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The purpose of this study is to understand how, when, and why emergency medicine residents learn while working in the chaotic environment of a hospital emergency room.

This research used a qualitative interview methodology with thematic data analysis that was verified with the entire population of learners.

Analysis of the data revealed four different types of learning episodes, each with facilitating factors. The episodes varied in intensity, duration, and the degree of motivation and self‐direction required of the learner. One episode could prompt another. Learning occurred both individually and in social interaction in the workplace during the episode, as well as outside of the workplace environment after the experience had occurred.

Recommendations for individuals to maximize their learning related to this chaotic work environment are identified, along with associated implications for their trainers. These suggestions advocate for current apprenticeship approaches to training to include a developmental perspective, providing effective feedback and supporting learner self‐assessment and reflection.

This paper makes an original contribution to the literature by describing the process of learning by emergency medicine residents in the chaotic work setting of an emergency department. The paper also expands understanding of the types of learning episodes and the factors that contribute to their occurrence. Finally, the research illustrates how the voice of the learners can be used to inform their training.

Emergency medicine is a new specialty in the Caribbean. With the development of specialist training over the past 20 years, the issues of quality assurance and governance have become more prominent. The purpose of this paper is to explore the successes and challenges of implementing systems of quality assurance in this unique environment, highlighting issues peculiar to the Caribbean setting.

This paper is a review of current practice in the emergency departments (ED) of the four major teaching hospitals of the University of the West Indies. Information was gathered through interviews with key stakeholders (including the respective ED residency directors, senior residents and senior nursing and administrative staff), review of departmental protocols and guidelines and reviews of current published and unpublished literature.

Examples of good practice were identified in all six components of the clinical governance framework (clinical audit, clinical effectiveness, research and development, openness, risk management and education and training). Challenges to implementation of quality management included an underdeveloped quality culture, inadequate data collection, poor incentives for improvement and high external pressures, including staff shortages, departmental crowding and lack of public empowerment.

This is the first published work on clinical governance and quality assurance in emergency medicine in the Caribbean. This paper gives an insight into the unique opportunities and challenges in the area of quality management and clinical governance in the developing world, and suggests ways forward with regard to more effective implementation of quality initiatives in under-resourced jurisdictions.

Facilitated by a decision support system tool, the purpose of this paper is to find the “best” allocated number of surgeons and medicine doctors that reduce patients' non‐value‐added time (NVAT) and total time in the system (TTS).

Interview and observation are first conducted in order to get general insights about (and to understand) the emergency ward of Sahlgrenska Hospital in Gothenburg (Sweden) and its value stream (flow). Then, time‐related data are collected by conducting time measurements empirically and through the triage database. The statistics of the collected empirical data represent the initial state of the system and are utilised as the input of ARENA^® simulation. A simulation scenario is designed by constructing a 3×3 table (= nine combinations) that contains a varying number of surgeons and medicine doctors allocated in the emergency ward. For each combination, 1,000 replications apply (=10 runs @ 100 replications). “Runs” are the cycles or how many times the simulation is executed, while “replications” refer to how many times a computer (automatically) repeats the simulation in a single execution. The simulation length of a single replication was set at 24 hours due to the fact that an emergency ward was always open. The selected feasible solution is the “best” combination of surgeons and medicine doctors that reduces the existing NVAT and TTS while ensuring that the resource utilisation is at a “reasonable” level (and did not exceed 100 per cent).

The simulation output indicates that the emergency ward may achieve considerable reduction in a patients' NVAT and total patients' time in the system by assigning three medicine doctors and three surgeons. This combination leads to (in average) 13 per cent reduction of NVAT while maintaining the TTS at approximately the same level.

An expanded simulation model with a higher level of complexity and ability to accommodate, e.g. cost of care, flow/layout reconfiguration would be greatly needed and is of interest. It would also be relevant to add greater flexibility by assigning more parameters in the simulation model (other than medicine doctor and surgeon).

