A realist analysis of streaming interventions in emergency departments

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Anwar, Mohammed Rashidul
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Background: Several Canadian jurisdictions have launched interventions and strategies to address the complex, multi-dimensional problem of Emergency Department (ED) crowding. Still many of the health systems struggle with long waits. Initiatives that seem to display positive results in one site/system are often unable to show similar results in another. To make sense of such patterns, I drew on a form of theory-based evaluation, Realistic Evaluation (RE). My realist analysis focused on streaming-type interventions such as Fast-track/Minor Treatment Areas, Intake/Rapid Assessment Zones, and diverse types of Short-Stay Units, which separate the whole care process of patients into different streams (based on acuity and service needs) to improve patient flow. Objective- The purpose of this thesis was to identify relevant mechanisms and contextual factors to generate "middle-range theories" for streaming-based flow interventions. Methods- This thesis used the interview data collected for a larger project, "Patient Flow and Health Systems". These interviews were conducted with 300 key stakeholders who were involved in initiatives to improve flow, in one of the ten urban/mostly-urban health regions and zones of Western Canada. I undertook a realist analysis based on participants' explanations for (perceived) success and failure. This work was grounded in the Population-Capacity-Process model, which helped to categorize factors in a meaningful way. Findings- Essential design features of streaming-type interventions that might have led to their success included identification of a designated population (population), allocation of dedicated space and resources (capacity), and establishment of rapid cycle time (process). These supported key mechanisms: patients wait only for services they need, variability among patients is reduced, standardized care is provided, lag time between care steps is prevented and provider attitude change promotes prompt discharge. Critical context factors that might have impacted the interventions were lack of outflow sites and the possibility of demand outstripping capacity. An important finding of this study was that failure of interventions was more commonly attributed to design flaws (in particular, lack of dedicated space) than to context factors. Conclusion- This study helped generate "middle-range theories" which sought to explain the outcomes of diverse interventions that share a basic program theory. In this way, it was able to provide transferable lessons for stakeholders wishing to implement similar interventions elsewhere.
Patient flow, Emergency department, Realist Analysis, Streaming interventions, ED crowding