An Emergency Department “gebrochenrolltreppe” phenomenon #WILTW

This is the 154th #WILTW

As you are ambling around a shopping centre you spy an escalator to take you to the level you need. It’s not working but hasn’t been cordoned off so you use it as stairs to climb to the floor above.

You know the escalator isn’t moving.

You have audio-visually confirmed this.

And yet as you walk onto it it starts moving forward so you overstep slightly before re-adjusting yourself.  You then realise it’s not actually moved forward at all.

This unnerving sensation has a scientific explanation although it wasn’t fully explained until the beginning of this century

Julie Beck wrote an article on the paper and coined the term “gebrochenrolltreppe” ( In German Google Translate “escalator” is “rolltreppe” and broken” is “gebrochen”)

One thing about our new Emergency Department, which opened this week, is that it’s not broken. Yes there are some snags, and lots of new processes to learn, but there is far more space, purpose built cubicles and a design that facilitates flow. These combine to create a department that is far quieter and more functional.

However this has created an unusual side effect.

You don’t need to be a experienced health care professional to notice when things are busy in a department or ward. There is a slightly distracting ambient noise level, a characteristic ‘hurry’ in people’s movements and a subtle but  inescapable increase in the atmospheric pressure that creates tension. These sensations often correlate to the number and acuity of patients on the electronic information systems. So much so, that if there are only a few patients in the department and it feels busy, you know something is wrong.

In our new building the converse of this is playing out. The information on the computer screen may tell you that patients are arriving at a seemingly exponential rate, you have a large mix of illnesses and injuries to deal with and there are two ambulances waiting to handover patients.

But the department feels calm.

(or certainly far less stressful that it previously would have done)

This cognitive dissonance was predicted by some but the reality of it has come as a shock to me. Situational awareness is a skill you can learn but there is an intuitive, almost reflexive, nature to it that definitely improves with experience.  I, and I think others, have had their situational awareness compass unbalanced with a discrepancy between what they are seeing (on the computer screens) and feeling (around them). This feeling will undoubtedly pass as we re-adjust and find new methods of abstracting clues from the environment about how the department is functioning. But it is reminder of the powerful influence the lived experience has on us and how many cues and reactions are based on our tacit knowledge of our environment rather than numbers on screens.

What have you learnt this week? #WILTW

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2 thoughts on “An Emergency Department “gebrochenrolltreppe” phenomenon #WILTW”

  1. Isn’t this a greater problem for senior clinicians rather than juniors? Whilst the former may have developed a greater sense for forming an over-arching view of departmental activity, the latter may be helped by the reduced distraction of a ‘busy’ department. There is a tendency in medicine to flock to acuity and often a reluctance to leave. Therefore anything that allows doctors and nurses to concentrate on their own area of work should be a good thing.

    As work begins on our new ED area (1 quarter of the funding raised so far) I hope we’ll be able to learn from your experiences.

  2. Be interesting to see the impact on the perceptions of patients & families – whilst totally acknowledging the benefits for everyone of a calm purpose-built environment for delivering clinical care, having worked in an environment that was more noisy/busy/crowded, there was more of an appreciation by those waiting that the department was busy & that there were sick children being dealt with, so a greater tolerance of having to wait to be seen/dealt with/for blood tests/passing that fluid challenge etc however when we moved to an area where the waiting room was more removed from the busy hustle & bustle, parents assumed we were not busy and therefore the level of frustration at waiting was greater….Be interesting to see whether the numbers on the screen and lovely decor/flowcharts on the wall will make all the difference…

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