Abstract for: Dynamics of How Adaptive Practices Bring Resilience to Emergency Departments

Emergency departments (EDs) work under highly turbulent conditions that require ongoing adaptations to keep the system operating at a functional and desirable level. When done well, these adaptations are expressions of resilience that sustain the ED’s ability to deliver vital services. This paper reports a first-hand observational study of an ED and explores the adaptive behaviors of the department’s resident physicians to address simultaneous arrivals of multiple acute patients. Results highlight the improvised, in-the-moment adaptations that occur regularly in the course of patient care. We develop a system dynamics model of patient care tightly grounded in first-hand observation and interview data. We use the model of patient care within the ED to simulate the consequences of both unsuccessful and successful adaptations. We identify a key reinforcing loop that distinguishes patient care in the ED from many other service settings. We further show that adaptations that help control the potentially bad-news reinforcing loop are highly effective achieving resilience for the ED. The simulations illuminate the resilience bestowed by improvised adaptations as a means of avoiding vicious cycles that can propel the system into crisis.