Simulation can be considered as a valuable decision‐support tool in the adoption of lean in healthcare due to its flexibility in the sense that it is able to show the output (outcome) of various scenarios before any actual change is made. The results of our study present another side of the adoption of lean thinking besides layoff.

The purpose of this paper is to report on gender differences in emergency physicians with respect to their attitudes, knowledge, and practices concerning health promotion and disease prevention.

A mail survey of 325 male and 97 female Canadian emergency physicians.

Results suggest female emergency physicians report having greater knowledge of health promotion topics, spend more time with each of their patients in the emergency setting, and engage in more health promotion counseling in the emergency setting than do their male counterparts.

The paper argues that in the future, educating and socializing emergency physicians, both male and female, in the practice of health promotion will enhance the potential of the emergency department to be a more effective resource for their community.

The purpose of this paper is to report on the implementation of the World Health Organization (WHO) trauma care checklist (TCC) (WHO, 2016) in an emergency department in a tertiary hospital in Nepal. This research was undertaken as part of a Hybrid International Emergency Medicine Fellowship programme (Subedi et al., 2020) across UK and Nepal, incorporating a two-year rotation through the UK National Health Service, via the Medical Training Initiative (MTI) (AoMRC, 2017). The WHO TCC can improve outcomes for trauma patients (Lashoher et al., 2016); however, significant barriers affect its implementation worldwide (Nolan et al., 2014; Wild et al., 2020). This article reports on the implementation, barriers and recommendations of WHO TCC implementation in the context of Nepal and argues for Transformational Leadership (TL) to support its implementation.

Explanatory mixed methods research (Creswell, 2014), comprising quasi-experimental research and a qualitative online survey, were selected methods for this research. A training module was designed and implemented for 10 doctors and 15 nurses from a total of 76 (33%) of clinicians to aid in the introduction of the WHO TCC in an emergency department in a hospital in Nepal. The quasi-experimental research involved a pre- and post-training survey aimed to assess participant’s knowledge of the WHO TCC before and after training and before the implementation of the WHO TCC in the emergency department. Post-training, 219 patients were reviewed after four weeks to identify if process measures had improved the quality of care to trauma patients. Subsequently six months later, a qualitative online survey was sent to all clinical staff in the department to identify barriers to implementation, with a response rate of 26 (n = 26) (34%) (20 doctors and 6 nurses). Descriptive statistics were used to evaluate quantitative data and the qualitative data were analysed using the five stepped approach of thematic analysis (Braun and Clarke, 2006).

The evaluation of the implementation of the WHO TCC showed an improvement in care for trauma patients in an emergency setting in a tertiary hospital in Nepal. There were improvements in the documentation in trauma management, showing the training had a direct impact on the quality of care of trauma patients. Notably, there was an improvement in cervical spine examination from 56.1% before training to 78.1%; chest examination 125 (57.07%) before training and 170 (77.62%) post-training; abdominal examination 121 (55.25%) before training and 169 (77.16%) post-training; gross motor examination 13 (5.93%) before training and 131 (59.82%) post-training; sensory examination 4 (1.82%) before training and 115 (52.51%) post-training; distal pulse examination 6 (2.73%) before training and 122 (55.7%) post-training. However, while the quality of documentation for trauma patients improved from the baseline of 56%, it only reached 78% when the percentage improvement target agreed for this research project was 90%. The 10 (n = 10) doctors and 15 (n = 15) nurses in the Emergency Department (ED) all improved their baseline knowledge from 72.2% to 87% (p = 0.00006), by 14.8% and 67% to 85%) (p = 0.006), respectively. Nurses started with lower scores (mean 67) in the baseline when compared to doctors, but they made significant gains in their learning post-training. The qualitative data reported barriers, such as the busyness of the department, with residents and medical officers, suggesting a shortened version of the checklist to support greater protocol compliance. Embedding this research within TL provided a steer for successful innovation and change, identifying action for sustaining change over time.

