) during pregnancy on postnatal depression (PND) in women in New South Wales (NSW), Australia. METHOD: An epidemiological population-based study using linked data from the NSW Emergency Department Data Collection (EDDC), the NSW Perinatal Data Collection (PDC) and the NSW Admitted Patients Data Collection (APDC) was conducted. Women who gave birth to their first child in NSW between 1 January 2006 and 31 December 2010 were followed up from pregnancy to the end of the first year after birth. RESULTS: The study population includes 154,328 women who gave birth to their first child in NSW between 2006 and 2010. Of these, 31,764 women (20.58%) presented to ED during pregnancy (95%CI = 20.38-20.78). Women who presented to ED during pregnancy were more likely to be admitted to hospital for the diagnosis of unipolar depression (the adjusted relative risk (RR) =1.86, 95%CI = 1.49-2.31) and the diagnosis of mild mental and behavioural disorders associated with the puerperium (the adjusted RR = 1.55, 95%CI = 1.29-1.87) than those without ED presentation. CONCLUSION: Women's hospital admissions for postnatal depression were associated with frequent ED presentations during pregnancy.

BACKGROUND: To investigate the impact of presenting to an Emergency Department (ED) during pregnancy on postnatal depression (PND) in women in New South Wales (NSW), Australia.METHOD: An epidemiological population-based study using linked data from the NSW Emergency Department Data Collection (EDDC), the NSW Perinatal Data Collection (PDC) and the NSW Admitted Patients Data Collection (APDC) was conducted. Women who gave birth to their first child in NSW between 1 January 2006 and 31 December 2010 were followed up from pregnancy to the end of the first year after birth.RESULTS: The study population includes 154,328 women who gave birth to their first child in NSW between 2006 and 2010. Of these, 31,764 women (20.58%) presented to ED during pregnancy (95%CI = 20.38-20.78). Women who presented to ED during pregnancy were more likely to be admitted to hospital for the diagnosis of unipolar depression (the adjusted relative risk (RR) =1.86, 95%CI = 1.49-2.31) and the diagnosis of mild mental and behavioural disorders associated with the puerperium (the adjusted RR = 1.55, 95%CI = 1.29-1.87) than those without ED presentation.CONCLUSION: Women's hospital admissions for postnatal depression were associated with frequent ED presentations during pregnancy.

BACKGROUND: To investigate the impact of presenting to an Emergency Department (ED) during pregnancy on postnatal depression (PND) in women in New South Wales (NSW), Australia.METHOD: An epidemiological population-based study using linked data from the NSW Emergency Department Data Collection (EDDC), the NSW Perinatal Data Collection (PDC) and the NSW Admitted Patients Data Collection (APDC) was conducted. Women who gave birth to their first child in NSW between 1 January 2006 and 31 December 2010 were followed up from pregnancy to the end of the first year after birth.RESULTS: The study population includes 154,328 women who gave birth to their first child in NSW between 2006 and 2010. Of these, 31,764 women (20.58%) presented to ED during pregnancy (95%CI = 20.38-20.78). Women who presented to ED during pregnancy were more likely to be admitted to hospital for the diagnosis of unipolar depression (the adjusted relative risk (RR) =1.86, 95%CI = 1.49-2.31) and the diagnosis of mild mental and behavioural disorders associated with the puerperium (the adjusted RR = 1.55, 95%CI = 1.29-1.87) than those without ED presentation.CONCLUSION: Women's hospital admissions for postnatal depression were associated with frequent ED presentations during pregnancy.

