Challenging the dominant logic of Emergency Departments: guidelines from chaos theory.

Chaos is order without predictability (1 ). Any unfortunate patient who has recently made a trek to an Emergency Department (ED) or even better, has watched the immensely popular TV show, ER, knows that the visit can be a frustrating and a time consuming experience. The waits are so protracted that one can observe all cycles of birth, death, love, and romance in the waiting room. The process is tedious for the patient who must tell one's tale to a triage nurse, a registration clerk, the primary nurse, the nursing care partner, and finally the emergency physician. Then, the patient must face more delays while being pushed, ineffectively, in a horizontal fashion, through vertical functional silos of care, such as laboratory and radiology. The mind-set or dominant logic of this system of ED patient flow assumes that waits are acceptable and unavoidable, and that the function of the ED is to care for only the truly emergent patient. This dominant logic, coupled with the market constraints of population-based versus case-based payment mechanisms, has led to a declining trend in ED visits for the first time in 20 years (2). In order to improve the quality of ED care as well as to increase acceptability for patient and payer, the dominant logic must be challenged. An understanding of chaos theory and perception of the Emergency Department as a complex adaptive system foster methods for challenging the dominant logic.