Credé et al.

BMC Health Services Research (2017) 17:355

DOI 10.1186/s12913-017-2299-8

RESEARCH ARTICLE Open Access

What is the evidence for the management

of patients along the pathway from the
emergency department to acute admission
to reduce unplanned attendance and
admission? An evidence synthesis
Sarah H. Credé1,4*, Colin O’Keeffe1, Suzanne Mason1, Anthea Sutton1, Emma Howe1, Susan J. Croft2
and Mike Whiteside3

Abstract
Background: 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.
Methods: 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.
Results: 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).
Conclusions: 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.
Keywords: Emergency medicine, Unplanned attendance, Avoidable admissions

* Correspondence: s.h.crede@sheffield.ac.uk
1
School of Health and Related Research (ScHARR), The University of Sheffield,
Sheffield, England
4
School of Health and Related Research (ScHARR), The University of Sheffield,
Regent Court, Regent Street, Sheffield S1 4DA, UK
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Credé et al. BMC Health Services Research (2017) 17:355 Page 2 of 18

Background searched, using a pre-determined search strategy, for the

The year-on-year increase in emergency hospital admis- years 2000 – current (2014). Search terms relating to
sions creates additional pressure on health systems inter- emergency medical services or acute care, medical as-
nationally and is a trend that is not abating. In the last sessment or clinical decision units, avoidable admissions
15 years these admissions have increased in England by or re-attendance, demand/burden on health services,
47% [1]. Admission rates are known to vary widely be- chronic disease, long-term conditions, comorbidities,
tween healthcare systems [2], the majority of this vari- and the aged, were combined into a single search strat-
ation is explained by unemployment rates and urban/ egy which was translated across the five bibliographic
rural status, however some variation is explained by fac- databases listed above. Searches were limited to all
tors that are modifiable within healthcare services [3]. adults (16 plus years) and English language publications
Healthcare service related factors associated with higher only. Comments, letters and editorials were excluded as
rates of potentially avoidable admissions included those publication types from the search. Supplementary
related to the patient pathway from the emergency de- searches included citation searching of key references
partment (ED) to acute admission, i.e. ED attendance and a thorough review of reference lists of included pa-
rate, the conversion rate of ED attendances to admis- pers and published reviews. Experts within the field of
sions as well as the proportion of short stay admissions emergency and acute medicine were also consulted for
[3]. Short stay admissions are often managed in desig- additional references.
nated assessment or observation wards/units to reduce
crowding in EDs and avoid unplanned admissions [4]. Selection criteria
A previous review suggests that there is insufficient Evidence included in this review was restricted to con-
evidence for interventions that reduce unplanned hos- trolled and observational studies in peer-reviewed
pital admission in secondary emergency and acute set- journals. Articles reporting on interventions to reduce
tings [5]. Patients arriving in the ED will typically be unnecessary or avoidable unplanned ED/hospital care
assessed, managed, discharged home or admitted to in emergency departments and acute medical units or
hospital. Prior to admission to a hospital ward, this acute care settings were included. Acute medical units
pathway may also involve assessment and management receive patients from emergency departments for ex-
in an acute medical unit, typically for 24 to 72 h [4]. pedited specialist assessment and treatment for a
Along this patient journey surprisingly little evidence period of 24–72 h before discharge or ward transfer
exists to inform the development of interventions to re- [4]. As not all hospitals have acute medical units it
duce unplanned hospital admissions and attendances at was decided that any study reporting an intervention
the ED. Management within the ED, acute assessment that began within 72 h of ED attendance or hospital
and observation units is key in establishing how to opti- admission would be included. Acknowledging that
mise care to reduce unnecessary variation in emergency many interventions occur along the patient’s clinical
admissions across urgent care systems. pathway and include important assessments before,
This study reviewed the evidence on interventions to and patient management after, the attendance we in-
manage people with medical presentations, including cluded interventions that occur within the ED, acute
those with long-term conditions and the frail elderly, who medical units or acute care settings or those that span
present with an acute event to reduce unplanned emer- these settings.
gency hospital attendance and admissions. This review fo- To be eligible for inclusion the study needed to report
cusses specifically on the patient pathway from the ED to at least one outcome related to attendance at the ED, re-
admission, including the observation ward or acute assess- attendance or unplanned admission to hospital. These
ment unit, and uses ED attendance, re-attendance, as well outcomes did not have to be the primary outcome of the
as hospital admission as primary outcome measures. studies to be eligible for inclusion; although in some
papers they will have been. Where the primary outcome
Methods was to reduce admissions or re-attendance this is indi-
A rapid evidence synthesis, using a systematic literature cated in the summary Tables 1 and 2. The definitions of
search, was undertaken. The search was further enhanced the study outcomes provided by the study authors were,
by supplementary search methods. As this was an evi- in many instances, insufficient to determine whether
dence synthesis, following systematic review methodology, re-attendances or readmissions included all presenta-
ethical approval and consent were not required. tions, for any presenting condition, within the defined
time period or only those for the same unresolved
Search strategy problem. Every attempt was made to identify whether
Electronic data bases of MEDLINE, EMBASE, CINAHL; re-attendances and readmissions were related to the
The Cochrane Library and Web of Science were original episode of care.
Table 1 Summary table of studies describing interventions based in the Emergency Department
Study Target population Study Design Intervention Control Outcomes Results/Main Findings Quality
(Author,
Year,
Country)
Emergency Department (ED) based interventions (during ed attendance)
Specialist aged care pharmacist
Mortimer Patients: ≥ 65 years with Non-randomised Medication reconciliation Usual-care review by Proportion of patients No significant difference Non-randomised study.
et al., chronic condition or study, alternative and review, patient ED doctor (n = 98). re-presenting (with between the proportions of Potential selection bias,
2011, ≥70 years without a allocation based on education by specialist Patients admitted or the same unresolved intervention and control pilot study only.
Australia chronic condition, all with time of presentation aged care pharmacist discharged from EM problem) to hospital patients re-presenting to
[12] Australian Triage Category and availability of (ACP) and referral where department. within 14 and 28 days. hospital within 14 and
classification >1 (do not practitioner. All necessary (n = 101). Patients 28 days. Intervention group
require immediate medical patients initially admitted or discharged patients had a significantly
attention). assessed by ED from Emergency Medicine greater average ‘length of
doctor. (EM) department. stay’ in the Department
of Emergency Medicine
compared with the control
Credé et al. BMC Health Services Research (2017) 17:355

group patients (12 hours :

