Can facility-based transitional care improve patient flow? Lessons from four Canadian regions

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

BACKGROUND

Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow.

METHODS

An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework.

RESULTS

The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction.

CONCLUSIONS

This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.

The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study

The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.

The downward referral experiences of stroke caregivers in the regional medical alliance in China: A phenomenological study

The downward referral platform in the regional medical alliance has provided more possibilities to follow-up rehabilitation and transitional care for increasing stroke survivors, which also has the most contributions in the rational use of resources and health promotion of stroke survivors. However the downward referral rate is low compared to upward referral. At present, no scholars have explored the downward referral experiences of medical demanders from the perspective of qualitative study, and these experiences may also most truly reflect the influencing factors of their unwillingness to downward referral. Therefore, this study explored the subjective experiences of stroke caregivers who had experienced the downward referral, because stroke attacks often lead to lack of autonomy of patients themselves, making it difficult to complete interviews with them. A descriptive phenomenological study was adopted. A purposive sampling strategy was used to recruit 13 stroke caregivers. Interviews were guided by a semi-structured interview-guide encouraging interviewees to reflect on their experiences with downward referral. Coliazzi's data analysis process was applied. The analysis of the data revealed 4 themes: coping challenges; disrupted information; gaps in medical and nursing transition, and potential enabling factors. The results of this study showed that the lack of knowledge of medical alliance, non-sharing of medical information and non-homogeneousness of medical quality were identified to be impeding positive attitude towards downward referral and be factors of bad experiences. Of course, the interviewees had positive experiences such as smooth referral and comfortable environment. These may be potential enabling factors to their attitude towards downward referral. The challenges and needs of medical demanders after downward referral are worthy of attention, and these should be solved by corresponding measures to improve the downward referral rate and referral experiences.

Despite Interventions, Emergency Flow Stagnates in Urban Western Canada

Purpose

This paper reports the quantitative component of a mixed-methods study of patient flow in the 10 urban health regions/zones of Western Canada. We assessed whether jurisdictions differed meaningfully in their emergency flow performance, defined as mean emergency department length of stay (ED LOS).

Methods

We used hierarchical linear modelling to compare ED LOS across jurisdictions, based on nationally reported data for 2017 to 2018. We also explored 36-month performance trends. Admitted and discharged patients were analyzed separately.

Results

With the exception of one high performer, no region's performance differed significantly from average for both admitted and discharged patients. The regions' levels of performance remained largely static throughout the study period.

Conclusions

Results precluded any mixed-methods comparison of high- and low-performing regions. However, they converged with our qualitative findings, which suggested that most regions were pursuing similar flow-improvement strategies with limited effectiveness. Deeper changes may be required to address persistent misalignment between capacity and demand.