A multistage mixed methods evaluation of the implementation and impact of a reconfiguration of acute medicine in Ireland’s hospitals

Abstract

Background. To address deficits in the delivery of acute medicineservices in Ireland, the National Acute Medicine Programme (NAMP) was established 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. It does so primarily via the development of Acute Medical Assessment Units (AMAUs),for the rapid assessment and management of medical patients presenting to hospital as an emergency. This thesis examines the implementation and impact of this programme and identifies the factors that influenced same.Methods. A multistage mixed methods evaluation with an explanatory sequential design, informed by the by the UK Medical Research Council's guidance for process evaluation of complex interventions,was undertaken. A logic model describing the programme's outcomes, components,and mechanisms of change,was developed and informed all stages of the evaluation. Implementation was examined from the perspective of fidelity of the AMAUs to the model of care, while programme reach was measured in terms of utilisation of the units and the conditions assessed.The impact of the programme was assessed by an examination of monthly overnight emergency hospitalisation rates (and rates of bed days used) for medical conditions, especially those termed 'potentially avoidable'. The factors which influenced programme implementation and outcomes were elicited via qualitative interviews with programme and clinical staff.Results:The logic model cast light on the complexity of the NAMP and its many assumptions, contingencies and inter-dependencies. The implementation evaluation found substantial heterogeneity across the units, and deficits in core components and critical inter-dependencies. An examination of the role the units play in the management of medical patients, found that the majority of patients admitted(nationally)as an emergency,do so via the conventional route of presentation toED and admission in-house from there. A smaller proportion are streamed to an AMAU, where almost two thirds are assessed and discharged directly.The impact evaluation found that rates of overnight emergency hospitalisations for total medical conditions were declining in the pre-intervention period (2009-2011), but remained stable in the post intervention period, signalling a lack of evidence to support the hypothesis that the wide scale opening of the units from 2012 had a demonstrable impact on hospitalisation rates. Similar pattern were observed in many of the ambulatory care conditions examined. A notable exception was a clear programme impact on overnight hospitalisations for chest pain non-specific, the most common conditions by far assessed in an AMAU. The interviews cast a light on the myriad of factors that hindered the established and routinisation of the AMAUs. Nationally, alack of strategic leadership from the organisations responsible for the programme contributed to operational difficulties on the ground. The relentless overcrowding in hospitals with extreme pressures on beds, contributed to the AMAUs not operating as per the model of care. Other cultural and contextual factors included a reluctance of medical specialists to participate in the new model of care, difficulties in upending status-quo and clear deficits in primary and community care.Conclusion: It is likely that the limited impact of the Programme can in part be attributed to difficulties in measurement which used an ecological approach during a turbulent economic period. The clear deficits in programme implementation make it difficult to draw firm conclusions on the effectiveness of AMAUs. It remains to be ascertained whether the preferential streaming of patients with medical conditions to an AMAU implemented with high fidelity would result in the reduction in hospitalisation rates akin to that observed with chest pain non-specific.