Credé Sarah H, O'Keeffe Colin, Mason Suzanne, Sutton Anthea, Howe Emma, Croft Susan J, Whiteside Mike
School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, England.
School of Health and Related Research (ScHARR), The University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
BMC Health Serv Res. 2017 May 16;17(1):355. doi: 10.1186/s12913-017-2299-8.
Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient's journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.
A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000-2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.
Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).
There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.
在全球范围内，医院急诊入院率正在上升。然而，几乎没有证据可用于指导制定干预措施以减少非计划的急诊科就诊和医院入院情况。本证据综合分析的目的是回顾在患者通过急诊科或急性护理机构的过程中所实施的干预措施的证据，这些干预措施旨在管理病情加重的患者，以减少非计划的急诊医院就诊和入院情况。
采用系统文献检索方法，在MEDLINE、EMBASE、CINAHL、Cochrane图书馆和科学网的电子数据库中对2000年至2014年期间的文献进行了快速证据综合分析。本综述纳入的证据仅限于同行评审期刊上发表的随机对照试验（RCT）和观察性研究（有对照组）。纳入的研究为评估针对急诊科或急性护理机构中病情急性加重患者的干预措施，且报告了至少一项与急诊科就诊或非计划入院相关的结果。
30篇论文符合我们的纳入标准：19项干预性研究（14项RCT）和11项对照观察性研究。16项研究在急诊科开展，14项在急性护理机构进行。两项在急诊科开展的研究（一项RCT）在减少急诊科就诊和医院入院方面有效。这两项干预措施均在急诊科启动，并包括出院后社区部分。矛盾的是，3项在急诊科启动的干预措施显示急诊科复诊率有所增加。6项在急性护理机构开展的研究（1项RCT）在减少以下情况方面有效：医院入院、急诊科复诊或再次入院（两项在观察病房，一项在急诊科评估单元，三项在入院后72小时内进行干预）。
没有明确证据表明从患者到达急诊科到入院后72小时这一过程中的特定干预措施对急诊科复诊或再次入院有益。针对高危患者，尤其是老年人的干预措施可能会减少急诊科的使用，值得未来进一步研究。一些在减少非计划的急诊科就诊和入院方面显示有效的干预措施是由经过适当培训的人员在有足够时间评估和管理患者的环境中实施的。
