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536 NEGOTIATING INDIVIDUALLY TAILORED URGENT CARE PLANS FOR OLDER PEOPLE IN AMBULATORY EMERGENCY CARE


 
 
 Ambulatory emergency care (AEC) provides hospital-equivalent medical care in out-of-hospital settings for acutely unwell complex older patients. This ethnography aimed to understand the cognitive work of the senior clinicians in the AEC environment.
 
 
 
 Three AEC sites were purposively sampled to recruit twelve clinicians with backgrounds in Geriatrics, General Practice, Emergency and Acute Medicine. This qualitative investigation used focused ethnography within a case study approach to understand the decision-making processes in the context of the AEC environment. Participant-observation during an AEC shift was complemented by informant interviews. A framework approach to thematic analysis used a priori and data derived codes to develop explanatory themes. Ethnographic principles of constant comparison and cognitive task analysis were used to evaluate the clinicians’ decision-making processes for index patient cases.
 
 
 
 This ethnographic case study showed that AEC clinicians tailored their management plans to the individual patient based on their clinical assessment and needs, using creative problem solving and reflexivity. The AEC clinicians personalised their interventions based on the patient assessment, the patients’ wishes and disease severity. The individual tailoring of the AEC plan was negotiated with the patient, their next-of-kin and the multidisciplinary team (MDT). The discussions with patient and families allowed discussion of the differing priorities and facilitated compromise. AEC plans were also negotiated with the MDT to build a shared understanding of the patients’ needs. The MDT also provided cognitive and emotional support by challenging and validating the senior decision-makers clinical plans.
 
 
 
 This tailored approach allowed the flexible delivery of AEC to meet the patients’ needs. It is hoped that by characterising the work of AEC clinician that this study will aid the development of medical training curricula, interdisciplinary working and health service design. Further research is needed on team-based decision-making for individually tailored care in urgent care settings.
