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.


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, 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, Centre for Healthcare Resilience and Implementation Science

Barbara Harrington, Cardiff University, Division of Population Medicine

Julie Hepburn, Cardiff University, Division of Population Medicine

Aloysius Niroshan Siriwardena, University of Lincoln, Community and Health Research Unit

Helen Snooks, Swansea University, Swansea University Medical School

Adrian Edwards, Cardiff University, Division of Population Medicine