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

This rapid evidence synthesis has found limited evidence of interventions along the patient journey through the ED that are effective in reducing hospital admission and/or ED attendance. This review provides a more in-depth review of the patient pathway from the ED to acute admission than a recent review which similarly found insufficient evidence to determine whether services in the ED reduced unplanned admissions [5]. The interventions included in this evidence synthesis are of varying complexity, often comprising a number of different components which may be unique to a particular study setting (such as assessment and discharge planning by different types of health professional, different discharge pathways and additional care). This means it is difficult to establish exactly which elements of an intervention are impacting on outcomes which affect the generalisability of study findings.

In addition, the nature of the health problems and severity of illness among patients in the included studies varied greatly and may impact on the degree to which the interventions were effective. The type of health problem, and severity of the presenting condition, plays a large role in determining whether or not a patient is eligible for an intervention; what the nature of this intervention is; and where this intervention occurs within the healthcare system. Some studies included all adult patients attending [11, 15, 31] while others risk stratified patients and only included those of low-moderate risk [27]; only those at high-risk [25] or those with potentially avoidable admissions [19, 20]. The selection of ‘high-risk’ patients or those with poor baseline health with a background of chronic illness may be a reason for lack of intervention effect if the underlying chronic conditions increase the risk of admission [8, 26]. In contrast Lee et al., [29], did not restrict their patient sample to ‘high-risk’ patients and suggest that had they chosen the group most likely to benefit from the intervention a positive intervention effect may have been seen.

What is apparent from the study findings is that high quality, prospective research is needed looking at complex interventions within the ED and acute care setting to reduce ED attendance or unplanned admission. In developing interventions researchers need to be guided by existing evidence regarding what may be effective; should ideally use randomised control trial methodology and include a pilot phase [38]. Furthermore, the intervention should be evaluated using an appropriate choice of outcome measures that provide an adequate assessment of the success of the intervention. The successful interventions included in this review include a number of features that may have contributed to their effectiveness and these warrant further high quality research.

Firstly, the literature suggests that ED initiated interventions that include comprehensive assessment or screening and community follow-up or referral have aspects that may have contributed to their effectiveness. The majority of the included studies (19/30) targeted their interventions at adults >55 years highlighting the focus on elderly care patients. Three studies that were effective in reducing admissions all included elderly patients, involved assessment by a specialist nurse and provided further treatment and referrals to appropriate providers [9, 10, 28]. These studies suggest that assessment and management of older people at risk of admission can improve their health outcomes. Accurate identification of patients in need of community support by trained nurses and services with appropriate follow up care may be effective in reducing ED attendance and hospital admission rates. Despite the promise that these interventions hold, the findings are not supported by Mion et al., [26], who reported no statistically significant effect on overall service use rates. This study intervention may have been weakened by a lack of advance practice nurse involvement after follow up which makes comparison with other studies difficult.

Secondly, the results suggest that the qualifications and specialties of the assessing and treating team members may impact on service utilization outcomes. A specialist nurse rather than a triage nurse, used in the intervention by Hegney et al., [10], impacted positively on service utilization. Guttman et al., [28], support this idea. In their intervention, study nurses were selected for their expertise in nursing care and had a minimum of 5 years nursing experience within acute care. This is important as the complexity of discharges and the hurried discharge conditions often present in the ED may be beyond the scope of a primary ED nurse [28]. In addition, as well as the usual emergency physicians, the clinical leads in Conroy et al’s., [15], paper included geriatricians and emergency medicine nurses with additional training in geriatric syndromes and manual handling. Ensuring that team members were appropriately trained to manage and treat or refer patients appropriately may have contributed to the effectiveness of some of the included interventions.

A systematic review that looked at geriatric specific interventions on ED utilization found that the source of patients (ED, out-patient or home care setting) and the type of intervention impacted on the utilization rates [39]. Studies which recruited patients in the ED had little effect on ED utilization, partly, the authors believe, related to the limited follow-up duration for patients discharge from the ED and the difficulty in facilitating appropriate community follow-up and referrals from the ED [39]. Given that only two of the 16 ED based studies in our review were effective in reducing ED attendances or admissions (and a further two on sub-group analysis) may suggest that intervention location may have impacted on these study results. It may be the case that interventions should be trialled away from the time pressured environment of the ED and within observation or assessment wards to reduce unplanned admissions [37]. For patients discharged directly from the ED allowing sufficient time to plan the discharge care of patients may reduce the proportion of unscheduled ED return visits.

Observation and assessment wards, allow a greater length of time to assess and manage patients compared to the ED, and this additional time may have contributed to the positive findings of interventions to prevent re-attendance and readmission in these settings. Older patients who receive comprehensive geriatric assessment, allied health intervention and referral prior to discharge, from an observation unit have decreased ED utilization [15, 33]. Allowing a greater length of time to assess and manage patients enables complaints, other than the primary complaint, to be addressed and these healthcare needs met resulting in reduced ED re-attendance and hospitalisation [33]. As it is not possible to provide comprehensive geriatric assessment to all patients, and for many this would be unnecessary, it is important that these interventions are targeted to high-risk patients [33].

Lastly, patient centred education within the ED may offer promise for specific chronic diseases. The results from the study by Smith et al., [14], found no significant difference in ED attendance rates although, after controlling for GP attendances, the intervention group had significantly fewer re-attendances. Educating patients according to their specific needs, guided by a curriculum, may be useful in reducing re-attendances to the ED as their healthcare needs are met. This finding is echoed in a Cochrane review that summarises education interventions for asthma in the ED which also suggests that hospital readmissions may be reduced through education interventions for asthmatics although the generalisability of the findings need to be confirmed in larger, multi-centred trials [40].

The interventions initiated within 72 h of patient admission have aspects that are similar to the above findings. Interventions that involved patient education, enhanced discharge and included patient follow up after discharge have been shown to decrease readmission and ED visits [25]. In addition, when high-risk patients are identified and their needs are met, including sufficient time to work with patients and families to agree a workable care plan, readmission rates have been seen to decrease [23].

Interventions that targeted specific chronic conditions were limited to four studies. The target populations included patients with: asthma [14], epilepsy [18], heart failure [27] and Type 2 diabetes [35]. The heterogeneity of the patient groups and the interventions precludes making meaningful statements about what is effective in chronic disease management. Patient education and specific clinical pathways require further research in the acute care setting.

It is also important to discuss the paradoxical increase in ED re-attendance and hospital admission that is evident in some of the included studies. Three ED based interventions had this effect [8, 30, 36]. The reasons for this paradoxical increase may be that greater assessment and screening of patients sensitizes patients to health problems and motivates them to seek healthcare and access further services [36]. McCusker et al., [30], also suggest that this increase may be as a result of lack of access to primary care services which is a known predictor for increased ED utilization. These findings have also been seen in a systematic review which concludes that while ED based interventions may show promise they can have the unintended consequence of increased demand on these services [41].

The interventions included in this study can be considered as complex interventions, which include several components [42]. It is acknowledged that interventions classified as ineffective in this review does not necessarily mean that the intervention was ineffective but the findings may be as a result of process failures, how the intervention was implemented or whether the follow-up time was sufficient to provide an adequate assessment of the success or failure of an intervention [38]. Furthermore, many of the interventions included in this study had beneficial effects on other service related outcomes, for example: decreased hospital length of stay [11, 35] or increased contact with PHC following discharge [22]. These outcomes are not covered by our review and it is acknowledged that these interventions may be effective in reducing other important outcomes.