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Table 1 Summary table of studies describing interventions based in the Emergency Department

From: 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

Study (Author, Year, Country)

Target population

Study Design

Intervention

Control

Outcomes

Results/Main Findings

Quality

Emergency Department (ED) based interventions (during ed attendance)

Specialist aged care pharmacist

Mortimer et al., 2011, Australia [12]

Patients: ≥ 65 years with chronic condition or ≥70 years without a chronic condition, all with Australian Triage Category classification >1 (do not require immediate medical attention).

Non-randomised study, alternative allocation based on time of presentation and availability of practitioner. All patients initially assessed by ED doctor.

Medication reconciliation and review, patient education by specialist aged care pharmacist (ACP) and referral where necessary (n = 101). Patients admitted or discharged from Emergency Medicine (EM) department.

Usual-care review by ED doctor (n = 98). Patients admitted or discharged from EM department.

Proportion of patients re-presenting (with the same unresolved problem) to hospital within 14 and 28 days.

No significant difference between the proportions of intervention and control patients re-presenting to hospital within 14 and 28 days. Intervention group patients had a significantly greater average ‘length of stay’ in the Department of Emergency Medicine compared with the control group patients (12 hours : 42 minutes, n = 101 vs. 10 hours : 05 minutes, n = 98, respectively, P < 0.01). Reduced admission rates for intervention group 73/101 vs 92/98 control group (not tested for significance).

Non-randomised study. Potential selection bias, pilot study only.

Patient education in the ED

Smith et al., 2008, Australia [14]

Adult patients, >18 years, arriving at the ED with an acute exacerbation of asthma (diagnosed prior to this visit). Patients excluded if too ill or require intensive medical treatment.

RCT, 2 inner city EDs.

Patient centred education (PCE) underpinned with learner centred principles. Patient had to prioritise the 6 asthma curriculum steps according to perceived need, patients then educated accordingly. Education given during ED presentation (n = 68).

Standard patient education. Following steps 1 to 6 (sequentially) through curriculum (n = 78).

ED secondary care re-attendance rates at 4 and 12 months.

No significant difference between groups at 4 months OR 0.4, (95% CI 0.2 -1.1. No significant difference in re-attendance at 12 months (p = 0.96). In the sub-group of patients with no prior GP care, the PCE patients had significantly fewer re-attendances at 4 months OR 0.1 95% CI 0.0-0.7) and 12 months OR 0.2 95% CI 0.0-0.6. In subset of patients discharged from ED: PCE group had significantly fewer re-attendances at 4 and 12 months OR 0.3 95% CI 0.1-0.9 and 0.3 95% CI 0.1-0.8.

Single researcher educated all patients. Possible contamination of control group patients admitted (may have received further education in hospital).

ED initiated interventions with community component

Comprehensive Geriatric Assessment

Mion et al., 2003, USA [26]

Patients ≥ 65 years, community-residing and fit for discharge (selected from two EDs). Patients designated either high or low risk for repeat ED attendance, hospitalization or nursing home placement and randomisation within each risk status group.

RCT. (2 EDs)

Block randomisation based on stratification by risk of re-attendance.

Comprehensive geriatric assessment in ED by advanced practice nurse & referral to community/social agency, primary care or geriatric clinic. Follow up by nurse after visit by telephone to confirm contact with follow up physician (n = 324).

Usual care (any referral recommendations to community responsibility of participant or proxy to follow up) (n = 326).

Subsequent ED visits at 30 and 120 days, hospitalization at 30 and 120 days after index visit.

No statistically significant effect on overall service use rates at 30 or 120 days.

Sub-group analysis by risk classification at triage. Among the low-risk patients usual care patients less likely to return to the ED in first 30 days than intervention group patients OR 1.9 95% CI 1.0-3.5. No difference in low risk group at 120 days or in high-risk group at 30 or 120 days.

Sample size did not reach the recruitment goal of 800.

McCusker et al., 2003, Canada [30]

ED patients aged ≥ 65, ready for discharge from ED without further intervention but identified as at risk of subsequent ED attendance on Identification of Seniors At

Risk (ISAR) questionnaire.

