Initial and refined theories described as context–mechanism–outcome configurations
| Process | Initial theory from rapid realist review and national patient safety incident reports | Refined theory from case site qualitative data | Example of supporting verbatim quote |
|---|---|---|---|
| 1. Streaming decisions | If patients present to the emergency department (C) but the streaming nurse is unclear which patients are appropriate for the GP service (because of unclear guidance or inexperience) (M) or the initial assessment is inadequate (limited history or lack of basic physiological observations) (M) then higher-risk patients may be streamed to the GP service (O). | If there is adequate staffing to meet standard triage targets and streaming is conducted by an experienced nurse, using early warning scores , with guidance based on the local GP service provision, and there is good communication between services about capacity and skillset (C) then the nurse understands which conditions are appropriate for the GP service (M), uses clinical judgement and early warning scores to identify sick patients (M), is aware of the flow and capacity in different streams in the department (M), and the department modifies the process based on experience and learning (M) then patients with appropriate conditions will be streamed (O). | ‘In the end what it really boils down to is having an experienced member of staff , working within fairly broad parameters of what is appropriate and what is not … There’s always a temptation amongst the nursing staff to put a less experienced person on streaming or triage simply to keep the most skilled people seeing the sickest patients, but that’s definitely the wrong thing to do, we have to have experience up front because it’s an extremely important job getting them in the right place I think .’ (Emergency consultant, hospital 10, outside–onsite model) |
| 2. GPs’ clinical decision makinga | GPs working in or alongside emergency departments seeing streamed patients (C) may be influenced by the prior decision making of the streaming nurse and at risk of framing or anchoring cognitive biases (M), or may incorporate their usual community pre-test probability of serious illness into their diagnostic reasoning and be at risk of availability or representativeness cognitive biases (M), or may have inadequate knowledge or skillset for the patients’ condition (M) and may be at risk of mismanaging the patient (O). | If GPs work in emergency departments with clear governance processes; are aware of their intended role and expectation depending on their experience, skillset, and patient demand (C); use communication skills to gather patient information for hypothesis generation (M); actively consider prevalence of more serious diseases that may present to the emergency department setting (M); use clinical skills to rule out serious diagnoses (M); refer to guidance when acute investigation/referral may be necessary to exclude serious disease (M); and use safety netting to help manage diagnostic uncertainty (M), then safe patient care will be facilitated (O). | ‘I think that the group of patients I see in A&E is very different to the patients that I see in general practice, so my level of concern, I’m quicker to be concerned with an A&E patient than I would be with a general practice patient . The ability of the patients to self-select to come to A&E never ceases to amaze me … Does it mean I investigate more? No , I don’t think it does, it just means I listen very carefully to the history and examine very carefully . That’s my own perception.’ (GP, hospital 3, inside–integrated model) |
| 3. Communication between services | If there is poor communication between the GP service and the emergency department service (C) because of a lack of awareness about capacity (M) and inadequate referral pathways (M) then patient assessment and treatment may be delayed (O). | Service models with strong clinical leadership, employing experienced, regular GPs with opportunity for face-to-face communication between services and compatible computer systems (C), with a culture that encourages interprofessional communication and learning (M) and clinical leadership that promotes mutual respect (M), encourages communication between services and teamwork to facilitate safe patient care (O). | ‘One of the biggest things we didn’t expect is the effect of education, that there’s a GP sitting in the department, seeing a frail elderly patient, the F2 is sitting next to them seeing a similar patient, and the F2 is going “Why are you sending your patient home and I’m admitting mine?” , the amount of cross-fertilisation knowledge and support was something that we didn’t expect that we’ve really benefited from.’ (Clinical director, hospital 14, inside–integrated model) |
↵a See Table 2 for further nuanced CMOs. C = context. M = mechanism. O = outcome.