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A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?
  1. Scott William Kirkland1,
  2. Amir Soleimani2,
  3. Brian H Rowe1,3,
  4. Amanda S Newton2
  1. 1 Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
  2. 2 Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
  3. 3 School of Public Health, University of Alberta, Edmonton, Alberta, Canada
  1. Correspondence to Dr Brian H Rowe, Department of Emergency Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada; brian.rowe{at}ualberta.ca

Abstract

Objectives Diverting patients away from the emergency department (ED) has been proposed as a solution for mitigating overcrowding. This systematic review examined the impact of interventions designed to either bypass the ED or direct patients to other alternative care after ED presentation.

Methods Seven electronic databases and the grey literature were searched. Eligible studies included randomised/controlled trials or cohort studies that assessed the effectiveness of pre-hospital or ED-based diversion interventions. Two reviewers independently screened the studies for relevance, inclusion and risk of bias. Pooled statistics were calculated as relative risks (RR) with 95% confidence intervals (CI) using a random effects model.

Results Fifteen studies were included evaluating pre-hospital (n=11) or ED-based (n=4) diversion interventions. The quality of the studies ranged from moderate to low. Patients deemed suitable for diversion among the pre-hospital studies (n=3) ranged from 19.2% to 90.4% and from 19% to 36% in ED-based studies (n=4). Of the eligible patients, the proportion of patients diverted via ED-based diversion tended to be higher (median 85%; IQR 76–93%) compared with pre-hospital diversion (median 40%; IQR 24–57%). Overall, pre-hospital diversion did not decrease the proportion of patients transferred to the ED compared with standard care (RR 0.92; 95% CI 0.80 to 1.06). There was no significant decrease in subsequent ED utilisation among patients diverted via pre-hospital diversion compared with non-diverted patients (RR 1.09; 95% CI 0.99 to 1.21). Of the three pre-hospital studies completing a cost analysis, none found a significant difference in total healthcare costs between diverted and non-diverted patients.

Conclusion There was no conclusive evidence regarding the impact of diversion strategies on ED utilisation and subsequent healthcare utilisation. The overall quality of the research limited the ability of this review to draw definitive conclusions and more research is required prior to widespread implementation.

  • emergency department
  • emergency department utilisation
  • crowding

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Footnotes

  • Contributors SWK drafted the protocol, screened abstracts and articles for inclusion, extracted data, assessed quality, analysed data and wrote the manuscript. AS drafted the protocol, screened abstracts and articles for inclusion, extracted data, assessed quality, analysed data and wrote the manuscript. BHR conceptualised the study, drafted the protocol, provided third party adjudication for inclusion screening and wrote the manuscript. ASN conceptualised the study, drafted the protocol, provided third party adjudication for inclusion screening, data extraction, and quality assessment and wrote the manuscript.

  • Funding Funding for this review was provided by the Emergency Strategic Clinical Network (Alberta). In-kind support of the research librarian services was provided by the Alberta SPOR Support Unit, Health Systems Research, Implementation Research & Knowledge translation platform. ASN holds a New Investigator Award from the Canadian Institutes of Health Research (CIHR). BHR research is supported by a Tier I Canada Research Chair in Evidence-based Emergency Medicine from CIHR through the Government of Canada (Ottawa, ON).

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data reported in this systematic review were retrieved from the published data reported in the included studies.

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