42 minutes, n = 101 vs.
10 hours : 05 minutes,
n = 98, respectively, P < 0.01).
Reduced admission rates for
intervention group 73/101
vs 92/98 control group (not
tested for significance).
Patient education in the ED
Smith et Adult patients, >18 years, RCT, 2 inner city EDs. Patient centred education Standard patient ED secondary care No significant difference Single researcher
al., 2008, arriving at the ED with an (PCE) underpinned with education. re-attendance rates at between groups at educated all patients.
Australia acute exacerbation of learner centred principles. Following steps 1 to 4 and 12 months. 4 months OR 0.4, (95% CI Possible contamination
[14] asthma (diagnosed prior to Patient had to prioritise the 6 (sequentially) 0.2 -1.1. No significant of control group patients
this visit). Patients excluded 6 asthma curriculum steps through curriculum difference in re-attendance admitted (may have
if too ill or require intensive according to perceived (n = 78). at 12 months (p = 0.96). In received further
medical treatment. need, patients then the sub-group of patients education in hospital).
educated accordingly. with no prior GP care,
Education given during ED the PCE patients had
presentation (n = 68). significantly fewer
re-attendances at 4 months
OR 0.1 95% CI 0.0-0.7) and
12 months OR 0.2 95% CI
0.0-0.6. In subset of patients
discharged from ED: PCE
group had significantly
fewer re-attendances at
4 and 12 months OR 0.3
95% CI 0.1-0.9 and 0.3
95% CI 0.1-0.8.
Page 3 of 18
Table 1 Summary table of studies describing interventions based in the Emergency Department (Continued)
ED initiated interventions with community component
Comprehensive Geriatric Assessment
Mion et Patients ≥ 65 years, RCT. (2 EDs) Comprehensive geriatric Usual care Subsequent ED visits No statistically significant Sample size did not
al., 2003, community-residing and Block randomisation assessment in ED by (any referral at 30 and 120 days, effect on overall service reach the recruitment
USA [26] fit for discharge (selected based on advanced practice nurse & recommendations hospitalization at 30 use rates at 30 or 120 days. goal of 800.
from two EDs). Patients stratification by risk referral to community/ to community and 120 days after Sub-group analysis by risk
designated either high of re-attendance. social agency, primary care responsibility of index visit. classification at triage.
or low risk for repeat ED or geriatric clinic. Follow participant or Among the low-risk
attendance, hospitalization up by nurse after visit by proxy to follow up) patients usual care patients
or nursing home placement telephone to confirm (n = 326). less likely to return to the
and randomisation within contact with follow up ED in first 30 days than
each risk status group. physician (n = 324). intervention group patients
OR 1.9 95% CI 1.0-3.5. No
difference in low risk group
at 120 days or in high-risk
group at 30 or 120 days.
McCusker ED patients aged ≥ 65, RCT, multisite (4 EDs). Geriatric nursing Usual care (n = 179). Return visits to ED in Intervention group patients ED staff not blinded to
Credé et al. BMC Health Services Research (2017) 17:355

et al., ready for discharge assessment in ED using month after ED visit. more likely to make a intervention. Individuals
2003, from ED without further standardized checklist. return visit to the ED OR not randomised (day of
Canada intervention but identified Referrals to community 1.6 (95% CI 1.0 to 2.6). week randomised).
[30] as at risk of subsequent health centre, primary Excess ED visits in Nearly a fifth of patients
ED attendance on physician or other intervention group limited randomised to
Identification of Seniors At community service where to patients who hadn’t intervention group were
Risk (ISAR) questionnaire. appropriate were made by visited their physician not able to receive
ED nurse (n = 166). before the index ED visit. intervention.
Caplan et Community dwelling older RCT (18 month Comprehensive geriatric Usual discharge Primary: admissions to At 18 months significant Assessments post
al., 2004, people (≥75 years) follow up). assessment (CGA) over a plan by medical any hospital within difference in the rate of intervention not blinded.
Australia discharged home from four week period. CGA team. (n = 369). 30 days of the initial emergency admissions in Some control group
[9] single urban ED. would involve any ED visit. Secondary: favour of intervention patients may have had
assessment by a specialist elective and emergency (44.4% vs 54.3%; p = .007). CGA from another
nurse who initiated urgent admissions. At 30 days after the initial service.
interventions and care plan ED visit significantly fewer
in ED. Consultation total admissions (elective
between nurse and inter- and emergency) in the
disciplinary team including intervention group than
geriatrician weekly led to in the control group (61
any further intervention/ intervention (16.5%); 82
referral to appropriate control (22.2%); p = 0 .048.
practitioner (n = 369). Although no significant
difference in number of
emergency admissions
at 30 days (P = 0.312).
No significant difference
in visits to ED (without
admission) within 30 days
(p = 0.349)
Page 4 of 18
Table 1 Summary table of studies describing interventions based in the Emergency Department (Continued)
Arendts et Patients ≥65 yrs presenting Non-randomised Early comprehensive input Usual pre-discharge Primary outcome: Unadjusted 2.4% absolute Non-randomised study.
al., 2012, to two EDs with one of the controlled clinical from allied health (care assessment Admission to an reduction in admissions in No follow up of short
Australia ten presenting complaints trial. (2 EDs) coordination team (CCT)) (n = 2100). inpatient bed from the the intervention group. term readmissions in
[7] often resulting in admission prior to discharge. ED. Adjusting for non- either group.
(UTI, respiratory tract CCT team included randomised design and
infection, fall with minor physiotherapist, patient factors the reduction
injury, hip/knee pain, back occupational therapist and in admissions overall was
pain, heart failure, angina, social worker. Physician non-significant (OR 0.88,
syncope, TIA, new (usually a geriatrician or 95% CI 0.76-1.00, p 0.046).
confusion/delirium). geriatric trainee), nursing Adjusted sub-group
Patients requiring urgent and other allied health analysis showed significant
medical treatment were staff such as speech differences in admissions
excluded. therapists were co-opted favouring intervention for
to assist the teams as angina OR = 0.71 (0.53-0.93)
required (n = 3165). and musculoskeletal
OR = 0.67 (0.49-0.93).
Arendts et Community dwelling Non-randomised Input from a care Usual assessment Primary outcome Unadjusted difference of Non-randomised study.
al., 2013, patients (≥65 yrs) attending controlled study coordination team (CCT) for patients in ‘no measure: unplanned 3% in 28 day unplanned Differences in outcomes
Credé et al. BMC Health Services Research (2017) 17:355

Australia 2 EDs with non-emergency (2 EDs). Patients prior to discharge for risk’ from early ED re-attendance ED re-attendance rates unadjusted. Patients in
[8] problem. identified as those fit patients screened as at discharge (n = 1098). within 28 days. (17.9% cases, 14.8% two groups at different
Patients screened at initial for discharge from risk from discharge. controls, P = 0.05). risk from discharge.
assessment to identify any ED and underwent CCT team included At 1 year 43.4% of cases
risk (e.g. falls risk, impaired discharge risk physiotherapist, and 29.5% of controls had
living) associated with early screening. occupational therapist and experienced at least one
discharge and assigned to Positive screen social worker. Physician unplanned hospitalisation
cases or controls based on formed the (usually a geriatrician or (P < 0.001).
‘risk’ or ‘no risk’. intervention group geriatric trainee), nursing
and matched with and other allied health
controls that were staff such as speech
identified as ‘low risk’ therapists were co-opted
on risk screen. to assist the teams as
required (n = 1098).
Foo et al., Patients ≥ 65 years with a Quasi-randomised Risk stratification and Standard ED care ED re-attendance and The reduction in ED Non-randomised study;
2014, TRST (triage risk screening controlled trial. focused geriatric screening (n = 587). hospitalisation. re-attendance (OR 0.75, large percentage of
Singapore tool) score of 2 or more by Geriatric Emergency CI 0.55-1.03, p = 0.07) and eligible patients refused
[32] and who were planned for Medicine nurse. Focused hospitalization (OR 0.77, to take part or had left
discharge. areas included cognition, CI 0.57-1.04, p = 0.09) ED prior to being asked
mood, continence, visual were not significant. to take part.
acuity and hearing, mobility
and social issues.
Medication reconciliation
and postural blood
pressure undertaken.
Intervention and referral
(e.g. geriatric assessment
clinic, post-acute home
care) and discharge
education provided where
appropriate (n = 569).
Page 5 of 18
Table 1 Summary table of studies describing interventions based in the Emergency Department (Continued)
Multi-factorial falls intervention
Shaw et Patients ≥65 years, RCT (2 EDs within Multifactorial intervention Assessment Fall-related attendances No significant differences Small trial, single trust.
al., 2003, cognitively impaired or same NHS trust.) initiated in ED. followed by to A&E and fall related between groups for fall Limited blinding, for
UK [21] with dementia, referred Multifactorial clinical conventional care admissions. related attendances to A&E certain outcome
after fall. Mini-mental state assessment (Medical, (n = 144). (OR 1.25; 95% CI: 0.91 to measurements only.
examination score <24. cardiovascular, physio, OT) 1.72), fall related admissions
Exclusions medical followed by intervention and mortality (OR 1.11; 95%
diagnosis causing fall such for all identified falls risk CI 0.61 to 2.00).
as CVA, unable to walk. factors (n = 130).
Davison et Patients ≥65 years RCT (2 EDs in a Multifactorial medical and Usual care provided Fall-related hospital No significant differences in Relatively small sample
al., 2005, presenting to ED with fall university teaching falls assessment including by ED and primary admissions and ED falls related ED attendance size of 313, only 282 of
UK [16] or fall-related injury and at hospital and an fall history, cardiovascular care physicians attendance over (RRR 0.90; CI: 0.55–1.47) patients remained in
least one additional fall in associated district assessment, gait and mobility (n = 154). 12 months. or fall-related hospital study at the end of year.
the preceding year. hospital). assessed by physio and admission (RR 0.80; There was lack of
assessment of home risk by CI: 0.41–1.56). comparative data on fall
OT. Intervention initiated in risk factors in the control
ED and continued at home population.
Credé et al. BMC Health Services Research (2017) 17:355

