The complex causes of delays in A&E

An extremely busy 48-h period in our Accident and Emergency (A&E) department prompted a close examination of clinical decision making. Decisions that were made both at the time of attendance at A&E and during the patients' subsequent hospital stay were gathered from patient records and the patient information system. A number of vignettes are presented to illustrate our findings. The brief case reviews provide a range of alternative explanations for the delays and prolongation of patient stays, aside from the often-cited `shortage of capacity'. Amongst the key difficulties that were identified were poor communication between clinicians and hospital teams, a lack of co-ordination in respect to assessment and care of patients and admissions to hospital for patients who could quite safely be treated in primary care settings. Data are also presented on the high number of different locations that patients were moved to within the hospital along with contextual information. All findings are discussed in the context of clinical decision making and the allocation of a fixed `hospital resource'. A number of specific suggestions are made for the improvement of both the local A&E system and more broad suggestions are made for clinicians in other A&E departments to consider.