A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland\u2019s hospitals

E Hurley,S Mchugh,J Browne,C Normand,L Vaughan

doi:10.1186/s12913-019-4629-5

Abstract

BackgroundTo address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation.MethodsWe will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme’s outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme’s implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme’s outcomes can be explained by the level of implementation.DiscussionThis formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

Highlights

To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care
Integration of programme outcomes and programme implementation To explain the variation in implementation and programme outcomes between sites, we will construct a joint display table presenting the data for each site - the constructs that were identified as influential and the outcomes achieved - and examine patterns and inconsistencies across and between cases [58, 59] In this manner, the constructs which influenced implementation (Stage 3), the level of implementation (Stage 2) and the programme outcomes achieved (Stage 5), will be presented for each case in line with our conceptual framework from Fig. 1. This protocol outlines a mixed methods study to evaluate whether the reconfiguration of acute medical care in hospitals, is effective in everyday practice
The study will examine the variation in implementation and effectiveness of Acute Medical Units from a national perspective, and be the first to comprehensively assess the factors that contribute to how well these Units are implemented and how well they perform

Summary

Introduction

As with other jurisdictions [1, 2], has seen a significant reduction in its acute beds with a 13% reduction in in-patient beds between 2007 and 2012 [3], and has a large unmet demand for long term care beds [3, 4] This situation, along with continued growth in demand for emergency services, is resulting in patients waiting longer in overcrowded Emergency Departments (EDs) [5,6,7,8,9], and often receiving suboptimal care on trolleys and wards which are not fit for purpose [10, 11].

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