While most health systems have implemented interventions to manage situations in which patient demand exceeds capacity, little is known about the long-term sustainability or effectiveness of such interventions. A large multi-jurisdictional study on patient flow in Western Canada provided the opportunity to explore experiences with overcapacity management strategies across 10 diverse health regions. Four categories of interventions were employed by all or most regions: overcapacity protocols, alternative locations for emergency patients, locations for discharge-ready inpatients, and meetings to guide redistribution of patients. Two mechanisms undergirded successful interventions: providing a capacity buffer and promoting action by inpatient units by increasing staff accountability and/or solidarity. Participants reported that interventions demanded significant time and resources and the ongoing active involvement of middle and senior management. Furthermore, although most participants characterized overcapacity management practices as effective, this effectiveness was almost universally experienced as temporary. Many regions described a context of chronic overcapacity, which persisted despite continued intervention. Processes designed to manage short-term surges in demand cannot rectify a long-term mismatch between capacity and demand; solutions at the level of system redesign are needed.

Units providing transitional, subacute, or restorative care represent a common intervention to facilitate patient flow and improve outcomes for lower acuity (often older) inpatients; however, little is known about Canadian health systems’ experiences with such “transition units.” This comparative case study of diverse units in four health regions (48 interviews) identified important success factors and pitfalls. A fundamental requirement for success is to clearly define the unit’s intended population and design the model around its needs. Planners must also ensure that the unit be resourced and staffed to deliver truly restorative care. Finally, streamlined processes must be developed to help patients access and move through the unit. Units that were perceived as more effective appeared to have satisfactorily addressed these population, capacity, and process issues, whereas those perceived as less effective continued to struggle with them. Findings suggest principles to support optimal design and implementation of transition units.

BackgroundSeveral of the many emergency department (ED) interventions intended to address the complex problem of (over)crowding are based on the principle of streaming: directing different groups of patients to different processes of care. Although the theoretical basis of streaming is robust, evidence on the effectiveness of these interventions remains inconclusive.MethodsThis qualitative research, grounded in the population-capacity-process model, sought to determine how, why and under what conditions streaming interventions may be effective. Data came from a broader study exploring patient flow strategies across Western Canada through in-depth interviews with managers at all levels. We undertook realist analysis of interview data from the 98 participants who discussed relevant interventions (fast-track/minor treatment areas, rapid assessment zones, diverse short-stay units), focusing on their explanations of initiatives’ perceived outcomes.ResultsEssential features of streaming interventions included separation of designated populations (population), provision of dedicated space and resources (capacity) and rapid cycle time (process). These features supported key mechanisms of impact: patients wait only for services they need; patient variability is reduced; lag time between steps is eliminated; and provider attitude change promotes prompt discharge. Conversely, reported failures usually involved neglect of one of these dimensions during intervention design and/or implementation. Participants also identified important contextual barriers to success, notably lack of outflow sites and demand outstripping capacity. Nonetheless, failure was more commonly attributed to intervention flaws than to context factors.ConclusionsWhile streaming interventions have the potential to reduce crowding, a theory-based intervention relies on its implementers’ adherence to the theory. Streaming interventions cannot be expected to yield the desired results if operationalised in a manner incongruent with the theory on which they are supposedly based.