Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

Samadbeik, Mahnaz; Staib, Andrew; Boyle, Justin; Khanna, Sankalp; Bosley, Emma; Bodnar, Daniel; Lind, James; Austin, Jodie A.; Tanner, Sarah; Meshkat, Yasaman; de Courten, Barbora; Sullivan, Clair

doi:10.1186/s12913-024-10725-6

Table 6 Management-organisation-policy interventions for patient flow improvement

From: Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

Main Category: Management-organisation-policy interventions		Phases
Main Category: Management-organisation-policy interventions		Pre-ED	Within-ED Ward	Post-ED
Category	Subcategories/Examples	Pre-ED	Within-ED Ward	Ward	Home	Residential care
Process improvement	Triage Process and protocol
	- Triage protocol to guide ambulance clinician's decision-making [56]	±
	- Triaged on scene [56]	NR
	- Prehospital or ED based diversion strategy [56, 70]	=	=
	- Low-Acuity Patient management at triage/Management of low priority tag [13, 15, 56, 69, 72]	±	±
	- Paramedics' accurate patient triage in on-scene triage [56, 67]	+
	-Tailored Care Pathways through Screening [30, 78]		NR
	- Streamlined consultation-to-decision process/Restructuring the consultation process [13, 15, 31, 78]		±
	- Observation unit interventions [30]		NR
	- Staggering of Elective Surgeries [34]			+
	Structural reorganisation/Operational Changes
	- Overcapacity protocols [7, 15, 27, 31, 75]		±	±
	- Extended operating hours (after-hours primary care and ED utilisation) [7, 36, 69, 75]	±	±	±	±
	- System-wide interventions/whole systems approach [7, 29]	+	+	+
	- Enhanced ED workflow (process) redesign [7, 30, 73]		NR
	- Implementation of resources, capacity, and demand Strategies for improvement [29, 75]		NR
Process improvement	- Additional support from hospital leaders and specialists provided to the ED during crowded periods [15, 75]		+
	- Standardise ED efficiency measures [35]		NR
	- Application of queuing theory to optimise patient flow [73]		+
	- Lean approach for ED process redesign [34, 35, 73, 75, 79]		±	±
	- Application of six sigma for improving the patient flow [15, 75, 79]		±	±
	- Implementing contingency strategy [75]		NR
	- Application of the Plan-Do-Check-Act (PDCA) or Plan, Do, Study, Act (PDSA) cycle for solving LOS and discharge problem [29, 73]		+	+
	- Data-driven management and implementation of a data-driven stat lab [29, 72, 75]		NR	NR
	- Standardisation of the admission process [15, 31, 75]		+
	- Implementation nationally mandated, timed patient disposition targets and guidelines [7, 31, 75]		NR
	- Bedside registration [7, 15, 72]		+
	- Interventions to bypass ED consultations with direct admission [78]		+
	- Capacity Command Centers (CCCs) for patient flow management [60]		+	+
	- Expanded Point of Care Testing [7, 30, 34, 35, 64]		±
	- Prioritising laboratory tests/Shorter turnaround-times for laboratory tests [7, 29]		+	+
	- Quality improvement program with feedback [65, 73]					+
Process improvement	- Care transitions (handover processes) and discharge management/Timely patient handover and discharge processes [29, 30, 32, 34, 67, 75, 76]		NR	+	+	NR
	- Identifying discharges, the day before [29]			NR
	- Lateral transfers and flexible bed allocation [34]		±	±
	- Investing in primary care [72]	+
	- Fast-Track Services/Streaming or Split-flow processes (for nonemergency cases) [7, 15, 34, 64, 69, 73]		±
	- Re-evaluating all patients staying in hospital for ≥ 14 days to facilitate their discharge [72]			+
	- Monitoring the ICU and cardiac telemetry census [15]			+
	- Minimising delays for patients being admitted [13]			+
Communication and collaboration	Care Coordination and Management
	- Implementation of coordinators/care coordination [7, 75, 76]	±	±	±
	- Formation of huddles and bed management meetings/bed management and bed allocation [15, 29, 75, 76]		+	+
	- Refined patient assignment and referral [30]		NR
	-On-site primary and acute treatment for specific conditions in long-term care facilities [65, 71]					+
	- Implementation of a surgical specialised care team [78]		+
	- Team composition interventions [30, 32, 60, 65, 69, 74]		±			±
	- Transfer documentation from long-term care to ED and vice versa [65]		=			=
	- Physician‒nurse triage teams/PHCPs (GPs, NP and nurses with increased authority in ED triage) [27, 29, 64, 68, 69]		+
Communication and collaboration	Integrated/collaborative care
	- Mental health team collocation models [34, 64, 70]			±
	- Early Interdisciplinary Assessment and Intervention in ED [15, 30, 59, 64, 74]		±
Accommodating the diverse needs of patients	- Bridge care for older adults occurring before and after ED discharge [67]	NR				NR
	- Geriatric focused nurse assessment and intervention in the ED [74, 80]		±
	- Integration of risk screening and comprehensive geriatric assessment into primary care [80]	±
	- "No wait" policy for older adults (immediate room placement) [32]		+
	- High-risk elderly patient identification (readmission prevention) [32]		NR			NR
	- Acute care emergency surgery service provision (ACCESS) [75]		+	+
	- Geriatric ED patient liaison [32, 66, 74]		NR			NR
	- Geriatric ED unit [32, 66, 67, 74]		±			±
	- Implementation of end-of-life or palliative care services [71]					+
	- Geriatric acute care unit [32, 74]		±
	- Aged Care Pharmacist Intervention [32, 67, 68, 74] (Patient education, medication reconciliation, and referrals)		±	±		±
	- Creating a frail-friendly environment in the ED [80]		NR
	- Implementation of a Stroke Discharge Nurse Navigator Program [76]			+
	- Implementing a Radiographer-Led Discharge (RLD) Program for minor injuries [77]		+
	- Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) of long-term care patients [71]					+
	- Implementation of Extended Care Paramedics in long-term care centres [71]					+
	- Availability of surgeons to provide nontraumatic surgical consults [78]		+
	- Specialised observation units [30]		NR
	- Patient-centred discharge coordination [32]		+
	- Volunteer-led patient support and engagement [32]		NR
	- ED hearing loss screening and assistive listening device provision [32]		+
	- Colocated psychiatry liaison personnel and spaces [30, 78]		±
	- Implementing Prognostic and diagnostic tools to identify frailty [74]		±	±
	- Professional Interpreters in ED (Language Support) [57, 75]		+
Community health-related interventions	- Increases in community-based healthcare capacity, accessibility and infrastructure (prehospital care, patient-centred medical home, rural health clinics) [13, 29, 34, 69, 74]	NR
	- Home-based healthcare optimisation [34, 74]				+
	- Free access to primary care for the uninsured [69, 75]	+			+
	- Providing long-term care facilities [34]					+
	- Epidemiology-based interventions [34]				NR

Outcomes of interventions: ( +): Positive outcome; (-): Negative outcome; ( ±): Mixed outcome/conflicting evidence; ( =): Nonsignificant outcome/no difference; (NR): Not reported/limited evidence

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ISSN: 1472-6963

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