Primary care professionals providing non-urgent care in hospital emergency departments.
Primary care professionals providing non-urgent care in hospital emergency departments.
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DOI：
10.1002/14651858.cd002097.pub3
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发表时间：
2012-11-14
影响因子：
8.4
通讯作者：
Shepperd, Sasha
中科院分区：
文献类型：
--
作者：
Khangura, Jaspreet K.;Flodgren, Gerd;Perera, Rafael;Rowe, Brian H.;Shepperd, Sasha
在许多国家，急诊部门面临着服务需求增加、长时间等待和严重拥挤的问题。缓解过度拥挤的一个对策是为非紧急问题的病人在医院急诊室附近或内部提供基层医疗服务。然而，目前尚不清楚这如何影响病人护理的质量，医院资源的利用，或者它是否具有成本效益。为了评估在医院艾德配置初级保健专业人员为非紧急健康问题患者提供护理的效果，与常规急诊医生（EP）提供的护理相比，我们检索了科克伦有效实践和护理组织（EPOC）组专业注册表;科克伦对照试验中心注册中心（科克伦图书馆，2011年，第4期），MEDLINE（1950年至2012年3月21日）; EMBASE（1980年至2011年4月28日）; CINAHL（1980年至2011年4月28日）; PsychINFO（1967年至2011年4月28日）;社会学文摘（1952年至2011年4月28日）; ASSIA（1987年至2011年4月28日）; SSSCI（1945年至2011年4月28日）; HMIC（1979年至2011年4月28日），未发表文献的来源，纳入论文的参考文献列表和相关系统综述。我们联系了该领域的专家，以获取任何已发表或未发表的研究，并手工检索了过去三年的艾德会议摘要。随机对照试验、非随机研究、前后对照研究和中断时间序列研究，这些研究评价了将初级保健专业人员引入医院急诊室以照顾非紧急患者与常规EP提供的护理相比的有效性。两名评审员独立提取数据，并评估每个纳入研究的偏倚风险。我们联系了纳入研究的作者以获得更多数据。二分结局以风险比（RR）和95%置信区间（CI）表示，连续结局以平均差（MD）和95% CI表示。由于异质性，无法合并。纳入了三项非随机对照研究，共涉及11203例患者，16名全科医生（GP）和52名EP。这些研究评估了引入全科医生为艾德非紧急问题患者提供护理的效果，并与EP进行了资源使用等结局比较。本综述中所有结局的证据质量较低，主要是由于纳入研究的非随机设计。研究的结果在研究中相似;但是存在高度异质性（I2> 86%）。研究之间的差异包括所使用的分类系统，医疗从业人员的专业知识和经验水平以及医院类型（城市教学，郊区社区医院）。其中两项纳入研究报告称，全科医生使用的医疗资源明显少于EP，血液检查次数较少（RR 0.22; 95%CI：0.14 - 0.33; N = 4641; RR 0.35; 95%CI 0.29 - 0.42; N = 4684），X线（RR 0.47; 95% CI 0.41 - 0.54; N = 4641; RR 0.77 95% CI 0.72 - 0.83; N = 4684），住院（RR 0.33; 95% CI 0.19 - 0.58; N = 4641; RR 0.45; 95% CI 0.36 - 0.56; N = 4684）和转诊至专家（RR 0.50; 95% CI 0.39 - 0.63; N = 4641; RR 0.66; 95% CI 0.60 - 0.73; N = 4684）。两项研究中有一项报告全科医生处方数量与EP相比无统计学显著差异（RR 0.95 95% CI 0.88 - 1.03; N = 4641），而另一项研究显示全科医生处方的药物显著多于EP（RR 1.45 95% CI 1.35 - 1.56; N = 4684）。这两项研究的结果表明，在医院急诊室引入全科医生可以节省边际成本。第三项研究（N = 1878）未能确定血液检查次数的显著差异（RR 0.96; 95% CI 0.76 - 1.2），X线（RR 1.07; 95%CI 0.99 - 1.15），或入院（RR 1.11; 95% CI 0.70 - 1.76），但报告转诊至专家的数量显著增加（RR 1.21; 95%CI 1.09 - 1.33）和处方（RR 1.12; 95%CI 1.01 - 1.23）。没有关于患者等待时间、住院时间或患者结局（包括不良反应或死亡率）的数据报告。总的来说，三项纳入研究的证据很弱，因为结果不同，既没有检查安全性也没有检查患者结局。没有足够的证据得出结论，实践或政策的有效性和安全性提供的护理非紧急病人由全科医生与EP在艾德，以减轻过度拥挤的问题，等待时间和病人流量。
In many countries emergency departments (EDs) are facing an increase in demand for services, long-waits and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. It is not known, however, how this impacts the quality of patient care, the utilisation of hospital resources, or if it is cost-effective. To assess the effects of locating primary care professionals in the hospital ED to provide care for patients with non-urgent health problems, compared with care provided by regular Emergency Physicians (EPs), We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialized register; Cochrane Central Register of Controlled Trials (The Cochrane library, 2011, Issue 4), MEDLINE (1950 to March 21 2012); EMBASE (1980 to April 28 2011); CINAHL (1980 to April 28 2011); PsychINFO (1967 to April 28 2011); Sociological Abstracts (1952 to April 28 2011); ASSIA (1987 to April 28 2011); SSSCI (1945 to April 28 2011); HMIC (1979 to April 28 2011), sources of unpublished literature, reference