What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

Abstract

BackgroundGlobally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.MethodsA rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.ResultsThirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).ConclusionsThere is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine

“…The existing lack of such translation-referred to as the 'know-do gap [10]"-hampers timely implementation of this knowledge. Because of the aim to deliver very short guidelines for clinical practice on one hand, and the expected low quantity and evidence-level of the literature [11,[25][26][27], we did not perform formal systematic reviews and no systematic evidencegrading, but rather used expert experience and consensus. The unmet urgent need to increase awareness, knowledge and competencies of professionals working in Geriatric Emergency Medicine validates such a pragmatic approach, but does not at all exclude that future research should further increase evidence-level and recommendations.…”

Converting acute inpatient take to outpatient take with fast-track assessment in internal medicine wards – a before-after study

“…Hospital readmission is reported as a post-discharge adverse outcome from admission and knowledge is limited on how to change the pathway for acute medical patients in order to overcome readmissions [9, 13]. Many factors have been highlighted as contributors to increased rates of patient readmission, and a common cause includes accelerated turnovers, which does not relieve the problem of overcrowded hospitals [27, 28].…”

“…It has been shown that use of acute medical units leads to lower admission rates and length-of-stay without increasing in-hospital mortality [9–12]. However, this type of entry includes an additional step in the trajectory for patients who require consultations with medical specialities and limited evidence exists for reducing hospital admissions along the patient pathway through the emergency department [13].…”

Comparison of Frailty Screening Instruments in the Emergency Department

“…The risk-stratification of older adults presenting to the Emergency Department (ED) is useful to target interventions that reduce their risk of adverse healthcare outcomes [1,2], particularly where frailty is identified [3]. This is challenging because frail patients often present atypically [4,5], and acutely unwell hospitalised older adults may appear frailer than their baseline suggests [6], meaning that resource-intensive, evidence-based interventions such as comprehensive geriatric assessment (CGA) [7] can be difficult to apply.…”