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Exploring and Explaining the Weekend Effect in a Danish Emergency Department

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Exploring and Explaining the Weekend Effect in a Danish Emergency Department Exploring and explaining the weekend effect in a Danish emergency department PhD dissertation Iben Duvald Pedersen Aarhus BSS Aarhus University Department of Business Development and Technology 2018 PhD student: Iben Duvald Pedersen, cand.scient.anth. Interdisciplinary Centre for Organizational Architecture, Department of Management, School of Business and Social Sciences, Aarhus University DESIGN-EM – Research Network for Organization Design and Emergency Medicine, Denmark Department of Business Development and Technology, School of Business and Social Sciences, Aarhus University Supervisors: Professor Børge Obel (main supervisor) Interdisciplinary Centre for Organizational Architecture, Department of Management, School of Business and Social Sciences, Aarhus University Associate Professor Rikke Sand Andersen Research Unit for General Practice, Institute of Public Health and Department of Anthropology, School of Culture and Society, Aarhus University Acknowledgements Being a PhD student for the last three years has been an individual journey in many ways. However, many people have contributed to make the entire process a great experience. Firstly, I would like to express my sincere gratitude to my supervisors Børge Obel and Rikke Sand Andersen for their continuous support of my PhD study. To my main supervisor, Børge, thank you for believing in me and opening the potential for a PhD study, introducing me to the field of organizational design with great enthusiasm, and inspiring and guiding me with your immense knowledge. To my co-supervisor Rikke, thanks for continuing to ask questions about my choices, providing detailed comments on my work, and reminding me of my anthropological point of view. My supervision has been characterized by enormous patience, encouragement, inspiration, and optimism throughout the whole project, and I am grateful for that. Thanks – I have learn a lot. To all my lovely colleagues at ICOA, thanks for an inspiring, interdisciplinary, ambitious and informal work environment. Thank you to Marianne, Karin, and Inger for secretarial assistance and cozy small talk. Thanks to the senior professors for your advice and good discussions along the way. To Erik, thanks for making it more fun working in weekends. Thanks to the PhD students: Thomas, Ioana (Jo), Maja, Henrike, Line, and Marianne for talking about everything from how to do a PhD to methodological issues to kids. In particular, I am grateful to you, Anders, for introducing me to the field and for our close collaboration during the last years. We have had endless discussions about the organization of the emergency departments, while you were eating my candy. As a part of the research network DESIGN-EM, I would also like to thank Professor Hans Kirkegaard from the Research Center of Emergency Medicine for your support and advice during these years. Without data, this project could not have been. A big thank-you to everyone at the emergency department at Viborg Regional Hospital, Regional Hospital Central Jutland. To the former management of the department, Larry Kristiansen and Bente Dam, and the head nurses, Helle Kornbek and Mette Haahr, thanks for believing in me and my project, and for giving me the opportunity to do fantastic fieldwork. Thanks to all the employees for letting me participate in your working day and for patiently answering my more and less meaningful questions – you all contributed with your valuable perspectives and helped to make my fieldwork a great experience. Jette Bjærge, thanks for nice accommodation when staying in Viborg. Christian Skjærbæk, thanks for your support along the way. Thanks to the new management of the department, Jacob Stouby Mortensen and Trine Agerskov, for giving me the opportunity to continue with my research based on the organization of the emergency department and improvement of patient care. Thanks to Betina Vest-Hansen for guiding me through my epidemiological study and our interesting talks about the weekend effect and possible explanations to why it exists. Thanks to Sarah Krøtel for helping me with my statistical analysis of the adverse events, and thanks to Nikolaj Raaber for inspiring talks, support and your company on the international emergency medicine conferences. I would also like to thank the Department of Business Development and Technology (BTECH) at Aarhus University, which hosted my enrollment into the PhD program. I am grateful for the opportunity to teach in qualitative methods and the financial support for my participation in various PhD courses, national and international conferences, and my research stay in Great Britain. Thanks to Professor Sue Ziebland and the