lists of included papers and relevant systematic reviews. We contacted experts in the field for any published or unpublished studies, and hand searched ED conference abstracts from the last three years. Randomised controlled trials, non-randomised studies, controlled before and after studies and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs to attend to non-urgent patients, as compared to the care provided by regular EPs. Two reviewers independently extracted data and assessed the risk of bias for each included study. We contacted authors of included studies to obtain additional data. Dichotomous outcomes are presented as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes are presented as mean differences (MD) with 95% CIs. Pooling was not possible due to heterogeneity. Three non randomised controlled studies involving a total of 11 203 patients, 16 General Practioners (GPs), and 52 EPs, were included. These studies evaluated the effects of introducing GPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The quality of evidence for all outcomes in this review was low, primarily due to the non-randomised design of included studies. The outcomes investigated were similar across studies; however there was high heterogeneity (I2>86%). Differences across studies included the triage system used, the level of expertise and experience of the medical practitioners and type of hospital (urban teaching, suburban community hospital). Two of the included studies report that GPs used significantly fewer healthcare resources than EPs, with fewer blood tests (RR 0.22; 95%CI: 0.14 to 0.33; N=4641; RR 0.35; 95%CI 0.29 to 0.42; N=4684), x-rays (RR 0.47; 95% CI 0.41 to 0.54; N=4641; RR 0.77 95% CI 0.72 to 0.83; N=4684), admissions to hospital (RR 0.33; 95% CI 0.19 to 0.58; N=4641; RR 0.45; 95% CI 0.36 to 0.56; N=4684) and referrals to specialists (RR 0.50; 95% CI 0.39 to 0.63; N=4641; RR 0.66; 95% CI 0.60 to 0.73; N=4684). One of the two studies reported no statistically significant difference in the number of prescriptions made by GPs compared with EPs, (RR 0.95 95% CI 0.88 to 1.03; N=4641), while the other showed that GPs prescribed significantly more medications than EPs (RR 1.45 95% CI 1.35 to 1.56; N=4684). The results from these two studies showed marginal cost savings from introducing GPs in hospital EDs. The third study (N=1878) failed to identify a significant difference in the number of blood tests ordered (RR 0.96; 95% CI 0.76 to 1.2), x-rays (RR 1.07; 95%CI 0.99 to 1.15), or admissions to hospital (RR 1.11; 95% CI 0.70 to 1.76), but reported a significantly greater number of referrals to specialists (RR 1.21; 95% CI 1.09 to 1.33) and prescriptions (RR 1.12; 95% CI 1.01 to 1.23) made by GPs as compared with EPs. No data were reported on patient wait-times, length of hospital stay, or patient outcomes, including adverse effects or mortality. Overall, the evidence from the three included studies is weak, as results are disparate and neither safety nor patient outcomes have been examined. There is insufficient evidence upon which to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs versus EPs in the ED to mitigate problems of overcrowding, wait-times and patient flow.