Original research
Interviews took place in private areas of the ED, including examination rooms and assessment cubicles. These were under- taken at points of participants’ healthcare journeys that were convenient to them and staff—typically while waiting for assessments, investigations or transfers. Conversations were semi-structured using a topic guide based on recent emer- gency care experience literature, developed iteratively through discussion among the study team and informally with ED patients (online supplemental material 1). 13 15 This was loosely organised around establishing rapport and context, exploring participants’ experiences of their ED attendance and encour- aging enablement through the elicitation of potential interven- tions. ‘Crowding’ frequently appeared in media coverage at the time of recruitment and the word was therefore avoided in the topic guide and interviewer questions, to reduce influence on participants. Interviews were audio-recorded, and observer notes were made. Following each interview, the study team debriefed on reflex- ivity and elicited topics, discussing emerging themes and plan- ning future interviews. Data quality was judged by the depth of discussion and expression of negative healthcare experiences. We expected that all participants would have some negative experiences but would express these less frequently in interviews affected by power dynamics or lack of trust. Analysis Interpretative phenomenological analysis was undertaken, proceeding through data immersion and note-making, formula- tion of emergent themes and connecting the synthesis. Analysis aimed first to understand and describe the meaningful context of ED crowding through interpretation of the participants’ experi- ences, and second to formulate recommendations for mitigating interventions both from participants’ experiences and their own suggestions. Recordings were transcribed verbatim and anonymised by an approved and contracted professional service. The last author listened to each recording twice and checked transcripts for accuracy. The first and last authors then read each transcript at least twice and appended observer notes. To organise the data set and facilitate review, transcripts and observer notes were annotated in Microsoft Word with open codes for instances discussing experience and potential interventions. The codes and corresponding quotes were tabulated using a macro script. The interviewers then met together twice to discuss interviews and reflections in depth. Common themes between experiences and interpretations were then explored through a review of quoted instances for similarity and connection.
Setting and population The study was conducted at a busy UK ED with a catchment population of 1.4 million. During the study period (March to April 2023) there were approximately 900 daily attendances. The department has separate entrances and environments for adults and children. The adult area is divided into physical zones with a 12-bed resuscitation room, two bedded adult majors with 32 and 16 cubicles, an adult ambulance assessment/initial triage area (10 beds indoors plus, at the time of this study, 10 beds in a temporary tented overflow structure) and separate seated areas totalling approximately 200 chairs for adult ambulatory majors, adult injuries and adult triage. Adult patients attending the ED during periods of crowding and not requiring immediate healthcare interventions were eligible. Prisoners were excluded. We sought to understand the experience of crowding rather than waiting, and so did not select based on minimum stay times or departmental disposi- tion. Current heterogeneous measures of crowding are gener- ally based on service metrics. 2 14 We acknowledged that local physical design may allow for crowding to be perceived in one or more zones within an overall non-crowded department. Therefore, we pragmatically identified crowding by: >75% waiting room seats occupied; >75% bed spaces occupied; ambu- lance handover times exceeding 30 min; or ward transfer times exceeding 60 min. During the recruitment period, however, bed space occupancy routinely exceeded 100% and ward transfer times often exceeded 12 hours. Transfer times were used as a proxy for hospital capacity and waiting time was not considered an inclusion criterion. Potential participants were approached purposively, seeking to represent the department’s typical demography in times of sample age, ethnicity, frailty, healthcare acuity and waiting time. Participant recruitment Our recruitment included evenings and weekends. Patient participants were recruited using opportunistic sampling across most ED areas. We did not recruit in resuscitation or the 32-bed majors area. Here, care is in doored cubicles away from waiting areas to reduce noise and distraction; we therefore felt people here would have less awareness of crowding. We did include the other bedded majors area as well as ambulatory majors, triage, injuries and the temporary outdoor overflow area. In keeping with the interpretative phenomenological approach there was no predetermined recruitment target, and rather the goal was richness of data and description over sample size or saturation. Potential participants were approached following identifica- tion with the zone’s nurse co-ordinator so that care would not be disrupted. The aims were explained, and individuals were given time to reflect on their involvement and to ask questions. We only included people who had the capacity to consent, as assessed by a clinician. People who were accompanied by another person were privately offered a joint interview. Verbal consent was obtained from participants and any accompanying person. Data collection Interviews in English were each conducted by two people: the last author (male middle-grade emergency physician with PhD training in qualitative and psychometric methodologies—all interviews) and by the first authors (two female and one male senior medical students—two to three interviews each). Inter- viewers introduced themselves explaining their interest as healthcare workers in improving quality by understanding both positive and negative experiences.
RESULTS Participant characteristics
Seven participants were recruited in the department’s adult triage area (two), adult ambulatory majors (three) and adult ambulance assessment temporary overflow structure (two). Four patient participants were accompanied during their interview. This was their partner in all cases. The sample broadly represented the characteristics of people using this ED (table 1). Experience of ED crowding Accounts of negative healthcare experiences predominated. Interpretations of perspectives were summarised by themes of ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’.
Craston AIP, et al . Emerg Med J 2024; 0 :1–6. doi:10.1136/emermed-2023-213751
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