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Samadbeik M, Staib A, Boyle J, Khanna S, Bosley E, Bodnar D, Lind J, Austin JA, Tanner S, Meshkat Y, de Courten B, Sullivan C. Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system. BMC Health Serv Res 2024; 24:274. [PMID: 38443894 PMCID: PMC10913567 DOI: 10.1186/s12913-024-10725-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024] Open
Abstract
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.
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Affiliation(s)
- Mahnaz Samadbeik
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia.
| | - Andrew Staib
- Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Justin Boyle
- The Australian E-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - Sankalp Khanna
- The Australian E-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Queensland Government, Brisbane, Australia
| | - Daniel Bodnar
- Queensland Ambulance Service, Queensland Government, Brisbane, Australia
| | - James Lind
- Gold Coast University Hospital, Gold Coast, Australia
| | - Jodie A Austin
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Sarah Tanner
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Yasaman Meshkat
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Barbora de Courten
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Clair Sullivan
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
- Department of Health, Metro North Hospital and Health Service, Brisbane, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
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Long JC, Carrigan A, Roberts N, Clay-Williams R, Hibbert PD, Zurynski Y, Maka K, Loy G, Braithwaite J. Consumer and provider perceptions of the specialist unit model of care: A qualitative study. PLoS One 2024; 19:e0293025. [PMID: 38346042 PMCID: PMC10861032 DOI: 10.1371/journal.pone.0293025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/04/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Specialist care units cater to targeted cohorts of patients, applying evidence-based practice to people with a specific condition (e.g., dementia) or meeting other specific criteria (e.g., children). This paper aimed to collate perceptions of local consumers and health providers around specialist care units, as a model of care that may be considered for a new local healthcare facility. METHODS This was a qualitative study using two-hour workshops and interviews to collect data. Participants were consumers and health providers in the planned facility's catchment: 49 suburbs in metropolitan Australia. Consumers and health providers were recruited through advertisements and emails. An initial survey collected demographic details. Consumers and health providers participated in separate two-hour workshops in which a scenario around the specialist unit model was presented and discussion on benefits, barriers and enablers of the model was led by researchers. Detailed notes were taken for analysis. RESULTS Five consumer workshops (n = 22 participants) and five health provider workshops (n = 42) were conducted. Participants were representative of this culturally diverse region. Factors identified by participants as relevant to the specialist unit model of care included: accessibility; a perceived narrow scope of practice; coordination with other services; resources and infrastructure; and awareness and expectations of the units. Some factors identified as risks or barriers when absent were identified as strengths and enablers when present by both groups of participants. CONCLUSIONS Positive views of the model centred on the higher perceived quality of care received in the units. Negative views centred on a perceived narrow scope of care and lack of flexibility. Consumers hinted, and providers stated explicitly, that the model needed to be complemented by an integrated model of care model to enable continuity of care and easy transfer of patients into and out of the specialist unit.
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Affiliation(s)
- Janet C. Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Ann Carrigan
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Natalie Roberts
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter D. Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Yvonne Zurynski
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Katherine Maka
- Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Graeme Loy
- Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Kreindler SA, Hunter M, Lea GW, Archibald M, Rieger K, West C, Hasan SM. Lifting the curtain on the emergency department crisis: a multi-method reception study of Larry Saves the Canadian Healthcare System. BMC Health Serv Res 2024; 24:13. [PMID: 38178141 PMCID: PMC10765753 DOI: 10.1186/s12913-023-10512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Despite growing evidence of the potential of arts-based modalities to translate knowledge and spark discussion on complex issues, applications to health policy are rare. This study explored the potential of a research-based theatrical video to increase public capacity and motivation to engage with the complex issues that make Emergency Department wait times such an intractable problem. METHODS Larry Saves the Canadian Healthcare System is a digital musical micro-series developed from extensive research examining system-level causes of Emergency crowding and the ineffectiveness of prevailing approaches. We released individual episodes and a revised full-length version on YouTube, using organic promotion strategies and paid advertising. We used YouTube Analytics to track views, engagement and viewer demographics, and content-analyzed viewer comments. We also conducted five university-based screenings; 92 students completed questionnaires, rating Larry on 16 descriptors using a 7-point Likert scale. RESULTS From June 2022 through May 2023, Larry garnered over 100,000 views (76,752 of the full-length version, 35,535 of episodes), 1329 likes, 2780 shares, and 139 comments. Views and watch time were higher among women and positively associated with age. Among YouTube comments, the predominating themes were praise for the video and criticism of the healthcare system. Many commenters applauded the show's accuracy, humor, and/or resonance with their experience; several shared healthcare horror stories. Students overwhelmingly agreed with all positive and disagreed with all negative descriptors, and nearly unanimously deemed the video informative, thought-provoking, and entertaining. Most also affirmed that it had increased their knowledge, interest, and confidence to participate in discussions about healthcare issues. Neither gender, primary language, nor employment in healthcare predicted ratings, but graduate students and those 25+ years old evaluated the video most positively. DISCUSSION These findings highlight the promise of research-informed musical satire to inform and invigorate discourse on an urgent health policy problem. Larry has reached tens of thousands of viewers, garnered excellent feedback, and received high student ratings. Further research should directly assess educational and behavioural outcomes and explore what facilitative strategies could maximize this knowledge translation product's potential to foster informed, impactful policy dialogue.