by physio/OT where
necessary (n = 159).
Specialist nurse assessment in ED
Hegney et Patients >70 years Before and after Specialist community nurse Before and after Primary outcomes: Re-presentation rates at the Before and after study
al., 2006, presenting to ED. Patients study. in the ED undertaking a design. re-presentation end of the post-intervention design.
Australia readmitted for renal risk-screening assessment (patients who had period 16% lower than the Differences in service use
[10] dialysis, chemotherapy, using Screening Tool for previously presented rates prior to the start of in intervention period
palliative care or mental Elderly People (STEPS) prior to the ED within the the intervention (X 2 = 15.59, may have been due to
health reasons; and patients to discharge. Referred to last seven days with P < 0.001) Readmission rates seasonal effect in
from high care residential Home and Community same presenting at the end of the post- demand.
care facilities excluded. Care Service co-ordination problem) and intervention period were
team (or direct to readmissions to 5.5% lower than the rates
community provider) if the ED. prior to the start of the inter-
necessary. (n = 2139). vention (X 2 = 4.61, P < 0.05).
Nobel et Adults ≥ 18 attending the Prospective, Epilepsy nurse specialist self- Recruited from 2 Epilepsy-related ED use No significant effect on ED Non-randomised
al., 2014, ED for established epilepsy non-randomised management intervention. EDs. Treatment as 12 months post visits at 12 months. OR 1.92 intervention. Low
UK [18] (documented diagnosis intervention study. Patients offered 2 one-to- usual (n = 41). recruitment. (95% CI 0.68, 5.41). recruitment rate of
≥1 year). (3 EDs). one sessions with epilepsy eligible patients.
nurse specialists (ENS) and
treatment as usual. Recruited
in one ED and intervention
on out-patient basis (n = 44).
ED initiated discharge interventions (discharged directly from ED)
Personal emergency response systems (PERS)
Lee et al., Patients ≥70 who presented RCT (Single blind). Conventional discharge Conventional Return visits to the ED Return to ED within 60 days Small RCT examining
2007, to single urban ED after a fall planning plus free use of discharge planning within one year of occurred in eight of 43 short term impact only.
Canada identified as fit for discharge personal emergency (included index visit to ED. patients in both the control Selection bias by patients
[29] to own home. Patients response systems (PERS). assessment by and treatment groups (RD, refusing to participate or
recruited in ED or within PERS could be triggered by Geriatric Emergency 0.0%; 95% CI −16% to 16%). withdrawing.
72 hours of discharge home. patient in an emergency Nurse) (n = 43). Hospitalization occurred
Page 6 of 18
Table 1 Summary table of studies describing interventions based in the Emergency Department (Continued)
and directed them to in six of 43 in the control
central monitoring station group versus three of 43
for assessment of response in the treatment group
required (e.g. neighbour/ (RD 7.0%; 95% CI −19.8%
relative or 911) (n = 43). to 5.9%).
Nurse led telephone/telehealth post discharge intervention
Biese et Patients aged ≥ 65 RCT (single ED). Post discharge telephone Placebo group- call Secondary outcome:. No differences in ED visits Small sample size 160
al., 2014, discharged to own home call–mediated intervention to assess patient Probability of return or hospital admissions initially, final analysis
USA [22] from ED with instruction to by a nurse at 1 to 3 days satisfaction with visit to the ED within within 35 days of discharge (120).
seek outpatient follow-up. after each patient’s index care (n = 35). 35 days of the index from the ED (p = 0.41). Study not powered to
ED visit to review discharge Control group - no ED visits. identify a decrease in
instructions and check follow up (n = 46). return visits to the ED.
compliance with medication
and/or physician follow up
(n = 39).
Wong et All patients (adults and RCT (single ED at Two follow up calls from an Usual post- 30 day ER return visits. Significant difference in A number of children
al., 2004, children) presenting to acute general ER nurse 1–2 days and 3–5 discharge care ER revisit within 30 days. included in this study.
Credé et al. BMC Health Services Research (2017) 17:355

China [36] ED with problems related hospital). days after ER discharge (n (n = 400). (p = 0.036). Intervention
to fever, respiratory or = 395). group more likely to return
gastrointestinal condition. within 30 days.
Discharged home from ED
and contactable by phone
after discharge.
Guttman Patients aged ≥ 75 years Pre/post study. Pre Nurse discharge plan Standard discharge Unscheduled revisits to Non-significant reduction in Pre/post design.
et al., discharged from ED who (standard discharge coordinator (NDPC) - care (n = 905). the ED within 14 days relative risk of unscheduled Patients not blinded.
2004, reside in private home or care). Post patient education, of the index visit. return visits in first 14 days Small sample size with
Canada residence and contactable (intervention - nurse coordination of for NDPC group (unadjusted complete data thus
[28] for follow-up telephone discharge plan appointments, telephone RR 0.79; 95% CI 0.62 - 1.02.) potentially affecting
interviews. coordinator) follow-up and access to Adjusted for severity of ability to reach
NDPC for 7 days after illness significant reduction significance.
discharge (n = 819). in unscheduled return visits
at day 14, RR = 0.74 (95% CI
0.57- 0.96), and day 8 RR = 0.7
(95% CI 0.51 - 0.96).
Adjusted for all co-variates
non-significant decrease in
unscheduled return visits:
day 14 RR 0.8 (95% Ci 0.55
to 1.15); day 8 RR 0.7 (95%
CI 0.44 to 1.10).
No significant difference in
unscheduled admission
within 14 days of ED
discharge (OR 0.92, 95%
CI 0.59 to 1.42).
Page 7 of 18
Table 2 Summary table of studies describing interventions based in acute care settings
Study Target population Study Design & setting Intervention Control Outcomes Results/Main Findings Quality
(Author,
Year,
Country)
Interventions in emergency observation and assessment wards
Emergency Department Observation or Decision units
Storrow et Patients ≥18 undergoing Observational sequential Observation unit available Heart failure standard Repeat visits to ED No significant difference in Potential for enrolment
al., 2005, evaluation for suspected cohort study (pilot study). to treating physician to care without and readmission hospital readmission rates bias by treating
USA [27] heart failure (HF) exacerbation. Observation unit use in treatment (n = 28). observation unit with primary (p = 0.538). physician.
Only those classified as low- established in ED. available to treating complaint of HF all Observational study.
to-moderate-risk eligible physicians (n = 36). within 30 days.
for inclusion.
Foo et al., Patients ≥ 65 in the Before/after prospective Geriatric assessment and Historical controls Unscheduled ED Significant reduction in ED Before/after design.
2012, emergency department study. intervention in the EDOU received usual EDOU re-attendance and re-attendance at 3, 6, 9 Possible that
Singapore observation unit (EDOU). Emergency department prior to discharge by care (n = 172). hospitalisation at 3, and 12 months: overall recruitment
[33] Thirteen conditions were observation unit. emergency nurse trained 6, 9 and reduction of 41% (adjusted process favoured a
accepted into the EDOU. in geriatric care; exploring 12 months. IRR 0.59, 95% CI 0.48–0. 71) positive outcome.
Credé et al. BMC Health Services Research (2017) 17:355

