Why do we play ping pong with the multimorbid patient?

Abstract

Background Emergency departments (ED) are under increasing pressure, a phenomenon often linked to the rising complexity of care rather than patient volume alone. This complexity is frequently driven by multimorbidity – the presence of two or more chronic conditions – which necessitates patient-centred, interdisciplinary decision-making. However, traditional hospital structures remain organised in a monodisciplinary, organ-specific manner, leading to fragmentation and coordination diliculties. This misalignment creates a socio-technical environment where patients with complex or undilerentiated complaints risk falling between departments.

Objectives The objective of this study was twofold. First, to describe how interdisciplinary decision-making regarding treatment and admission occurs in practice for patients with multimorbidity in the ED. Second, to identify and explain the factors that shape this decisionmaking process within the socio-technical system of the hospital.

Methods A single-case study design based on Yin’s methodology was employed at the Erasmus Medical Centre (EMC) ED. The study was divided into two phases. The first phase utilised a holistic, descriptive approach grounded in Safety-II principles to map the "Work-as-Imagined" (WAI), derived from grey literature and protocols, against the "Work-as-Done" (WAD), observed in practice. The second phase used an embedded, explanatory approach to analyse subunits of analysis – individual professional behaviours and information flows – based on theoretical propositions regarding the Health Information System (HIS). Data collection involved 19 days of observations, ten semi-structured interviews with medical specialists, and a tabletop session with stakeholders.

Results The comparison of WAI and WAD revealed significant discrepancies; while protocols assume clear assignment of a "lead practitioner," practice is characterised by ambiguity and a "consultation carrousel" where multiple specialisms are consulted to find a problem owner. The study identified that defensive behaviours among medical specialists are prevalent, particularly when patients present with "discordant multimorbidity" (conflicting treatment goals) or "concordant multimorbidity" (undilerentiated complaints without a clear organ-specific owner). Superspecialists often utilise an "opt-in" strategy, accepting only patients fitting narrow diagnostic criteria, electively forcing generalist departments to "opt-out" or become the default safety net. Furthermore, technological systems (EHR) were found to be passive and fragmented, failing to adequately support the identification of responsibility or facilitate rapid communication.

Discussion The "ping pong" phenomenon is not merely a diagnostic dilemma but a symptom of deeper systemic issues. Hyperspecialisation has eroded generalist competencies, fostering a culture of defensive medicine where specialists avoid complex cases to mitigate risk. Additionally, external factors heavily influence ED decision-making; hospital budgeting prioritises elective care, incentivising departments to protect bed capacity and creating a "push" system where the ED struggles to admit patients to wards. To ameliorate these issues, the study recommends a cultural shift towards shared responsibility, the implementation of ‘active’ technological notifications and improved reachability to support interdisciplinary decisionmaking, and the formalisation of joint bedside decision-making to establish a ‘common ground’ for complex cases.