Health Experiences Research Group, Oxford University, for hosting me during my research stay. Your qualitative research within the field of primary care is inspiring. I enjoyed both our formal meetings and informal lunches. My research stay was made possible by financial support from several foundations: Torben & Alice Frimodts Foundation, Christian og Ottilia Brorsons Travel Grant, Oticon Foundation, and Knud Højgaards Foundation. My greatest gratitude goes to my friends, and particularly my family and my son Laurits, for reminding me about all the other important things in life. A huge thank-you to my parents, Jette and Keld; without your help and endless support, this journey would not have been possible. Iben Duvald Aarhus, Marts 2018 Contents English summary i Dansk resume (Danish summary) v List of figures and tables ix List of figures…………………………………………………………………………....... ix List of tables……………………………………………………………………………… ix Preface xi Overview of the dissertation…………………………………………………………........ xiii Chapter 1: Introduction 1 1.1 The weekend effect…………………………………………………………………….….1 1.2 Looking at the system: different possible explanations of the weekend effect………...… 3 1.3 Zooming in on the empirical field: the Danish emergency departments………………….11 1.4 Summary and concluding comments…………………………………………………..….13 Chapter 2: Methodology 15 2.1 Studying a case………………………………………………………………………….... 15 2.2 The setting……………………………………………………………………………...… 16 2.3 Definition on weekday and weekend…………………………………………………….. 18 2.4 Research methods ……….………………………………………………………...…...… 20 2.4.1 Mixed methods research design……………..……………………………...…….….20 2.4.2 Quantitative methods (papers I + II)…………………………………………………23 2.4.3 Qualitative methods (papers II + III)……………………………………………....... 26 2.4.4 Theoretical framework used in the analysis (paper III)……………….……………..39 Chapter 3: Paper I 45 Day of the week of admission, patient characteristics and patient outcomes: a study of the weekend effect in an emergency department 3.1 Abstract……………………………………………………………………………….. 46 3.2 Background…………………………………………………………………………… 47 3.3 Methods………………………………………………………………………….…… 49 3.4 Results……………………………………………………………………………...….56 3.5 Discussion…………………………………………………………………………..… 63 3.6 Conclusion……………………………………………………………………………. 67 Chapter 4: Paper II 69 Adverse events in an emergency department weekdays and weekends – a critical study of registration practices 4.1 Abstract……………………………………………………………………………….. 70 4.2 Introduction…………………………………………………………………………....71 4.3 Methods………………………………………………………………………….…….74 4.4 Results……………………………………………………………………………...….81 4.5 Discussion and conclusion…...……………………………………………………..… 90 Chapter 5: Paper III 97 Fits and misfits between the information processing requirements and capacities: the weekend effect in a hospital emergency department 5.1 Abstract……………………………………………………………………………….. 98 5.2 Introduction………………………………………………………………………...….99 5.3 An information processing perspective.……………………………………….…...… 102 5.4 Research setting and methods………………….………………………...………….... 105 5.5 Fit and misfit analysis of the emergency department, weekdays and weekends……... 111 5.6 Strategies used to deal with the misfits………………………………………………..148 5.7 Discussion and conclusion………………………………………………………….… 157 Chapter 6: Concluding discussion 163 6.1 Answering the research questions……………………………………………………....... 163 6.2 Connecting results from the three individual papers…....……………..…………….…… 166 6.3 Limitations and contributions……………………………..……………………………… 170 6.4 Future research………………………………………………………………………….... 172 6.5 Concluding remarks……………………………………………………………………….175 References 176 Appendix 193 Appendix I: Questionnaire……………………………………………………………….. 194 Appendix II: Flowchart for all patient-visits to the emergency department in 2014-2015..200 Appendix III: ICD-10 codes of each primary diagnostic group……………………..…….201 Declaration of co-authors 202 English summary Patients should be able to expect the same standard of emergency care whatever day of the week they are admitted. However, a large number of studies have demonstrated that patients admitted to hospitals on weekends experience worse outcomes (i.e., mortality rates, number of adverse events, and length of stay) than patients admitted during the week. Emergency patients seem to be most affected by this phenomenon, which is also called the weekend effect. Only a few studies have investigated the weekend effect in Denmark. One study shows that patients attending a Danish emergency department during weekends have a higher risk of dying within 30 days than patients attending during weekdays. The existing studies are based on epidemiological analysis of administrative data and focus on whether or not the weekend effect exists. Thus, they do not investigate explanations of this weekend effect. There are various suggestions in the existing studies as to why
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