Patients excluded if had the patient’s medical, social at 12 months.

poor premorbid condition, and functional status (with Hospitalisation rates
nursing home resident or referral to physiotherapist, significantly reduced at 3, 6,
those admitted to inpatient appropriate community or 9 and 12 months: overall
ward from EDOU. social care services or GP if reduction of 36% (adjusted
required) (n = 315). IRR 0.64, 95% CI 0.51–0.79)
Schull et Data suggest adult Retrospective analysis of the 7 Pilot CDU sites. Staffing 9 EDs without a CDU. Admission rates, Small decrease in hospital Only 4% of ED patients
al., 2012, patients attending ED. difference in median ED LOS models varied by site. ED had been ED revisit rates admission rate high-acuity admitted to CDUs. No
Canada and admission rates among Variation in CDU protocols. unsuccessful in applying (after 48 hours, patients: −0.8% (−1.5% mention of target
[31] all ED visits after versus Number of beds varied by for pilot-CDU funding 72 hours, 7 days to −0.03%) and moderate- population. Difficult to
before CDU implementation CDU site (n = 455, 942). (n = 1,172,305). and 30 days) and acuity patients: −0.6% see efficiency gains.
at pilot-CDU and control ED length of stay. (−1.1% to −0.2%). No Pilot study. Missing
sites. First 18 months of CDU changes in ED revisit rates. retrospective data.
operation compared with 4% of ED patients admitted Different sites had
1 year baseline period to CDUs. different protocols,
prior to CDU. staffing etc.
Pilot-CDU sites (7). All
CDUs within or next to ED.
Conroy et Patients presenting to ED Pre-post cohort before and Comprehensive geriatric Usual care (model of Primary: ED Admissions (ED conversion No concurrent control
al., 2014, ≥16 years. after establishment of assessment in the EFU. care using Emergency conversion rate rate) for patients >85 years group therefore causal
UK [15] Emergency Frailty Unit Unit included input of Decision Unit without (admission fell from 69.6% (control) to effect difficult to
(EFU). acute medical consultant specialist geriatric input) avoidance). 61.2% (intervention) (95% establish.
Emergency Frailty Unit and later full geriatrician situated in ED (n = 109, Secondary: CI: 66.0– 73.1%) in the
(EFU). coverage (08 h00 – 18 h00, 994). readmissions control period, p < 0.001.
7 days a week). Intervention following RR 0.88 (95% CI 0.81-0.95)
moved to geriatrician attendance at 7,30 Readmission rates fell across
integrated assessment and 90 days. all age groups comparing
with focus on patients intervention and control
identified for discharge and groups. Readmission risk
improvement of pathways to ratio for those 85+ 0.77
community. (n = 110, 517). (95% CI: 0.63–0.93) for
Page 8 of 18

90 day readmissions.
Table 2 Summary table of studies describing interventions based in acute care settings (Continued)
ED attendance increased in
older people (65+) over the
study period. ED attendance
decreased for 16–64 year
olds over study period.
Emergency Department Assessment units/wards
Li et al., All general medical Retrospective before and Establishment of an acute ED patients requiring Rate of unplanned No change in the rates of Observational,
2010, patients presenting to ED. after study. Before and assessment unit. Remit to admission either readmissions unplanned readmissions uncontrolled study.
Australia after the establishment of receive adult patients referred to subspecialty within 7 and within 7 and 28 days. At May be affected by
[11] an AAU. who were not clinically service or to an 28 days. 7 days 3.8% (pre AAU) vs unknown bias and
Acute assessment unit at a appropriate for sub-speciality ‘on-take’ medical team 3.7% (post AAU). At 28 days confounders.
University teaching medical unit or for a surgical of the day (n = 2652). 8.7% (pre AAU) and 8%
hospital service (n = 3992). (post AAU) (p = 0.80).
Roberts et Patients ≥16 with Retrospective cohort. CDU All patients who Three comparison 30-day unplanned Significant difference found Historical cohorts can’t
al., 2010, probable medical cohort compared to three participated in the pilot cohorts chosen from re-attendance rate in admission patterns of exclude residual
UK conditions, likely to be age-stratified, historical CDU were included in the the preceding 3 years for those not the different cohorts. confounding.
(Northern admitted through cohorts from same study cohort (n = 854). −2003, 2004 & 2005. hospitalized, and Approximately 511 (59.8%,
Credé et al. BMC Health Services Research (2017) 17:355