Con el propósito de evaluar el efecto del encalado en la esporulación de los hongos formadores de simbiosis micorrízica, se estableció esta investigación en condiciones de vivero, con suelo ácido y esterilizado en autoclave. Se utilizaron dosis de 0, 1, 2, 3, 4 y 5 t.ha-1 de cal agrícola. Como planta hospedera se utilizó el pasto Brachiara decumbens sembrado 30 días después del encalado y micorrizado con 5 g de micorriza comercial por matera. El grado de colonización se hizo en raicillas 60 días después de la emergencia del pasto, mediante técnica de tinción de raíces (Phillips y Hauman, 1970), y la evaluación de cantidad de esporas, por metodología propuesta por Sieverding (1991). Se utilizó un diseño completamente al azar con seis (6) tratamiento y tres (3) repeticiones. Se encontró que el pH del suelo inicial fue de 4.5 y con el encalado se incrementa a 6.1 cuando se aplicaron 5 t.ha-1 de cal, con una correlación del 92.22%. Con el encalado se pudo notar una ligera tendencia a decrecer el grado de colonización, sin diferencias estadísticas significativas, oscilando entre 65.7% que se logró con 5 t.ha-1 de cal agrícola y 83.0% con la dosis de 3 t/ha de cal. El incremento del pH del suelo trajo consigo una disminución en la producción de esporas totales, de 202 esporas.g-1 se redujo a 96, con diferente tendencia en cada especies. Se concluye que el encalado disminuye la producción de esporas y el grado de colonización cuando se utiliza como planta hospedera a Brachiara decumbens.

Con el propósito de evaluar el efecto del encalado en la esporulación de los hongos formadores de simbiosis micorrízica, se estableció esta investigación en condiciones de vivero, con suelo ácido y esterilizado en autoclave. Se utilizaron dosis de 0, 1, 2, 3, 4 y 5 t.ha-1 de cal agrícola. Como planta hospedera se utilizó el pasto Brachiara decumbens sembrado 30 días después del encalado y micorrizado con 5 g de micorriza comercial por matera. El grado de colonización se hizo en raicillas 60 días después de la emergencia del pasto, mediante técnica de tinción de raíces (Phillips y Hauman, 1970), y la evaluación de cantidad de esporas, por metodología propuesta por Sieverding (1991). Se utilizó un diseño completamente al azar con seis (6) tratamiento y tres (3) repeticiones. Se encontró que el pH del suelo inicial fue de 4.5 y con el encalado se incrementa a 6.1 cuando se aplicaron 5 t.ha-1 de cal, con una correlación del 92.22%. Con el encalado se pudo notar una ligera tendencia a decrecer el grado de colonización, sin diferencias estadísticas significativas, oscilando entre 65.7% que se logró con 5 t.ha-1 de cal agrícola y 83.0% con la dosis de 3 t/ha de cal. El incremento del pH del suelo trajo consigo una disminución en la producción de esporas totales, de 202 esporas.g-1 se redujo a 96, con diferente tendencia en cada especies. Se concluye que el encalado disminuye la producción de esporas y el grado de colonización cuando se utiliza como planta hospedera a Brachiara decumbens.

Con el propósito de evaluar el efecto del encalado en la esporulación de los hongos formadores de simbiosis micorrízica, se estableció esta investigación en condiciones de vivero, con suelo ácido y esterilizado en autoclave. Se utilizaron dosis de 0, 1, 2, 3, 4 y 5 t.ha-1 de cal agrícola. Como planta hospedera se utilizó el pasto Brachiara decumbens sembrado 30 días después del encalado y micorrizado con 5 g de micorriza comercial por matera. El grado de colonización se hizo en raicillas 60 días después de la emergencia del pasto, mediante técnica de tinción de raíces (Phillips y Hauman, 1970), y la evaluación de cantidad de esporas, por metodología propuesta por Sieverding (1991). Se utilizó un diseño completamente al azar con seis (6) tratamiento y tres (3) repeticiones. Se encontró que el pH del suelo inicial fue de 4.5 y con el encalado se incrementa a 6.1 cuando se aplicaron 5 t.ha-1 de cal, con una correlación del 92.22%. Con el encalado se pudo notar una ligera tendencia a decrecer el grado de colonización, sin diferencias estadísticas significativas, oscilando entre 65.7% que se logró con 5 t.ha-1 de cal agrícola y 83.0% con la dosis de 3 t/ha de cal. El incremento del pH del suelo trajo consigo una disminución en la producción de esporas totales, de 202 esporas.g-1 se redujo a 96, con diferente tendencia en cada especies. Se concluye que el encalado disminuye la producción de esporas y el grado de colonización cuando se utiliza como planta hospedera a Brachiara decumbens.

Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding. © 2013 Elsevier Ltd.

Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding. © 2013 Elsevier Ltd.

The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.

Objectives: In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding. Methods: An ethnographic approach was used, which involved direct observation of on-the-ground behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses, emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and thematically analyzed more than 800 pages of field notes to identify indicators of and responses to pressure in the day-to-day ED work environment. Results: In response to the inability to control inflow, and the reactions of inpatient departments to whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions; negotiated and determined patients' admission-discharge status early in their trajectories; pursued predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised flexibility to reduce work pressure by managing scarce time and space in the ED. Conclusions: To redress the linearity of most literature on patient flow, this study adopts a systems perspective and ethnographic methods to bring to light the dynamic role that individuals play, interacting with their work contexts, to maintain patient flow. The study provides an empirical foundation, uniquely discernible through qualitative research, about aspects of ED work that previously have been the subject only of discussion or commentary articles. This study provides empirical documentation of the moment-to-moment responses of emergency clinicians to work pressure brought about by factors outside much of their control, establishing the relationship between patient flow and

Objectives: In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding. Methods: An ethnographic approach was used, which involved direct observation of on-the-ground behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses, emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and thematically analyzed more than 800 pages of field notes to identify indicators of and responses to pressure in the day-to-day ED work environment. Results: In response to the inability to control inflow, and the reactions of inpatient departments to whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions; negotiated and determined patients' admission-discharge status early in their trajectories; pursued predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised flexibility to reduce work pressure by managing scarce time and space in the ED. Conclusions: To redress the linearity of most literature on patient flow, this study adopts a systems perspective and ethnographic methods to bring to light the dynamic role that individuals play, interacting with their work contexts, to maintain patient flow. The study provides an empirical foundation, uniquely discernible through qualitative research, about aspects of ED work that previously have been the subject only of discussion or commentary articles. This study provides empirical documentation of the moment-to-moment responses of emergency clinicians to work pressure brought about by factors outside much of their control, establishing the relationship between patient flow and

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a " continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach 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 and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries.

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a "continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach 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 and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries.

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a "continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach 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 and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries.

We conducted a pilot study to develop and assess the effectivness of three interventions to promote consumption of fruits and vegetables, promote physical activity, and negotiate smoke-free homes among home caregivers in Bogota, Colombia. Colombian home caregivers were defined as women who take care of minors in their local communities regardless of kinship or family ties.

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1557281%5DMICH-V-1557281, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1557281/MICH-V-1557281/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1557281%5DMICH-V-1557281, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1557281/MICH-V-1557281/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1546377%5DMICH-V-1546377, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1546377/MICH-V-1546377/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1550855%5DMICH-V-1550855, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1550855/MICH-V-1550855/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1550034%5DMICH-V-1550034, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1550034/MICH-V-1550034/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1527279%5DMICH-V-1527279, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1527279/MICH-V-1527279/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy

Angiosperms, http://name.umdl.umich.edu/IC-HERB00IC-X-1546377%5DMICH-V-1546377, https://quod.lib.umich.edu/cgi/i/image/api/thumb/herb00ic/1546377/MICH-V-1546377/!250,250, The University of Michigan Library provides access to these materials for educational and research purposes. Some materials may be protected by copyright. If you decide to use any of these materials, you are responsible for making your own legal assessment and securing any necessary permission. If you have questions about the collection, please contact the Herbarium professional staff: herb-dlps-help@umich.edu. If you have concerns about the inclusion of an item in this collection, please contact Library Information Technology: libraryit-info@umich.edu., https://www.lib.umich.edu/about-us/policies/copyright-policy