Reconfigured times: constraints We previously discussed how emergency care was deemed unsatisfactory because of the long waiting times, particularly for patients with minor injuries

or illnesses who were constantly pushed to the back of the queue. The 4 hour wait target was intended to minimise this failure of the system by attempting to control time in emergency care work, often by dividing the overall patient volume into Inhibitors,research,lifescience,medical smaller, more homogenised units. However, no matter how well-configured these processes were, the messiness of real-world practice would inevitably interfere. Processes interfered with one another, obstructed the ordered flows of patients and stretched the department’s capability for meeting Inhibitors,research,lifescience,medical the target. For example, a patient attending an ED with a presenting complaint could not always be maintained in the same stream for her entire trajectory. Clinicians had to deal with these irregularities on the spot. Therefore, patients were only allocated to streams temporarily. They Inhibitors,research,lifescience,medical acted as a first attempt to briefly (and quite vaguely)

determine the expected resources and people that would be needed for a particular condition. This was a new managerial task and an opportunity for workarounds to best serve patients’ needs. “I am going to be putting them in the ‘majors’ area and they need to be seen quite quickly, but because they are in ‘minors’ still, or do they automatically Inhibitors,research,lifescience,medical become a ‘majors’ because they’ve got a nasty injury? Or are they still a ‘minors’ because it’s an injury? The other one would be with injuries again, you’ve

got your 26s Proteasome structure category 6 which is your doctors’ minors and you’ve got your category 7 which is your ENP and then your category 4 which is your ENP priority, but you’ve not got a category for doctors’ priority ‘minors’, so they would just go as a 6, if they need to see a doctor and they were an injury, but then how do you put down”; (Clinician 7). However, the Inhibitors,research,lifescience,medical busier it got in the ED, the greater the need to speed up clinical performance. The target, more than actual illness and its urgency, gradually Linifanib (ABT-869) became a critical measure of accountability and, crucially, the target had the authority to instigate specific actions. “Obviously, if there is a patient that needs to stay in the Department because they are unstable or because of their clinical condition, there’s a lot of pressure put upon the nurses in charge or the coordinators…that they move them” (Clinician 1). There were many legitimate reasons why critical (to the target) delays may unfold in the ED, such as waiting for test results or for a specialist to come and see a patient. The ED inevitably required the timely cooperation of many different clinical units and professionals from elsewhere in the hospital.