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Affiliation(s)
- Sara A Kreindler
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W, Canada.
| | - Mikayla Hunter
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W, Canada
| | - Graham W Lea
- Faculty of Education, University of Manitoba, 71 Curry Pl, Winnipeg, MB, R3T 2N2, Canada
| | - Mandy Archibald
- College of Nursing, University of Manitoba, 99 Curry Pl, Winnipeg, MB, R3T 2M6, Canada
| | - Kendra Rieger
- School of Nursing, Trinity Western University, 22500 University Drive, Neufeld Science Building, Langley, BC, V2Y 1Y1, Canada
| | - Christina West
- College of Nursing, University of Manitoba, 99 Curry Pl, Winnipeg, MB, R3T 2M6, Canada
| | - Shaikh Mehdi Hasan
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W, Canada
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Dionne É, Haggerty J, Scott CM, Doucet S, Stewart T, Quesnel-Vallée A, Montelpare W, Urquhart R, Sutherland JM, Couturier Y. Toward Comprehensive Care Integration in Canada: Delphi Process Findings from Researchers, Clinicians, Patients and Decision Makers. Healthc Policy 2023; 19:24-38. [PMID: 37850703 PMCID: PMC10594939 DOI: 10.12927/hcpol.2023.27181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
Introduction From a larger study examining policy and program information on how Canadian provinces integrate care services, this study aimed to create "priority lists" of 10-15 services that are "absolutely needed" for care integration. Methodology A diverse group of over 50 Canadian stakeholders participated in virtual consensus-building using the nominal group technique and a modified e-Delphi method to identify services that focused on two different groups: children and youth with high functional health needs and older adults in functional decline. Results Three lists - containing services, processes and infrastructure elements - emerged: one per tracer condition group and a consolidated list. The latter identified the following five services as top priority for primary care integration: mental health and addictions services; home care; transition between urgent-emergency-acute care; medication reconciliation in community pharmacies; and respite care. No single social service was a clear priority, but those that mitigate material deprivation emerged within the top 10. Discussion This humble pan-Canadian study shows that priority services in health and social services are neither well integrated nor connected to primary care. It also suggests that effective policy strategizing for primary care integration for those with complex care needs may require thinking beyond the logic of services - given their siloed organization.
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Affiliation(s)
- Émilie Dionne
- Researcher and Adjunct Professor, VITAM - Centre de recherche en santé durable, Department of Sociology, Faculty of Social Sciences, Laval University, Quebec City, QC
| | - Jeannie Haggerty
- McGill Research Chair in Family and Community Medicine, McGill University and St. Mary's Hospital Research Centre, Montréal, QC
| | - Catherine M Scott
- Adjunct Professor, University of Calgary and University of British Columbia-Okanagan, Executive Coach and Knowledge Mobilisation Consultant, K2A Consulting, Calgary, AB
| | - Shelley Doucet
- Jarislowsky Chair in Interprofessional Patient-Centred Care, Associate Professor, Department of Nursing and Health Sciences, University of New Brunswick, Saint John, NB
| | - Tara Stewart
- Assistant Professor, Department of Community Health Sciences, University of Manitoba, Researcher/Evaluator, George & Fay Yee Centre for Healthcare Innovation, Manitoba SPOR SUPPORT Unit, Winnipeg, MB
| | - Amélie Quesnel-Vallée
- Canada Research Chair in Policies and Health Inequalities, Professor, Department of Epidemiology, Biostatistics and Occupational Health, Department of Sociology, McGill University, Montréal, QC
| | - William Montelpare
- Margaret and Wallace McCain Chair in Human Development and Health, Professor, Department of Applied Human Sciences, University of Prince Edward Island, Charlottetown, PEI
| | - Robin Urquhart
- Endowed Chair in Population Cancer Research, Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS
| | - Jason M Sutherland
- Professor, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC
| | - Yves Couturier
- Scientific Director and Réseau-1 Quebec Professor, École de travail social, Faculté des lettres et des sciences humaines, Université de Sherbrooke, Sherbrooke, QC
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Mendelsohn E, Honeyford K, Brittin A, Mercuri L, Klaber RE, Expert P, Costelloe C. The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study. Sci Rep 2023; 13:15417. [PMID: 37723183 PMCID: PMC10507077 DOI: 10.1038/s41598-023-41966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Luca Mercuri
- Information Communications and Technology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Robert Edward Klaber
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Academic Centre for Paediatrics and Child Health, Imperial College London, London, UK
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Kreindler SA, Schull MJ, Rowe BH, Doupe MB, Metge CJ. Despite Interventions, Emergency Flow Stagnates in Urban Western Canada. ACTA ACUST UNITED AC 2021; 16:70-83. [PMID: 34129479 DOI: 10.12927/hcpol.2021.26498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Sara A Kreindler
- Assistant Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
| | - Michael J Schull
- Professor, Department of Medicine, University of Toronto; President and CEO, Institute for Clinical Evaluative Sciences, Toronto, ON
| | - Brian H Rowe
- Professor, Department of Emergency Medicine, University of Alberta, Edmonton, AB
| | - Malcolm B Doupe
- Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
| | - Colleen J Metge
- Associate Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
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