Grant Kiran L, Bayley Conrad J, Premji Zahra, Lang Eddy, Innes Grant
Faculty of Medicine, University of Toronto, Toronto, ON.
Faculty of Medicine, University of Alberta, Edmonton, AB.
CJEM. 2020 Nov;22(6):864-874. doi: 10.1017/cem.2020.426.
Emergency department (ED) throughput efficiency is largely dependent on staffing and process, and many operational interventions to increase throughput have been described.
We systematically searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials to find studies describing the impact of throughput strategies on ED length of stay and left without being seen rates. Two independent reviewers screened studies, evaluated quality and risk of bias, and stratified eligible studies by intervention type. We assessed statistical heterogeneity using the chi-squared statistic and the I-squared (I2) statistic, and pooled results where appropriate. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.
Ninety-four (94) studies met inclusion criteria (Cohen's k = 0.7). Most were observational, five were determined to be low quality (Cohen's k = 0.6), and almost all reported modest reductions in length of stay and left without being seen rates, although there was substantial variability within and between intervention types. Fast track and patient streaming interventions showed the most consistent reduction in length of stay and left without being seenrates. Shifting high-level providers to triage appears effective and generally cost neutral. Evidence for enhanced testing strategies and alternative staffing models was less compelling.
Introducing a fast track and optimizing processes for important case-mix groups will likely enhance throughput efficiency. Expediting diagnostic and treatment decisions by shifting physician-patient contact to the earliest possible process point (e.g., triage) is an effective cost-neutral strategy to increase flow. Focusing ED staff on operational improvement is likely to improve performance, regardless of the intervention type.
急诊科（ED）的 throughput 效率在很大程度上取决于人员配备和流程，并且已经描述了许多提高 throughput 的运营干预措施。
我们系统地检索了 Medline、Embase、CINAHL 和Cochrane 对照试验中央注册库，以查找描述 throughput 策略对 ED 住院时间和未就诊离开率影响的研究。两名独立的评审员筛选研究、评估质量和偏倚风险，并按干预类型对符合条件的研究进行分层。我们使用卡方统计量和 I 方（I2）统计量评估统计异质性，并在适当情况下汇总结果。遵循系统评价和 Meta 分析的首选报告项目（PRISMA）指南。
94 项研究符合纳入标准（Cohen's k = 0.7）。大多数是观察性研究，5 项被判定为低质量（Cohen's k = 0.6），几乎所有研究都报告住院时间和未就诊离开率有适度降低，尽管干预类型内部和之间存在很大差异。快速通道和患者分流干预措施在住院时间和未就诊离开率方面显示出最一致的降低。将高级医疗人员转移到分诊似乎有效且总体成本中性。增强检测策略和替代人员配备模式的证据不太有说服力。
引入快速通道并优化重要病例组合组的流程可能会提高 throughput 效率。通过将医患接触转移到尽可能早的流程点（例如分诊）来加快诊断和治疗决策是一种有效的成本中性策略，可增加流程。无论干预类型如何，让急诊科工作人员专注于运营改进可能会提高绩效。