RCT, multisite (4 EDs).

Geriatric nursing assessment in ED using standardized checklist. Referrals to community health centre, primary physician or other community service where appropriate were made by ED nurse (n = 166).

Usual care (n = 179).

Return visits to ED in month after ED visit.

Intervention group patients more likely to make a return visit to the ED OR 1.6 (95% CI 1.0 to 2.6). Excess ED visits in intervention group limited to patients who hadn’t visited their physician before the index ED visit.

ED staff not blinded to intervention. Individuals not randomised (day of week randomised). Nearly a fifth of patients randomised to intervention group were not able to receive intervention.

Caplan et al., 2004, Australia [9]

Community dwelling older people (≥75 years) discharged home from single urban ED.

RCT (18 month follow up).

Comprehensive geriatric assessment (CGA) over a four week period. CGA would involve any assessment by a specialist nurse who initiated urgent interventions and care plan in ED. Consultation between nurse and inter-disciplinary team including geriatrician weekly led to any further intervention/referral to appropriate practitioner (n = 369).

Usual discharge plan by medical team. (n = 369).

Primary: admissions to any hospital within 30 days of the initial ED visit. Secondary: elective and emergency admissions.

At 18 months significant difference in the rate of emergency admissions in favour of intervention (44.4% vs 54.3%; p = .007).

At 30 days after the initial ED visit significantly fewer total admissions (elective and emergency) in the intervention group than in the control group (61 intervention (16.5%); 82 control (22.2%); p = 0 .048. Although no significant difference in number of emergency admissions at 30 days (P = 0.312).

No significant difference in visits to ED (without admission) within 30 days (p = 0.349)

Assessments post intervention not blinded. Some control group patients may have had CGA from another service.

Arendts et al., 2012, Australia [7]

Patients ≥65 yrs presenting to two EDs with one of the ten presenting complaints often resulting in admission (UTI, respiratory tract infection, fall with minor injury, hip/knee pain, back pain, heart failure, angina, syncope, TIA, new confusion/delirium). Patients requiring urgent medical treatment were excluded.

Non-randomised controlled clinical trial. (2 EDs)

Early comprehensive input from allied health (care coordination team (CCT)) prior to discharge.

CCT team included physiotherapist, occupational therapist and social worker. Physician (usually a geriatrician or geriatric trainee), nursing and other allied health staff such as speech therapists were co-opted to assist the teams as required (n = 3165).

Usual pre-discharge assessment (n = 2100).

Primary outcome: Admission to an inpatient bed from the ED.

Unadjusted 2.4% absolute reduction in admissions in the intervention group. Adjusting for non-randomised design and patient factors the reduction in admissions overall was non-significant (OR 0.88, 95% CI 0.76-1.00, p 0.046). Adjusted sub-group analysis showed significant differences in admissions favouring intervention for angina OR = 0.71 (0.53-0.93) and musculoskeletal OR = 0.67 (0.49-0.93).

Non-randomised study. No follow up of short term readmissions in either group.

Arendts et al., 2013, Australia [8]

Community dwelling patients (≥65 yrs) attending 2 EDs with non-emergency problem.

Patients screened at initial assessment to identify any risk (e.g. falls risk, impaired living) associated with early discharge and assigned to cases or controls based on ‘risk’ or ‘no risk’.

Non-randomised controlled study (2 EDs). Patients identified as those fit for discharge from ED and underwent discharge risk screening.

Positive screen formed the intervention group and matched with controls that were identified as ‘low risk’ on risk screen.

Input from a care coordination team (CCT) prior to discharge for patients screened as at risk from discharge.

CCT team included physiotherapist, occupational therapist and social worker. Physician (usually a geriatrician or geriatric trainee), nursing and other allied health staff such as speech therapists were co-opted to assist the teams as required (n = 1098).

Usual assessment for patients in ‘no risk’ from early discharge (n = 1098).

Primary outcome measure: unplanned ED re-attendance within 28 days.

Unadjusted difference of 3% in 28 day unplanned ED re-attendance rates (17.9% cases, 14.8% controls, P = 0.05).