Ireland) processes of standard ED clinical centre. Most patients in the CDU These patients monthly medical 95% CI: 56.5-63.1%) to 560
[19] care, but may potentially Clinical decision unit (CDU) group sourced from the identified as those admission figures. (65.6%, 95% CI: 62.3-68.7%)
have been managed by a located within ED. Pilot ‘Major’ area in the ED. classified as ‘Medical’ admitted in comparison
GP or as an out-patient CDU (3 beds). Staffed by by triage nurse a group group vs 186 (21.8%, 95%
following senior review. middle-grade physician most likely to have CI: 19.1-24.7%) in CDU
and experienced nurses. been diverted to the (intervention) group P <
‘Major area’. These 0.05. A greater proportion
were selected on an of patients from CDU had
age-stratified basis, unplanned re-attendances
using the study cohort 11.8% (95% CI: 9.5-14.5%)
as the template (n = compared with between
854 for each cohort). 4.4% (95% I 2.6-7.4%) and
7.5% (95% CI: 5.1-11%).
P > 0.05 NOT SIGNIFICANT
for all cohorts. Modestly
significant compared to
2003 and 2004 cohorts.
Rogers et Adults (≥18 years). All GP Before and after study. Team of GPs working near 6 months prior to GPSU Number of Mean number of GP Before and after
al., 2011, referrals with a view to Observational analysis. emergency MAU (GP in situ. patients referred referrals to MAU per day design.
UK [20] medical admission, but Analysis of number of support unit). All GP and admitted on decreased by 1.55 (−2.45
that are possibly patients referred and emergency medical week days by to −0.51). Non-significant
avoidable, included either admitted to an MAU referrals made between different modes decrease in mean number
in MAU and/or by the GP during a 6 month 10:00–19:00 on weekdays (A&E, GP and GP admitted to hospital per day
support unit (GPSU). intervention period discussed with GPSU rather via A&E). Total from MAU 0.48 (−1.39 to
compared to control than MAU. number of referrals 0.44). GP admissions not
period. and admissions. targeted through GPSU
Emergency MAU in one increased by 3.99 per day
acute hospital. (2.64 to 5.33). Modest
reduction in GP admissions
to MAU but no reduction
in number of GP admissions
to hospital wards.
Page 9 of 18
Table 2 Summary table of studies describing interventions based in acute care settings (Continued)
Ong et al., Patients ≥65 years. Retrospective case–control. Patients admitted to Patients admitted to Hospital No significant difference in Small sample size and
2012, Diagnosis groups: falls and Medical files of patients Medical Assessment Unit General medical wards readmissions in readmission rate. short duration of
Australia gait disorder, COPD, other reviewed. (MAU) before ED through standard ED 1 month Readmissions within study. Retrospective
[13] major respiratory diseases, MAU and general medical assessment completed and assessment and 1 month similar in both design. Confounding.
cellulitis. Target patients ward. MAU “Assess and allied health review management (n = 42). groups (4.2% MAU) and
those requiring a short manage undifferentiated initiated when required (4.8% non-MAU group).
stay admission with patients for 36-48 h before (n = 47). MAU group shorter ED
potential discharge within transfer to medical ward or LOS (4.9 + − 3 h vs 6.5 + −
48 hr and sub-acute discharge home.” 2.8 h, p = 0.012).
patients with multiple-
comorbidities.
Hospitalised patients enrolled into study within 72 hours of admission
Enhanced care/discharge planning
Koehler et High-risk elderly medical RCT – pilot. Intensive patient-centred Usual care (n = 21). Unplanned 0-30 day post discharge Small sample size.
al., 2009, in-patients. ≥70 years, Medical in-patients. 2 med- educational program hospital readmission/ED visit rates Incomplete blinding.
USA [25] use of ≥ 5 medications ical units. (by ‘highly experienced’ readmission or ED lower in intervention Pilot study.
regularly, ≥ 3 chronic research staff) starting no visitation at 30 and group (n = 2 vs 8) p = 0.03.
Credé et al. BMC Health Services Research (2017) 17:355

comorbid conditions, later than 24 hours after 60 days post No difference in 31–60
require assistance with ≥1 enrolment. Medication discharge. day readmission/ED visits.
ADL (predisposed to counselling/reconciliation, Longer time to first visit
unplanned readmission or condition specific event in intervention vs
ED re-attendance). Patients education/enhanced usual care group (36.2
enrolled within 72 hours of discharge planning by a versus 15.7 days p = 0.05).
admission and likely to be care coordinator, and
able to be discharged home. phone follow-up (n = 20).
Lisby et al., Patients ≥70 years, in RCT, non-blinded. Clinical pharmacist Usual medication Number of No difference in ED visits Possible contamination
2010, acute internal medicine Acute Internal medicine conducted medication review in ward (n = 49). emergency Mean (95% CI) Intervention bias. Trial in one
Denmark ward and taking at least ward. reviews and drug Usual medication department visits. 0.1 (0.0-0.2) and control 0.1 clinical setting and
[34] one drug daily with counselling after usual review on admission Readmissions. (0.0 to 0.2). No significant contamination bias
expected admission medication review in the (junior physician) and difference in readmissions could have optimized
>24 hr. ward. Medication history within 24 hr of admission intervention 0.4 (0.3-0.6) drug prescriptions in
conferred to pharmacologist by senior physician. Ward and control 0.5 (0.3-0.7). the control arm.
and medication changes physicians not obliged to Insufficient statistical
recommended (n = 50). follow recommendations power to detect a
Intervention conducted of routine medication significant difference.
within 24 hr of admission or review.
by first-coming day of week.
Bowles et Hospitalized patients Quasi-experimental study The Discharge Decision Usual care. D2S2 Readmission Percentage of high-risk Two-phase study:
al., 2014, aged ≥55 years. at one medical centre. Support System (D2S2) completed but outcomes at 30 patients readmitted by 30 additional
USA [23] Study data collected 4 medical units at one used to assess patients information not and 60 days. and 60 days decreased by interventions may
within 24–48 hours of urban hospital, “Primary within 24–48 hrs of shared with case 6% and 9% respectively. have resulted in the
hospital admission. practice setting”. admission. Results shared managers (n = 281). Showing a 26% relative changes seen. Limited
with case managers to alert reduction in readmission to a single hospital -
them of patient’s risk status of high-risk patients in lacks generalizability.
and to arrange referral for pre and post intervention
post-acute care where phases.
necessary (high-risk – refer
and low-risk –do not refer)
(n = 252).
Page 10 of 18
Table 2 Summary table of studies describing interventions based in acute care settings (Continued)
Goldman Hospitalized adults RCT In-hospital, one-on-one, Usual discharge care ED visits or No statistically significant Study lacked power
et al.,2014 ≥55 years with anticipated Safety-net hospital (provide self-management disease- (n = 353). readmissions at 30, differences in ED visits or due to lower than
USA [24] discharge into community. care for patients at high specific education by nurse 90 and 180 days readmissions between expected rates of
Patients enrolled who had risk of readmission.) within 24 hours of discharge after discharge. intervention and control readmission. Possible
been admitted in the Hospitalized adults (in preferred language). groups. HR (30 days) 1.26 enhanced care given
previous 24 hours. (internal or family Telephone follow-up after 95% CI; 0.89 to 1.78 (p = to’usual care patients’.
medicine, cardiology or discharge (on days 1 to 3 0.19). HR (90 days) 1.21 95% Single centre study.
neurology departments) and 6 to 10). Patients had CI 0.91 to 1.62 (p = 0.19). HR
access to telephone support (180 days) 1.11 95% CI 0.86
line – calls returned within to 1.43 (p = 0.44).
24 hours. On discharge ED VISITS (not hospitalised)
patients received ‘After 30 days HR 1.41 95% CI
Hospital Care Plan’ booklet 0.81-2.44 (p = 0.22). 90 days
(n = 347). HR 1.41 (0.88-2.24) (p =
0.15). 180 days HR 1.41
(0.97-2.06) (p = 0.07).
Intervention group had
greater proportion of
Credé et al. BMC Health Services Research (2017) 17:355

patients with 2–5 ED visits.