The study is a single-centre study that involved trauma patients in an emergency department in one hospital in Nepal. There is a lack of internationally recognised trauma training in Nepal and very few specialist trauma centres; hence, it was challenging to teach trauma to clinicians in a single 1-h session. High levels of transformation of health services are required in Nepal, but the sample for this research was small to test out and pilot the protocol to gain wider stakeholder buy in. The rapid turnover of doctors and nurses in the emergency department, creates an additional challenge but encouraging a multi-disciplinary approach through TL creates a greater chance of sustainability of the WHO TCC.

International protocols are required in Nepal to support the transformation of health care. This explanatory mixed methods research, which is part of an International Fellowship programme, provides evidence of direct improvements in the quality of patient care and demonstrates how TL can drive improvement in a low- to medium-income country.

The Nepal/UK Hybrid International Emergency Medicine Fellowships have an opportunity to implement changes to the health system in Nepal through research, by bringing international level standards and protocols to the hospital to improve the quality of care provided to patients.

To the best of the authors’ knowledge, this research paper is one of the first studies of its kind to demonstrate direct patient level improvements as an outcome of the two-year MTI scheme.

Although adverse events are less studied in the prehospital setting, the evidence is beginning to paint an alarming picture. Consequently, improvements in Emergency Medical Services (EMS) demand a paradigm shift regarding the way care is conceptualized. The chapter aims to (1) support the dialogue on near-misses and adverse events as a learning opportunity and (2) to provide insights on applications of multiteam systems (MTSs).

To offer discussion on near-misses and adverse events and knowledge on how MTSs are applicable to emergency medical care, we review and dissect a complex patient case.

Throughout this case discussion, we uncover seven pertinent issues specific to this particular MTS: (1) misunderstanding with number of patients and their locations, (2a) lack of context to build a mental model, (2b) no time or resources to think, (3) expertise-facilitated diagnosis, (4) lack of communication contributing to a medication error, (5) treatment plan selection, (6) extended time on scene, and (7) organizational culture impacting treatment plan decisions.

By dissecting a patient case within the prehospital setting, we can highlight the value in engaging in dialogue regarding near-misses and adverse events. Further, we can demonstrate the need to expand the focus from simply teams to MTSs.

This paper aims to investigate the forces that influence the shifting of professional boundaries on the entry of a new medical occupation in Dutch hospitals – non‐specialist emergency physicians.

Five case studies of Dutch hospitals were conducted and the emergency physicians' implementation process was analyzed by means of force field analysis.

Emergency physicians were conceptualized as being the answer to unequivocal contextual changes. However, their contribution to better performance varies due to problems in the implementation process. Strong socio‐political forces between traditional specialties and these new doctors mediate the intended improvement. The emergency physicians aim to establish their own organizational‐, patient‐ and knowledge‐domain by redrawing professional boundaries but they are not on a par with the specialists who set these boundaries. Consequently, emergency physicians only gradually redraw the existing boundaries, resulting in limited added value. Their reaction is to obtain power by striving to develop into a recognized specialty; ironically, by becoming an additional layer in the traditional medical hierarchy they might lose their envisaged added value.

This paper is based on the first Dutch hospitals that implemented emergency physicians. The number of cases is therefore limited. Moreover, the study took place at an early stage of emergency physician implementation.

The extent of successful redrawing depends on the implementation's transition logic, the existing degree of differentiation and boundary permeability and on the ideological power developed by the leaders.

The introduction of emergency physicians is currently being discussed in many countries worldwide, and some countries consider following the Dutch example of non‐specialist doctors. This paper supports health professionals and hospital managers in not falling prey to the same pitfalls as some Dutch hospitals.

The purpose of this paper is to examine the implementation of lean methods in an Emergency Department (ED) and the role of the professions in this process.

Qualitative, semi-structured interviews with ED staff in a UK NHS hospital.

Lean was met with more engagement and enthusiasm by the professionals than is usually reported in the literature. The main reasons for this were a combination of a national policy, the unique clinical environment and the status of the professional project for doctors in emergency medicine.

Single site, one-off study.

