Organisational influences on the activity of chest pain units during the ESCAPE trial: a case study.
BACKGROUND
The ESCAPE trial was a multicentre randomised controlled trial investigating the effectiveness of Chest Pain Unit (CPU) care. The process of CPU implementation and the activity of individual CPUs varied substantially between hospitals. The study reported here explored the organisational factors that influenced this variation.


METHODS
A multiple case study approach was taken treating each site as a 'case'. Six intervention sites were studied. Qualitative data were collected through interviews with key personnel at each site.


RESULTS
Activity of individual CPUs was not adequately explained by simple structural differences between hospitals, such as their size or location, or between CPUs, such as staffing and hours. Analysis suggested that the more active CPUs tended to have more of the following characteristics: being 'primed' by previous initiative or experience; appropriate leadership; a positive climate for innovation; established relationships between key staff/departments; role clarity amongst staff; an enthusiast for the development; and continuity of staffing. Role conflict, particularly between specialist nurses and others, was reported and had potential to interfere with development.


CONCLUSIONS
Organisational factors were identified that could have impacted on the outcomes of the ESCAPE trial through, for example, delays in discharge, and missed recruitment opportunities. Complex interventions such as the ESCAPE trial are prone to the effects of local organisational issues, some of which could be predicted and planned for. Findings from single centre studies of complex interventions should be treated with caution before a decision is taken to implement in a new setting.
Centre for Health and Social Care Studies, University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK. m.j.macintosh@sheffield.ac.uk
Michael
M
Macintosh
Steve
S
Goodacre
Angela
A
Carter
D000328:Adult; D001291:Attitude of Health Personnel; D002637:Chest Pain / Q000628:therapy*; D003325:Coronary Care Units / Q000458:organization & administration*; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital; D006333:Heart Failure / Q000517:prevention & control; D006801:Humans; D007400:Interprofessional Relations; D019982:Organizational Case Studies; D015279:Organizational Culture; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care; D011369:Professional-Patient Relations; D016032:Randomized Controlled Trials as Topic