Greening Patients aged ≥40 RCT. Early rehabilitation Standard care from in- Readmission rate No significant difference in Excluded patients
et al., admitted to hospital with An acute cardiorespiratory intervention started within patient physiotherapist, at 12 months. readmission rates between with more than 5
2014, UK an exacerbation of chronic unit and an acute medical 48 hours of admission and dietician referral if ne- Readmissions for intervention and control admissions in the
[17] respiratory disease. unit. delivered by physiotherapists cessary. Out-patient pul- respiratory and groups (HR 1.1, 95% CI preceding 12 months.
Patients randomised and nurses. Education and monary rehabilitation other causes. 0.86 to 1.43, p = 0.4).
within 48 hours of hospital self-management package offered three months
admission. also part of intervention. after discharge (n =
Intervention lasted 6 weeks. 193).
Post discharge unsupervised
home based program with
telephone support at 48 hrs,
two weeks and four weeks
(n = 196).
Chronic disease specific interventions
Kampan, Type 2 Diabetic patients RCT Counselling and clinical Conventional treatment Readmissions Significant decrease Insufficient
2006, hospitalized with One hospital pathway for treatment for hypoglycaemia with recurrent in readmissions with evidence regarding
Thailand hypoglycaemia. of hypoglycaemia. (n = 32). hypoglycaemia at hypoglycaemia at 1 and randomisation.
[35] Assessment and treatment 1 and 3 months. 3 months in intervention Study staff aware of
within the first 3 compared to control treatment allocation.
consecutive days of group (6.06% intervention Likely not blind to
hospitalization (n = 33). vs 34.38% control group; intervention.
p = 0.036).
Page 11 of 18
Credé et al. BMC Health Services Research (2017) 17:355 Page 12 of 18

Studies that were exclusively of children attending the included papers to experts within the field of emergency
ED were excluded. The included evidence was restricted and acute medicine, no additional papers were identified.
to countries within The Organisation for Economic Co- In total 30 papers met the inclusion criteria and are in-
operation and Development (OECD) to ensure relative cluded in this review. Figure 1 details the process of
health system comparability to the United Kingdom study identification and final inclusion.
(UK) National Health Service (NHS) and needed to be
an English language publication. Characteristics of the reviewed studies
Two authors (AS and EH) conducted the database The thirty papers included in this study all describe
searches. Two reviewers (SHC and EH) undertook an studies that enrolled or conducted an intervention with
initial title and abstract screen, using the review’s in- patients on the ‘journey’ from ED arrival to in-patient
clusion and exclusion criteria. A third reviewer (CO) ward admission (within 72 h of admission). Of these
undertook a random screen of 10% of these and any studies 19 were intervention studies (14 randomised
discrepancies were resolved through discussion with controlled trials (RCTs)) the remaining 11 were con-
this third reviewer. The full texts of all potentially trolled observational studies. The majority (8) of the
eligible papers were reviewed by two reviewers (CO papers were conducted in Australia [7–14]. Seven
and SHC) and the final list of papers was agreed by studies were conducted in the UK [15–21], six in the
consensus. USA [22–27], four in Canada [28–31], two in Singapore
[32, 33] and one each in: Denmark [34], Thailand [35]
Data extraction and China [36]. Study sample sizes ranged from 41 pa-
Three reviewers (CO, SHC and EH) extracted data into tients (pilot RCT) to 1, 628, 247 patient records in a
standardised data extraction forms. The following data retrospective analysis.
was extracted for each study: standard bibliographic in- Sixteen studies were set in the ED and the remaining
formation; target population; study setting; study design; 14 studies were conducted in an observation unit, acute
description of the intervention; description of the con- assessment ward or in-patient ward. The study charac-
trol; reported outcomes and relevant study findings. teristics as well as the principle findings of each study
Information on the study quality was also extracted. A are summarized in Tables 1 (ED) and 2 (Acute care).
10% sample of papers was cross-checked between re- Emergency department interventions were pragmatically
viewers to ensure accurate data extraction. categorised into three groups, according to the stage of
the patient’s journey during which the intervention took
Assessment of quality place. These categorizations included: interventions that
Quality assessment of each paper was undertaken by the took place during the ED attendance; interventions
reviewers extracting the data. This assessment included which were initiated in the ED and included a compo-
a review of each paper according to the Critical Ap- nent in the community and post-discharge interventions
praisal Skills Programme (CASP) checklist appropriate which were initiated in the ED.
for the study design being reported [6]. The assessment In order to classify the interventions according to
of quality was further informed by the limitations as re- where they occurred on the patient journey after ED
ported by the authors of the studies under review. presentation the following definitions, as proposed by
Cooke et al., [37] have been used. Papers were classified
Data synthesis according to the name given to the study setting by the
Data for this review was extracted into tabular form and author or the length of time the patient was anticipated
used to inform the narrative review. The considerable to be in a particular setting as reported in the study.
heterogeneity of the included studies did not lend itself
to the consideration of a meta-analysis. Assessment unit/ward
An area where emergency patients are assessed and ini-
Results tial management undertaken by inpatient hospital teams.
Study selection The patient is only in this area while early assessment
The database search for this review identified 4545 refer- is made, for example, up to 12 h and is then moved to
ences; after removal of duplicate references 3216 unique another ward.
references were identified. Of these, the full texts of 62
papers were examined and 15 papers included. Fifteen Observation ward
additional papers were included from those identified An area where patients can be observed or have early
through additional search strategies – nine papers from investigation/management within the A&E [Accident
citation searching and six were identified from the refer- and Emergency] department. Patients are admitted to
ence lists of included papers. Having sent the final list of this area with an expectation of discharge within 24 h.
Credé et al. BMC Health Services Research (2017) 17:355 Page 13 of 18

Records identified through

database searching (n =4545)

Records after duplicates removed

Records excluded at title
(n =3216) level (n =3108)

Abstracts screened for Abstracts excluded (n =46)

eligibility (n =108)

Full papers assessed for Full papers included (n=15)

eligibility (n =62)

Records identified Records identified via Records identified via Records identified via
through citation patient and public reference lists of reference lists of
searching (n=777) groups and clinical published reviews included papers
experts (n=0) (n=0)
(n=20 papers)

Records excluded Records excluded Records excluded

(n = 768) (n =0) (n =14)

Full papers included Full papers included Full papers included Full papers included
(n=9) (n=0) (n=0) (n=6)

Fig. 1 Flow chart of study identification

Admission ward ED based interventions (occurring during ED attendance)

A ward to which people are admitted after clinical as- Two studies described interventions that took place dur-
sessment for their continuing management [37]. ing the patient’s time in the ED [12, 14]. One of these
studies, which was non-randomised, involved the intro-
ED results duction of a specialist aged care pharmacist to provide
Of the 16 studies based in the ED, two studies reported medication reconciliation and review as well as patient
on interventions that took place during ED presentation, education to elderly patients [12]. This study was not
ten were studies that were initiated in the ED and include effective in reducing ED re-attendance but showed a
a component in the community and the remaining four possible reduction in admission rates for the interven-
studies were post-discharge interventions started in the tion group [12]. However, this result was not tested for
ED. Of these 16 studies, 13 interventions targeted patients significance. The other study, set in the ED, was a rando-
65 years or older [7–10, 12, 16, 21, 22, 26, 28–30, 32], mised controlled trial, of patient centred education for
two included all adults over 18 years [14, 18] and one asthmatic patients [14]. Results from this study suggest
reported on both adults and children attending an A&E that at 4 months there was no significant difference in
[36]. Fifteen papers set in the ED measured ED attend- ED attendance between the intervention and control
ance, six of these also measured hospital admission (in- groups [14]. However, after controlling for general
cluding readmission) as outcomes; one paper reported practitioner (GP) attendance the intervention group
hospital admission only. had significantly fewer ED re-attendances [14].
Credé et al. BMC Health Services Research (2017) 17:355 Page 14 of 18