At 1 year 43.4% of cases and 29.5% of controls had experienced at least one unplanned hospitalisation (P < 0.001).

Non-randomised study. Differences in outcomes unadjusted. Patients in two groups at different risk from discharge.

Foo et al., 2014, Singapore [32]

Patients ≥ 65 years with a TRST (triage risk screening tool) score of 2 or more and who were planned for discharge.

Quasi-randomised controlled trial.

Risk stratification and focused geriatric screening by Geriatric Emergency Medicine nurse. Focused areas included cognition,

mood, continence, visual acuity and hearing, mobility and social issues. Medication reconciliation and postural blood pressure undertaken. Intervention and referral (e.g. geriatric assessment clinic, post-acute home care) and discharge education provided where appropriate (n = 569).

Standard ED care (n = 587).

ED re-attendance and hospitalisation.

The reduction in ED re-attendance (OR 0.75, CI 0.55-1.03, p = 0.07) and hospitalization (OR 0.77, CI 0.57-1.04, p = 0.09) were not significant.

Non-randomised study; large percentage of eligible patients refused to take part or had left ED prior to being asked to take part.

Multi-factorial falls intervention

Shaw et al., 2003, UK [21]

Patients ≥65 years, cognitively impaired or with dementia, referred after fall. Mini-mental state examination score <24. Exclusions medical diagnosis causing fall such as CVA, unable to walk.

RCT (2 EDs within same NHS trust.)

Multifactorial intervention initiated in ED. Multifactorial clinical assessment (Medical, cardiovascular, physio, OT) followed by intervention for all identified falls risk factors (n = 130).

Assessment followed by conventional care (n = 144).

Fall-related attendances to A&E and fall related admissions.

No significant differences between groups for fall related attendances to A&E (OR 1.25; 95% CI: 0.91 to 1.72), fall related admissions and mortality (OR 1.11; 95% CI 0.61 to 2.00).

Small trial, single trust. Limited blinding, for certain outcome measurements only.

Davison et al., 2005, UK [16]

Patients ≥65 years presenting to ED with fall or fall-related injury and at least one additional fall in the preceding year.

RCT (2 EDs in a university teaching hospital and an associated district hospital).

Multifactorial medical and falls assessment including fall history, cardiovascular assessment, gait and mobility assessed by physio and assessment of home risk by OT. Intervention initiated in ED and continued at home by physio/OT where necessary (n = 159).

Usual care provided by ED and primary care physicians (n = 154).

Fall-related hospital admissions and ED attendance over 12 months.

No significant differences in falls related ED attendance (RRR 0.90; CI: 0.55–1.47) or fall-related hospital admission (RR 0.80; CI: 0.41–1.56).

Relatively small sample size of 313, only 282 of patients remained in study at the end of year. There was lack of comparative data on fall risk factors in the control population.

Specialist nurse assessment in ED

Hegney et al., 2006, Australia [10]

Patients >70 years presenting to ED. Patients readmitted for renal dialysis, chemotherapy, palliative care or mental health reasons; and patients from high care residential care facilities excluded.

Before and after study.

Specialist community nurse in the ED undertaking a risk-screening assessment using Screening Tool for Elderly People (STEPS) prior to discharge. Referred to Home and Community Care Service co-ordination team (or direct to community provider) if necessary. (n = 2139).

Before and after design.

Primary outcomes: re-presentation (patients who had previously presented to the ED within the last seven days with same presenting problem) and readmissions to the ED.

Re-presentation rates at the end of the post-intervention period 16% lower than the rates prior to the start of the intervention (X 2 = 15.59, P < 0.001) Readmission rates at the end of the post-intervention period were 5.5% lower than the rates prior to the start of the intervention (X 2 = 4.61, P < 0.05).

Before and after study design.

Differences in service use in intervention period may have been due to seasonal effect in demand.

Nobel et al., 2014, UK [18]

Adults ≥ 18 attending the ED for established epilepsy (documented diagnosis ≥1 year).

Prospective, non-randomised intervention study. (3 EDs).

