Integrated care in the emergency department: a complex adaptive systems perspective

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.