Review article: Systematic review of three key strategies designed to improve patient flow through the emergency department

Abstract

To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/ throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.

Interventions to improve patient flow in emergency departments: an umbrella review

“…Many of the primary studies were weak, mostly belonging to the BA study design. The systematic reviews conducted by Elder  et al ,19 Georgiou  et al 20 and Jennings  et al 23 did not present quality assessments of the primary studies. The review by Bond  et al 17 presented a quality assessment but an interpretation of the scores was not provided.…”

Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study

“…In the United States, an evidence‐based toolkit was developed to assist hospitals with reducing ambulance offload delays . Other broader measures that may warrant consideration, implementation and evaluation (including economic analysis) include the allocation of other nurses with extended scope of practice or nurse practitioners to the triage area and the development of a physician‐assisted triage process . ED avoidance models have also been developed where nurses accompany paramedics on low acuity ambulance calls to treat patients on site (i.e.…”

Selected state of the art research in internal medicine, 2017

“…There are tantalising hints of single or bundled process of care interventions and mandates (such as the 4-h NEAT) hold promise in improving ED care. Elder et al 18 gathered widely scattered evidence in assessing strategies to improve ED delays in a systematic review. Increased nursing scope of practice, physician-assisted triage and medical assessment units were all found to work.…”