They are also a cause of patients

leaving the ED before being seen by a clinician [7-9], adverse events [10], restricted access to emergency care [11] and increased mortality rates [12]. To address these chronic problems in EDs, wait targets have been applied as a means to monitor, assess and, Inhibitors,research,lifescience,medical therefore, improve the overall experience and quality of care. The focus on targets has triggered controversy about their effectiveness [13-20]. Findings from a recent systematic review [21], suggest that the 4 hour ED wait target in the English NHS has failed to consistently improve clinical outcomes and cautions countries which have embarked upon similar schemes [22,23] to learn these Inhibitors,research,lifescience,medical lessons. Certainly, these targets can speed up the patients’ journey through the ED [24,25], particularly as they concentrate organisational and clinical efforts in meeting them [26-30]. However, qualitative studies, focusing Inhibitors,research,lifescience,medical on clinicians’ understanding of the target’s impact suggest that although patient flow and ED experience for staff and patients may have been improved, this has happened at the expense of quality time for communication and treatment [31]. This paper aims to fulfil a gap in the literature

Inhibitors,research,lifescience,medical by examining changes in clinical and organisational processes that preceded or followed the introduction of an ED wait target. Its main

objective is to demonstrate the role of space, time and information technology in the optimisation of patient flows. It Inhibitors,research,lifescience,medical does this by examining how these social and technical elements were used to support the 4 hour wait time target in the English NHS and what it means for clinicians to practice emergency care in this environment. Study context The (arbitrary [31]) 4 hour wait target was announced by the English Department of Health in 2000 [32,33], and took effect in Checkpoint activation January 2005. Without any reference Thiamine-diphosphate kinase to other equally important sources of ED overcrowding, such as resources, staffing and bed availability [34,35], the idea was that through this target, EDs would be forced to adopt private sector styles of management [36-38] so as to optimise their operations [39], particularly in an NHS of increasing number of ED attendees (from 13.9 m in 1988 to 21.3 m in 2011) and of fewer hospital EDs (from 310 in 1988 to 150 in 2009). Politically, the context for this policy direction was one of the perennial “crises” in the NHS, with extensive media coverage [40] of patients waiting for long periods of time on trolleys in EDs.