Effectiveness and Safety of Short-stay Units in the Emergency Department: A Systematic Review

Galipeau, James; Pussegoda, Kusala; Stevens, Adrienne; Brehaut, Jamie; Curran, Janet; Forster, Alan J.; Tierney, Michael; Kwok, Edmund; Worthington, James; Campbell, Samuel; Moher, David

doi:10.1111/acem.12730

Cited by 55 publications

(55 citation statements)

References 44 publications

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“…In utilising this study design, we cannot de nitively conclude whether the achieved effectiveness is indeed due to the Acute Medical Consultants' professionalism, or whether it is due to the time-framed treatment or other optimised processes. However, the national and international trends towards effective hospital stays with shorter LOS in order to meet increased hospitalisation rates 42 do align with the results from this study.…”

Section: Medicalsupporting

confidence: 81%

The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

Lindstroem¹,

Andersen²,

Kallemose³

et al. 2019

Preprint

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Background Crowding and bed occupancy are challenging issues in the hospitals with increasing acute admissions, caused by an aging population. Crowding in Emergency Departments (EDs) has a negative impact on length of hospitalisation, in-hospital mortality, patient safety, and flow. Thus, the Danish Health Authorities recommend the presence of specialist doctors in the ED who are dedicated to execute the clinical decision-making process. Thus, in 2016, the model of acute care was changed in the ED at Hvidovre Hospital, Denmark, to include consultant-led triage and continuous presence of consultants, referred to as Acute Medical Consultants. However, there is little evidence concerning the effect of consultants treating patients in the ED, and how it affects care for patients of varying socioeconomic status compared with other models of ED staffing. This study investigated whether the employment of Acute Medical Consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of stay, readmission, mortality, and secondly how this effect was distributed across socioeconomic status in patients. Methods Admission data for 9,869 adult medical patients admitted for up to 48 hours in the ED was collected in two separate 7-month periods, one prior to and one after the organisational intervention. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education, and employment status were applied. Results Following the employment of Acute Medical Consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by an Acute Medical Consultant with a reduced mean length of stay by 1.4 hours (95% CI: 1.0 – 1.9). No significant change was found in in-hospital mortality, readmission, or mortality within 90 days after discharge. No difference was found in quality of care across socioeconomic status. Conclusion The employment of Acute Medical Consultants in the ED was associated with reduced length of admission without a negative effect on the quality of care for ED-admitted medical patients in general, or for patients with lower socioeconomic status. Yet, in order to reduce readmission and mortality among acutely admitted patients, other means must be initiated.

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Section: Medicalsupporting

confidence: 81%

The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

Lindstroem¹,

Andersen²,

Kallemose³

et al. 2019

Preprint

View full text Add to dashboard Cite

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“…Transitional services may indeed be useful when they meet a need for time-limited care or reliably connect patients to other services; dysfunction occurs when the planned journey ends before patient needs are met. It is noteworthy that all the studies that have supported short-stay units investigated the delivery of protocol-driven care to a tightly defined population with short-term needs 13 31…”

Section: Discussionmentioning

confidence: 99%

“…In the inpatient context, the family of discharge-planning and care-transition interventions shows evidence of reducing readmissions and potentially length of stay (LOS); however, in recent years, only the most complex, resource intensive of such interventions appear to yield an incremental benefit over usual care 11 12. Many flow interventions involve a net addition of resources, obscuring whether their active ingredient is efficiency improvement or merely resource enhancement 7 11 13. Moreover, initiatives that appear to succeed in one organisation may achieve little in another, an issue that studies are only beginning to explore 14–16.…”

Section: Introductionmentioning

confidence: 99%

Six ways not to improve patient flow: a qualitative study

Kreindler

2016

BMJ Qual Saf

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Background Although well-established principles exist for improving the timeliness and efficiency of care, many organisations struggle to achieve more than small-scale, localised gains. Where care processes are complex and include segments under different groups' control, the elegant solutions promised by improvement methodologies remain elusive. This study sought to identify common design flaws that limit the impact of flow initiatives. Methods This qualitative study was conducted within an explanatory case study of a Canadian regional health system in which multitudinous flow initiatives had yielded no overall improvement in system performance. Interviews with 62 senior, middle and departmental managers, supplemented by ∼700 documents on flow initiatives, were analysed using the constant comparative method. Results Findings suggested that smooth flow depends on linking a defined population to appropriate capacity by means of an efficient process ; flawed initiatives reflected failure to consider one or more of these essential elements. Many initiatives focused narrowly on process, failing to consider that the intended population was poorly defined or the needed capacity inaccessible; some introduced capacity for an intended population, but offered no process to link the two. Moreover, interveners were unable to respond effectively when a bottleneck moved to another part of the system. Errors of population, capacity and process, in different combinations, generated six ‘formulae for failure’. Conclusions Typically, flawed initiatives focused on too small a segment of the patient journey to properly address the impediments to flow. The proliferation of narrowly focused initiatives, in turn, reflected a decentralised system in which responsibility for flow improvement was fragmented. Thus, initiatives' specific design flaws may have their roots in a deeper problem: the lack of a coherent system-level strategy.

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“…However most solutions to crowding and boarding are system-based, with economic incentives along with bed occupancy and demand management the commonly used methods 44. Observation units have been widely used to address issues with crowding and access block, but there is no evidence that they improve safety 46. Time targets which focus on the ED in isolation have similarly failed to demonstrate an improvement in patient safety 47…”

Section: Which Features Of Em Impacts On Safety?mentioning

confidence: 99%

The safety of emergency medicine

et al. 2015

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The patient safety movement has been active for over a decade, but the issue of patient safety in emergency care and the emergency department (ED) has only recently been brought into the forefront. The ED environment has traditionally been considered unsafe, but there is little data to support this assertion. This paper reviews the literature on patient safety and highlights the challenges associated with using the current evidence base to inform practice due to the variability in methods of measuring safety. Studies looking at safety in the ED report low rates for adverse events ranging from 3.6 to 32.6 events per 1000 attendances. The wide variation in reported rates on adverse events reflects the significant differences in methods of reporting and classifying safety incidents and harm between departments; standardisation in the ED context is urgently required to allow comparisons to be made between departments and to quantify the impact of specific interventions. We outline the key factors in emergency care which may hinder the provision of safer care and consider solutions which have evolved or been proposed to identify and mitigate against harm. Interventions such as team training, telephone follow-up, ED pharmacist interventions and rounding, all show some evidence of improving safety in the ED. We further highlight the need for a collaborative whole system approach as almost half of safety incidents in the ED are attributable to external factors, particularly those related to information flow, crowding, demand and boarding.

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Effectiveness and Safety of Short-stay Units in the Emergency Department: A Systematic Review

Cited by 55 publications

References 44 publications

The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

Six ways not to improve patient flow: a qualitative study

The safety of emergency medicine

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