A work systems approach to characterizing emergency department disposition decision-making under low and high demand

Emergency department (ED) clinical decision-making, specifically for transfer or disposition decisions, has been challenging to characterize. The purpose of this descriptive study is to identify the work system elements that influence the ED disposition decision-making process and to identify those work system elements that vary under low and high demands. We conducted a work systems analysis of 20 contextual inquiry-based ED visit observations and 18 semi-structured interviews with ED clinicians. Results identified work system elements not previously characterized (i.e., physical environment) and revealed that a subset of elements within the ED work system vary with demand. To fully elucidate the meaning and effect of these differences, we must develop a systematic approach to eliciting the influence each work system element has on disposition decision-making process performance. • All six work system elements configure to produce disposition processes. • Work system elements vary in their presentation with demands. • Physical environment elements cross work system boundaries. • Configuration can be used to characterize and detect changes in demand.