Epilepsy nurse specialist self-management intervention. Patients offered 2 one-to-one sessions with epilepsy nurse specialists (ENS) and treatment as usual. Recruited in one ED and intervention on out-patient basis (n = 44).

Recruited from 2 EDs. Treatment as usual (n = 41).

Epilepsy-related ED use 12 months post recruitment.

No significant effect on ED visits at 12 months. OR 1.92 (95% CI 0.68, 5.41).

Non-randomised intervention. Low recruitment rate of eligible patients.

ED initiated discharge interventions (discharged directly from ED)

Personal emergency response systems (PERS)

Lee et al., 2007, Canada [29]

Patients ≥70 who presented to single urban ED after a fall identified as fit for discharge to own home. Patients recruited in ED or within 72 hours of discharge home.

RCT (Single blind).

Conventional discharge planning plus free use of personal emergency response systems (PERS). PERS could be triggered by patient in an emergency and directed them to central monitoring station for assessment of response required (e.g. neighbour/relative or 911) (n = 43).

Conventional discharge planning (included assessment by Geriatric Emergency Nurse) (n = 43).

Return visits to the ED within one year of index visit to ED.

Return to ED within 60 days occurred in eight of 43 patients in both the control and treatment groups (RD, 0.0%; 95% CI −16% to 16%). Hospitalization occurred in six of 43 in the control group versus three of 43 in the treatment group (RD 7.0%; 95% CI −19.8% to 5.9%).

Small RCT examining short term impact only. Selection bias by patients refusing to participate or withdrawing.

Nurse led telephone/telehealth post discharge intervention

Biese et al., 2014, USA [22]

Patients aged ≥ 65 discharged to own home from ED with instruction to seek outpatient follow-up.

RCT (single ED).

Post discharge telephone call–mediated intervention by a nurse at 1 to 3 days after each patient’s index ED visit to review discharge instructions and check compliance with medication and/or physician follow up (n = 39).

Placebo group- call to assess patient satisfaction with care (n = 35).

Control group - no follow up (n = 46).

Secondary outcome:. Probability of return visit to the ED within 35 days of the index ED visits.

No differences in ED visits or hospital admissions within 35 days of discharge from the ED (p = 0.41).

Small sample size 160 initially, final analysis (120).

Study not powered to identify a decrease in return visits to the ED.

Wong et al., 2004, China [36]

All patients (adults and children) presenting to ED with problems related to fever, respiratory or gastrointestinal condition. Discharged home from ED and contactable by phone after discharge.

RCT (single ED at acute general hospital).

Two follow up calls from an ER nurse 1–2 days and 3–5 days after ER discharge (n = 395).

Usual post-discharge care (n = 400).

30 day ER return visits.

Significant difference in ER revisit within 30 days. (p = 0.036). Intervention group more likely to return within 30 days.

A number of children included in this study.

Guttman et al., 2004, Canada [28]

Patients aged ≥ 75 years discharged from ED who reside in private home or residence and contactable for follow-up telephone interviews.

Pre/post study. Pre (standard discharge care). Post (intervention - nurse discharge plan coordinator)

Nurse discharge plan coordinator (NDPC) - patient education, coordination of appointments, telephone follow-up and access to NDPC for 7 days after discharge (n = 819).

Standard discharge care (n = 905).

Unscheduled revisits to the ED within 14 days of the index visit.

Non-significant reduction in relative risk of unscheduled return visits in first 14 days for NDPC group (unadjusted RR 0.79; 95% CI 0.62 - 1.02.)

Adjusted for severity of illness significant reduction in unscheduled return visits at day 14, RR = 0.74 (95% CI 0.57- 0.96), and day 8 RR = 0.7 (95% CI 0.51 - 0.96).

Adjusted for all co-variates non-significant decrease in unscheduled return visits: day 14 RR 0.8 (95% Ci 0.55 to 1.15); day 8 RR 0.7 (95% CI 0.44 to 1.10).

No significant difference in unscheduled admission within 14 days of ED discharge (OR 0.92, 95% CI 0.59 to 1.42).

Pre/post design. Patients not blinded.

Small sample size with complete data thus potentially affecting ability to reach significance.