What is full capacity protocol, and how is it implemented successfully?

Full capacity protocol (FCP) is an internationally recognized intervention designed to address emergency department (ED) crowding. Despite FCP international recognition and positive effects on hospital performance measures, many hospitals, even the most crowded ones, have not implemented FCP. We conducted this study to identify the core components of FCP, explore the key barriers and facilitators associated with the FCP implementation, and provide practical recommendations on how to overcome those barriers.

To identify the core components of FCP, we used a non-experimental approach. We conducted semi-structured interviews with key informants (e.g., division chiefs, medical directors) involved in the implementation of FCP. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We used a template analysis approach to determine the relevance of the CFIR constructs to implementing the FCP. We analyzed the responses to the interview questions about FCP definition and FCP key principles, compared different hospitals’ FCP official documents, and consulted with the original FCP developer. We then used an adaptation framework to categorize the core components of FCP into three main groups. Finally, we summarized practical recommendations for each barrier based on information provided by the interviewees.

A total of 32 interviews were conducted. We observed that FCP has evolved from the idea of transferring boarded patients from ED hallways to inpatient hallways to a practical hospital-wide intervention with several components and multiple levels. The key determinant of successful FCP implementation was collaboration with inpatient nursing staff, as they were often reluctant to have patients boarded in inpatient hallways. Other determinants of successful FCP implementation were reaching consensus about the criteria for activation of each FCP level and actions in each FCP level, modifying the electronic health records system, restructuring the inpatient units to have adequate staffing and resources, complying with external regulations and policies such as fire marshal guidelines, and gaining hospital leaders’ support.

The key determinant in implementing FCP is creating a supportive and cooperative hospital culture and encouraging key stakeholders, including inpatient nursing staff, to acknowledge that crowding is a hospital-wide problem that requires a hospital-wide response.