ED initiated interventions which include a post-discharge geriatric assessment, multi-disciplinary team intervention
community component and community referral and two evaluated the effectiveness
Ten studies initiated an intervention in the ED that of the unit/ward on the outcomes of interest. Two interven-
involved a post-discharge community component [7–10, tions, both before-after studies, were effective in reducing
16, 18, 21, 26, 30, 32]. Each intervention differed but the review outcomes of interest: ED re-attendance [33] and
could be grouped under the following headings (Table 1): hospital admissions (ED conversion rate) [15], one of these
comprehensive geriatric assessment; multi-factorial falls was also effective in reducing re-admissions [15]. Foo et al.,
intervention or specialist nurse assessment. Nine out of [33], provided geriatric assessment and appropriate inter-
these ten studies included patients over the age of vention in an emergency department observation unit with
65 years. Of the ten studies in this setting, two were follow up referral where necessary. Conroy et al., [15],
effective in improving their primary outcomes [9, 10], evaluated the establishment of an emergency frailty unit
one of these was an RCT. The RCT had an intervention on patient admission and readmission.
which involved comprehensive geriatric assessment over
a four week period [9]. The other study provided specialist ED assessment units/wards
community nurse risk screening for elderly patients prior The interventions that took place within an ED assess-
to discharge [10]. A further two studies initiated in the ment unit either assessed the establishment of the unit
ED showed a paradoxical increase in intervention pa- [11, 13, 19] or assessed the impact of a general practi-
tients re-attending the ED [8, 30]. tioner (GP) support unit within a medical assessment unit
(MAU) [20]. One study, a retrospective cohort, showed a
ED initiated post-discharge interventions significant reduction in admissions in favour of the study
The third categorization included four studies where the group [19]. However, in this study a greater proportion of
intervention was initiated at ED discharge and included patients in the intervention group had an unplanned ED
a component of follow up or monitoring post discharge re-attendance [19].
[22, 28, 29, 36]. These included a study of an interven-
tion that used personal emergency response systems and Hospitalized patients enrolled within 72 hours of admission
a further three that provided a nurse led telephone or The studies into which patients were enrolled within 72 h
telehealth post discharge intervention. One study, which of hospital admission [17, 23–25, 34, 35] involved enhanced
adjusted for severity of patient illness, found a significant care or discharge planning [17, 23–25, 34] and one paper
reduction in unscheduled return visits following dis- reported on a chronic disease specific intervention for Type
charge facilitated by a nurse discharge plan co-ordinator 2 Diabetes [35]. All of the studies reported hospital readmis-
[28]. A further study paradoxically found that interven- sions as an outcome and three reported ED revisit rates [24,
tion patients were significantly more likely to return to 25, 34]. Three studies showed a significant reduction in ED
the ED within 30 days of initial attendance [36]. readmission [23, 25, 35]. One of these was an RCT which
included Type 2 diabetic patients and offered counselling
Acute care setting and a clinical pathway for the treatment of hypoglycaemia
Results in comparison to usual care [35]. The second study which
Within the acute care setting, four studies were conducted was also an RCT, but a pilot RCT, provided intensive
in observation wards or decision units [15, 27, 31, 33], patient-centred education for high-risk elderly medical in-
where the patient is expected to be discharged within patients [25]. The final study which showed effectiveness
24 h, and four were conducted in ED assessment units or was a quasi-experimental design comparing a discharge
wards [11, 13, 19, 20]. The remaining six papers describe decision support system to usual care [23].
studies where the patients were enrolled within 72 h of
hospital admission [17, 23–25, 34, 35]. Nine of the studies Discussion
within the acute care setting targeted adult patients This rapid evidence synthesis has found limited evidence
[13, 17, 20, 23–25, 27, 33, 34] one study included patients of interventions along the patient journey through the
from 16 years [15] and three studies included patients of ED that are effective in reducing hospital admission and/
any age meeting their other inclusion criteria [11, 31, 35]. or ED attendance. This review provides a more in-depth
All of the papers in the acute setting reported admission review of the patient pathway from the ED to acute
(including readmission) as an outcome, seven of these admission than a recent review which similarly found
(50%) also reported ED attendance as an outcome. insufficient evidence to determine whether services in
the ED reduced unplanned admissions [5]. The interven-
ED observation or decision units tions included in this evidence synthesis are of varying
Of the studies set in observation wards or decision units, complexity, often comprising a number of different com-
two evaluated complex interventions that involved ponents which may be unique to a particular study
Credé et al. BMC Health Services Research (2017) 17:355 Page 15 of 18

setting (such as assessment and discharge planning by support by trained nurses and services with appropriate
different types of health professional, different discharge follow up care may be effective in reducing ED attendance
pathways and additional care). This means it is difficult and hospital admission rates. Despite the promise that
to establish exactly which elements of an intervention these interventions hold, the findings are not supported
are impacting on outcomes which affect the generalis- by Mion et al., [26], who reported no statistically signifi-
ability of study findings. cant effect on overall service use rates. This study inter-
In addition, the nature of the health problems and se- vention may have been weakened by a lack of advance
verity of illness among patients in the included studies practice nurse involvement after follow up which makes
varied greatly and may impact on the degree to which comparison with other studies difficult.
the interventions were effective. The type of health Secondly, the results suggest that the qualifications
problem, and severity of the presenting condition, plays and specialties of the assessing and treating team mem-
a large role in determining whether or not a patient is bers may impact on service utilization outcomes. A spe-
eligible for an intervention; what the nature of this inter- cialist nurse rather than a triage nurse, used in the
vention is; and where this intervention occurs within the intervention by Hegney et al., [10], impacted positively on
healthcare system. Some studies included all adult pa- service utilization. Guttman et al., [28], support this idea.
tients attending [11, 15, 31] while others risk stratified In their intervention, study nurses were selected for their
patients and only included those of low-moderate risk expertise in nursing care and had a minimum of 5 years
[27]; only those at high-risk [25] or those with poten- nursing experience within acute care. This is important as
tially avoidable admissions [19, 20]. The selection of the complexity of discharges and the hurried discharge
‘high-risk’ patients or those with poor baseline health conditions often present in the ED may be beyond the
with a background of chronic illness may be a reason for scope of a primary ED nurse [28]. In addition, as well as
lack of intervention effect if the underlying chronic con- the usual emergency physicians, the clinical leads in Con-
ditions increase the risk of admission [8, 26]. In contrast roy et al’s., [15], paper included geriatricians and emer-
Lee et al., [29], did not restrict their patient sample to gency medicine nurses with additional training in geriatric
‘high-risk’ patients and suggest that had they chosen the syndromes and manual handling. Ensuring that team
group most likely to benefit from the intervention a members were appropriately trained to manage and treat
positive intervention effect may have been seen. or refer patients appropriately may have contributed to
What is apparent from the study findings is that high the effectiveness of some of the included interventions.
quality, prospective research is needed looking at com- A systematic review that looked at geriatric specific in-
plex interventions within the ED and acute care setting terventions on ED utilization found that the source of pa-
to reduce ED attendance or unplanned admission. In tients (ED, out-patient or home care setting) and the type
developing interventions researchers need to be guided of intervention impacted on the utilization rates [39].
by existing evidence regarding what may be effective; Studies which recruited patients in the ED had little effect
should ideally use randomised control trial methodology on ED utilization, partly, the authors believe, related to
and include a pilot phase [38]. Furthermore, the inter- the limited follow-up duration for patients discharge from
vention should be evaluated using an appropriate choice the ED and the difficulty in facilitating appropriate com-
of outcome measures that provide an adequate assess- munity follow-up and referrals from the ED [39]. Given
ment of the success of the intervention. The successful that only two of the 16 ED based studies in our review
interventions included in this review include a number were effective in reducing ED attendances or admissions
of features that may have contributed to their effective- (and a further two on sub-group analysis) may suggest
ness and these warrant further high quality research. that intervention location may have impacted on these
Firstly, the literature suggests that ED initiated interven- study results. It may be the case that interventions should
tions that include comprehensive assessment or screening be trialled away from the time pressured environment of
and community follow-up or referral have aspects that the ED and within observation or assessment wards to re-
may have contributed to their effectiveness. The majority duce unplanned admissions [37]. For patients discharged
of the included studies (19/30) targeted their interventions directly from the ED allowing sufficient time to plan the
at adults >55 years highlighting the focus on elderly care discharge care of patients may reduce the proportion of
patients. Three studies that were effective in reducing ad- unscheduled ED return visits.
missions all included elderly patients, involved assessment Observation and assessment wards, allow a greater
by a specialist nurse and provided further treatment and length of time to assess and manage patients compared
referrals to appropriate providers [9, 10, 28]. These studies to the ED, and this additional time may have contributed
suggest that assessment and management of older people to the positive findings of interventions to prevent re-
at risk of admission can improve their health outcomes. attendance and readmission in these settings. Older pa-
Accurate identification of patients in need of community tients who receive comprehensive geriatric assessment,
Credé et al. BMC Health Services Research (2017) 17:355 Page 16 of 18

