Original research
Relationships with existing literature Our patient-level enquiry echoed literature reporting deleterious consequences of crowding on patient satisfaction, where boarding was associated with poorer survey responses. 16 These considered professional communication and responsiveness, and responses may have reflected the uncertainty over processes and reluctance to interrupt professionals which we observed. Crowding has been associated with missed or delayed treatments. 17 18 Similarly, participants in this current work were aware of such risks, even if they were unharmed. Such delays perhaps occurred due to the effects of crowding on efficiency; while this has been studied at the service level, here we identified the frustration and deperson- alisation experienced by individuals. 19 Identifying mitigating interventions is a research priority. 20 The imminent impact of crowding on patient care is widely acknowledged and represented in National Health Service-wide strategy. 21 Those system-level interventions aim to reduce occu- pancy to avoid crowding-related harms. Here, we identified interventions that may help to alleviate poor experiences once crowding has occurred, with particular focus on information. Information improves patient satisfaction. 22 While these focused on summary information at discharge, our findings highlight a need for updates and direction throughout attendances during times of crowding. This need not create an additional profes- sional workload as participants suggested maximising existing departmental signage space and passing updates within existing care interactions. While these recommendations appear simple, further evalu- ation of effects will be required. Simple, generic interventions may present new issues with understanding: as examples, people with atypical presentations requiring complex care flows (as is often the case for those living with frailty) may be even more confused by signage designed for a standardised pathway, and diagrams detailing professionals’ uniforms cannot account for agency workers. It is notable that information screens were already installed but had been switched off due to issues about the accuracy of previous information regarding waiting times. Issues and compliments capture only the extremes of health- care experiences, and so implementation of quality improve- ment interventions might better be appraised using validated measures on a routine or targeted basis. The identified themes are represented in existing emergency care patient-reported measures. 15 23 24 Limitations These findings may be relevant to other settings; however, the methodology sought internal validity for local interventions rather than necessarily transferability. 25 We aimed to describe and interpret experiences, and a richer understanding of under- lying social constructs and theories was beyond the scope. The setting had certain qualities that may limit external validity: the floorplan prevented the use of corridors for boarding and cubicles had soundproofing. Here, crowding disproportionately affected people early in attendances or with lower acuity presen- tations, as they queued in waiting rooms or overflow areas. In alternative operating models, people move rapidly into assess- ment areas but subsequently experience crowding in corridors. The proposed mitigating interventions require evaluation for feasibility and efficacy. Opportunistic sampling recruited participants around researchers’ availability and crowded periods. This risked intro- ducing selection bias. People who were more comfortable sharing opinions or less unwell may have been more likely to participate.
It was confusing where to sit. Some chairs had stickers on saying different things but it wasn’t obvious where you should sit. I think some better instructions so you know you’re in the right place to hear your name. Person B There is always going to be a change, but it would be nice to know there’s seven people ahead of you. Person E These could be enacted using a rolling presentation. This would display realistic waiting times, a medical priority system overview and aid for recognising professional roles from their uniforms. The department was already fitted with suitable screens. However, these had been switched off following issues that information was imprecise. Unmet expectations Participants felt that access to food and drink would improve comfort, and that distractions such as television made the setting more tolerable: A nice old cup of tea would help. Person F I don’t know if you’re able to get a sandwich if you’re really hungry. Person D Last time I came there wasn’t a TV on so that’s a bit of distraction. I’d say that’s an improvement. Person D Signage could aid in accessing the existing toilets and water station. The procedure to access refreshments should also be displayed. All current signage was in English, often with small text and required improvement for maximal accessibility. Vulnerability Suggestions to improve efficiency and clarity were often borne of concerns for other patients: People with broken legs, they’re struggling to get up there. It should all be done in one go. Person A If I couldn’t see the sign, I’m sure it will be confusing for older people. Person C Feelings of frustration and abandonment might be overcome with information overviewing processes, including interventions such as triage which might already have taken place. The pres- ence of security staff should be displayed. Crowding negatively impacted on patient’s emergency care experiences, encapsulated in three overarching themes of ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’. Partic- ipants described their uncertainty and discomfort. Negative events were often compounded by both the lonely invisibility and the constant disturbance of being in a crowd. We identified local recommendations from participants’ suggestions. These centred around information provision and clear signage for care and waiting areas within the department. DISCUSSION Summary of findings
Craston AIP, et al . Emerg Med J 2024; 0 :1–6. doi:10.1136/emermed-2023-213751
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