A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?
A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?
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DOI：
10.1136/emermed-2017-207045
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发表时间：
2019-02-01
影响因子：
3.1
通讯作者：
Newton, Amanda S.
中科院分区：
文献类型：
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作者：
Kirkland, Scott William;Soleimani, Amir;Newton, Amanda S.
目标 将患者从急诊科 (ED) 转移出去作为缓解过度拥挤的解决方案。这项系统评价研究了旨在绕过急诊科或在急诊科就诊后引导患者接受其他替代护理的干预措施的影响。方法检索7个电子数据库和灰色文献。符合条件的研究包括评估院前或基于急诊科的分流干预措施有效性的随机/对照试验或队列研究。两名评审员独立筛选了研究的相关性、包容性和偏倚风险。使用随机效应模型将汇总统计数据计算为具有 95% 置信区间 (CI) 的相对风险 (RR)。结果 纳入了 15 项研究，评估院前 (n=11) 或基于急诊室 (n=4) 的分流干预措施。研究的质量从中到低不等。院前研究 (n=3) 中被认为适合分流的患者范围为 19.2% 至 90.4%，基于急诊科的研究 (n=4) 中被认为适合分流的患者范围为 19% 至 36%。在符合条件的患者中，与院前转院（中位数 40%；IQR 24-57%）相比，通过急诊科转院转院的患者比例往往更高（中位数 85%；IQR 76-93%）。总体而言，与标准护理相比，院前分流并没有降低转入急诊室的患者比例（RR 0.92；95% CI 0.80 至 1.06）。与未转院的患者相比，通过院前转院转院的患者随后的急诊室利用率没有显着下降（RR 1.09；95% CI 0.99 至 1.21）。在完成成本分析的三项院前研究中，没有发现转移患者和非转移患者之间的总医疗费用存在显着差异。结论 没有确凿的证据表明分流策略对急诊室利用和随后的医疗保健利用的影响。研究的整体质量限制了本次审查得出明确结论的能力，在广泛实施之前需要进行更多研究。
Objectives Diverting patients away from the emergency department (ED) has been proposed as a solution for mitigating overcrowding. This systematic review examined the impact of interventions designed to either bypass the ED or direct patients to other alternative care after ED presentation. Methods Seven electronic databases and the grey literature were searched. Eligible studies included randomised/controlled trials or cohort studies that assessed the effectiveness of pre-hospital or ED-based diversion interventions. Two reviewers independently screened the studies for relevance, inclusion and risk of bias. Pooled statistics were calculated as relative risks (RR) with 95% confidence intervals (CI) using a random effects model. Results Fifteen studies were included evaluating pre-hospital (n=11) or ED-based (n=4) diversion interventions. The quality of the studies ranged from moderate to low. Patients deemed suitable for diversion among the pre-hospital studies (n=3) ranged from 19.2% to 90.4% and from 19% to 36% in ED-based studies (n=4). Of the eligible patients, the proportion of patients diverted via ED-based diversion tended to be higher (median 85%; IQR 76-93%) compared with pre-hospital diversion (median 40%; IQR 24-57%). Overall, pre-hospital diversion did not decrease the proportion of patients transferred to the ED compared with standard care (RR 0.92; 95% CI 0.80 to 1.06). There was no significant decrease in subsequent ED utilisation among patients diverted via pre-hospital diversion compared with non-diverted patients (RR 1.09; 95% CI 0.99 to 1.21). Of the three pre-hospital studies completing a cost analysis, none found a significant difference in total healthcare costs between diverted and non-diverted patients. Conclusion There was no conclusive evidence regarding the impact of diversion strategies on ED utilisation and subsequent healthcare utilisation. The overall quality of the research limited the ability of this review to draw definitive conclusions and more research is required prior to widespread implementation.