The status and development of professionals involved may play a big part in the acceptability of initiatives like lean methods in health care. The longer term sustainability of the organisational changes introduced remains open to question.

This paper analyses the success of lean methods in health care with reference to the professional status and stage of development of the professions involved, using the sociology of professions. This approach has not been used elsewhere.

The purpose of this paper is to report on the dynamics of “identity leadership” with a quality improvement project undertaken by an International Medical Graduate (IMG) from Sri Lanka, on a two year Medical Training Initiative (MTI) placement in the National Health Service (NHS) [Academy of Medical Royal Colleges (AoMRC), 2017]. A combined MTI rotation with an integrated Fellowship in Quality Improvement (Subedi et al., 2019) provided the driver to implement the HEART score (HS) in an NHS Emergency Department (ED) in the UK. The project was undertaken across ED, Acute Medicine and Cardiology at the hospital, with stakeholders emphasizing different and conflicting priorities to improve the pathway for chest pain patients.

A social identity approach to leadership provided a framework to understand the insider/outsider approach to leadership which helped RH to negotiate and navigate the conflicting priorities from each departments’ perspective. A staff survey tool was undertaken to identify reasons for the lack of implementation of a clinical protocol for chest pain patients, specifically with reference to the use of the HS. A consensus was reached to develop and implement the pathway for multi-disciplinary use of the HS and a quality improvement methodology (with the use of plan do study act (PDSA) cycles) was used over a period of nine months.

The results demonstrated significant improvements in the reduction (60%) of waiting time by chronic chest pain patients in the ED. The use of the HS as a stratified risk assessment tool resulted in a more efficient and safe way to manage patients. There are specific leadership challenges faced by an MTI doctor when they arrive in the NHS, as the MTI doctor is considered an outsider to the NHS, with reduced influence. Drawing upon the Social Identity Theory of Leadership, NHS Trusts can introduce inclusion strategies to enable greater alignment in social identity with doctors from overseas.

More than one third of doctors (40%) in the English NHS are IMGs and identify as black and minority ethnic (GMC, 2019a) a trend that sees no sign of abating as the NHS continues its international medical workforce recruitment strategy for its survival (NHS England, 2019; Beech et al., 2019). IMGs can provide significant value to improving the NHS using skills developed from their own health-care system. This paper recommends a need for reciprocal learning from low to medium income countries by UK doctors to encourage the development of an inclusive global medical social identity.

This quality improvement research combined with identity leadership provides new insights into how overseas doctors can successfully lead sustainable improvement across different departments within one hospital in the NHS.

The purpose of this paper is to describe the structure and impact of a Queensland Research Support Network (RSN) in emergency medicine (EM).

This paper presents a descriptive summary of EM networks, network evaluations and the structure and development of the Emergency Medicine Foundation’s (EMF) RSN in Queensland, including an observational pre- and post-study of research metrics.

In two years, the RSN supported 33 Queensland emergency departments (EDs), of which 14 developed research strategies. There was an increase in research active clinicians, from 23 in 2015 to 181 in 2017. Collaborator engagement increased from 9 in 2015 to 276 in 2017 as did the number of research presentations, from 6 in 2015 to 61 in 2017. EMF experienced a growth in new researchers, with new investigators submitting approximately 60 per cent of grant applications in 2016 and 2017. EMF also received new applications from a further three HHS (taking EMF-funded research activity from 8 to 11 HHS).

This paper describes changes in KPIs and research metrics, which the authors attribute to the establishment of the RSN. However, it is possible that attribution bias plays a role in the KPI improvements.

This network has actively boosted and expanded EM research capacity and capability in Queensland. It provides services, in the form of on-the-ground managers, to develop novice clinician-researchers, new projects and engage entire EDs. This model may be replicated nationwide but requires funding commitment.

The RSN improves front-line clinician research capacity and capability and increases research activity and collaborations with clear community outcomes. Collaborations were extended to community, primary health networks, non-government organisations, national and international researchers and academic institutions. Evaluating and measuring a network’s benefits are difficult, but it is likely that evaluations will help networks obtain funding.