allied health intervention and referral prior to discharge, Interventions that targeted specific chronic conditions
from an observation unit have decreased ED utilization were limited to four studies. The target populations in-
[15, 33]. Allowing a greater length of time to assess cluded patients with: asthma [14], epilepsy [18], heart
and manage patients enables complaints, other than failure [27] and Type 2 diabetes [35]. The heterogeneity
the primary complaint, to be addressed and these of the patient groups and the interventions precludes
healthcare needs met resulting in reduced ED re- making meaningful statements about what is effective
attendance and hospitalisation [33]. As it is not pos- in chronic disease management. Patient education and
sible to provide comprehensive geriatric assessment to specific clinical pathways require further research in
all patients, and for many this would be unnecessary, it the acute care setting.
is important that these interventions are targeted to It is also important to discuss the paradoxical increase
high-risk patients [33]. in ED re-attendance and hospital admission that is evident
Lastly, patient centred education within the ED may in some of the included studies. Three ED based interven-
offer promise for specific chronic diseases. The results tions had this effect [8, 30, 36]. The reasons for this para-
from the study by Smith et al., [14], found no significant doxical increase may be that greater assessment and
difference in ED attendance rates although, after con- screening of patients sensitizes patients to health problems
trolling for GP attendances, the intervention group had and motivates them to seek healthcare and access further
significantly fewer re-attendances. Educating patients ac- services [36]. McCusker et al., [30], also suggest that this
cording to their specific needs, guided by a curriculum, increase may be as a result of lack of access to primary
may be useful in reducing re-attendances to the ED as care services which is a known predictor for increased ED
their healthcare needs are met. This finding is echoed in utilization. These findings have also been seen in a sys-
a Cochrane review that summarises education interven- tematic review which concludes that while ED based inter-
tions for asthma in the ED which also suggests that hos- ventions may show promise they can have the unintended
pital readmissions may be reduced through education consequence of increased demand on these services [41].
interventions for asthmatics although the generalisability The interventions included in this study can be con-
of the findings need to be confirmed in larger, multi- sidered as complex interventions, which include several
centred trials [40]. components [42]. It is acknowledged that interventions
The interventions initiated within 72 h of patient classified as ineffective in this review does not necessarily
admission have aspects that are similar to the above mean that the intervention was ineffective but the findings
findings. Interventions that involved patient education, may be as a result of process failures, how the intervention
enhanced discharge and included patient follow up was implemented or whether the follow-up time was suffi-
after discharge have been shown to decrease readmis- cient to provide an adequate assessment of the success or
sion and ED visits [25]. In addition, when high-risk pa- failure of an intervention [38]. Furthermore, many of the
tients are identified and their needs are met, including interventions included in this study had beneficial effects
sufficient time to work with patients and families to on other service related outcomes, for example: decreased
agree a workable care plan, readmission rates have been hospital length of stay [11, 35] or increased contact with
seen to decrease [23]. PHC following discharge [22]. These outcomes are not

Fig. 2 Key aspects of interventions, identified in rapid review, that warrant future research
Credé et al. BMC Health Services Research (2017) 17:355 Page 17 of 18

covered by our review and it is acknowledged that these Acknowledgements

interventions may be effective in reducing other important Not applicable.

outcomes. Funding
This research was funded by by the National Institute for Health Research
Collaboration for Leadership in Applied Health Research and Care Yorkshire
Limitations and Humber (NIHR CLAHRC YH). www.clahrc-yh.nihr.ac.uk. The views and
The studies included in this rapid review were carried opinions expressed are those of the authors, and not necessarily those of
out in a variety of national settings with heterogeneous the NHS, the NIHR or the Department of Health.
study designs and using different outcome measures Availability of data and materials
and this limited our ability to synthesise the results of All data supporting the conclusions of this article are included within the
individual studies. article and the referenced literature.
As this was a rapid review we did not score the quality Authors’ contributions
of each individual included paper but took into account All authors (SHC, CO, SM, AS, EH, SC and MW) contributed to the
the limitations described by each author. The limitations conceptualization and design of the review. AS and EH conducted the
database searches. Two reviewers (SHC and EH) undertook an initial title and
of the papers were considered and these included non- abstract screen, using the review’s inclusion and exclusion criteria. A third
randomised studies or before and after design cohort reviewer (CO) undertook a random screen of 10% of these and any
studies which are more susceptible to certain bias than discrepancies were resolved through discussion with this third reviewer. The full
texts of all potentially eligible papers were reviewed by two reviewers (CO and
RCTs, such as selection bias [7, 9, 12]. Without evi- SHC) and the final list of papers was agreed by consensus. SC drafted the initial
dence from randomised controlled trials, confounding manuscript and all authors participated in manuscript revisions. All authors
and other methodological flaws cannot be discounted (SHC, CO, SM, AS, EH, SC and MW) read and approved the final manuscript.
in evaluating the findings. Competing interests
As this was a rapid review, with limited time frame, The authors declare that they have no competing interests.
we did not attempt to identify all relevant evidence
Consent for publication
through an exhaustive search. Through a well thought Not applicable.
out and devised search strategy we aimed to identify the
key evidence of most relevance to our review question. Ethics approval and consent to participate
Not applicable.

Conclusions Publisher’s Note

In the UK, emergency department attendances and emer- Springer Nature remains neutral with regard to jurisdictional claims in
gency hospital admissions are continuing to increase. As published maps and institutional affiliations.
the population ages medical admissions are also becoming
Author details
increasingly complex as patients live longer with chronic 1
School of Health and Related Research (ScHARR), The University of Sheffield,
medical conditions [1]. This review looked at the current Sheffield, England. 2Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, England. 3Doncaster and Bassetlaw Hospitals NHS Foundation
evidence on interventions that reduce emergency hospital
Trust, Doncaster, England. 4School of Health and Related Research (ScHARR),
admissions and emergency department attendances with The University of Sheffield, Regent Court, Regent Street, Sheffield S1 4DA, UK.
the aim of informing the design of new interventions to
Received: 26 November 2015 Accepted: 8 May 2017
decrease service utilization.
A number of findings from this review (shown in Fig. 2)
may be helpful in designing future interventions. Firstly, References
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