The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety.

We observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes.

Mechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors.

We recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.


University of Lincoln, College of Social Science Research

Michelle Edwards, Cardiff University, Division of Population Medicine

Alison Cooper, Cardiff University, Division of Population Medicine

Thomas Hughes, John Radcliffe Hospital, Emergency Department

Freya Davies, Cardiff University, Division of Population Medicine

Delyth Price, Cardiff University, Division of Population Medicine

Pippa Anderson, Swansea University, College of Human and Health Sciences, Swansea Centre for Health Economics

Bridie Evans, Swansea University, Swansea University Medical School

Andrew Carson-Stevens, Cardiff University, Division of Population Medicine

Jeremy Dale, Warwick University, Academic Primary Care

Peter Hibbert, Macquarie University, Australian Institute of Health Innovation, Centre for Healthcare Resilience and Implementation Science

Barbara Harrington, Cardiff University, Division of Population Medicine

Julie Hepburn, Cardiff University, Division of Population Medicine

Niro Siriwardana, University of Lincoln, School of Health & Social Care, Community and Health Research Unit

Helen Snooks, Swansea University, Swansea University Medical School

Adrian Edwards, Cardiff University, Division of Population Medicine