BackgroundEmergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions.AimThe aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding.MethodThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439).ResultsFrom 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions.ConclusionsThe negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.

Objectives Intestinal colonization by ESBL Escherichia coli and its association with community-acquired MDR infections is of great concern. This review determined the worldwide prevalence of human faecal ESBL E. coli carriage and its trend in the community over the past two decades. Methods A systematic literature search was conducted using PubMed, EMBASE and Google Scholar to retrieve articles published between 1 January 2000 and 13 February 2020 that contained data on the prevalence of faecal carriage of ESBL E. coli among healthy individuals. A cumulative (for the whole period) meta-analysis was used to estimate the global and regional pooled prevalence rates. Articles were grouped into study periods of 3 years, and subgroup meta-analyses were undertaken to examine the global pooled prevalence over time. Results Sixty-two articles covering 29 872 healthy persons were included in this meta-analysis. The cumulative (2003–18) global pooled prevalence of ESBL E. coli intestinal carriage in the community was 16.5% (95% CI 14.3%–18.7%; P  <  0.001). The pooled prevalence showed an upward trend, increasing from 2.6% (95% CI 1.6%–4.0%) in 2003–05 to 21.1% (95% CI 15.8%–27.0%) in 2015–18. Over the whole period, the highest carriage rate was observed in South-East Asia (27%; 95% CI 2.9%–51.3%), while the lowest occurred in Europe (6.0%; 95% CI 4.6%–7.5%). Conclusions Globally, an 8-fold increase in the intestinal carriage rate of ESBL E. coli in the community has occurred over the past two decades. Prevention of its spread may require new therapeutic and public health strategies.

BackgroundReadmission rates following hospitalisation for COPD exacerbations are unacceptably high, and the contributing factors are poorly understood. Our objective was to summarise and evaluate the factors associated with 30- and 90-day all-cause readmission following hospitalisation for an exacerbation of COPD.MethodsWe systematically searched electronic databases from inception to 5 November 2019. Data were extracted by two independent authors in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality was assessed using a modified version of the Newcastle–Ottawa Scale. We synthesised a narrative from eligible studies and conducted a meta-analysis where this was possible using a random-effects model.ResultsIn total, 3533 abstracts were screened and 208 full-text manuscripts were reviewed. A total of 32 papers met the inclusion criteria, and 14 studies were included in the meta-analysis. The readmission rate ranged from 8.8–26.0% at 30 days and from 17.5–39.0% at 90 days. Our narrative synthesis showed that comorbidities, previous exacerbations and hospitalisations, and increased length of initial hospital stay were the major risk factors for readmission at 30 and 90 days. Pooled adjusted odds ratios (95% confidence intervals) revealed that heart failure (1.29 (1.22–1.37)), renal failure (1.26 (1.19–1.33)), depression (1.19 (1.05–1.34)) and alcohol use (1.11 (1.07–1.16)) were all associated with an increased risk of 30-day all-cause readmission, whereas being female was a protective factor (0.91 (0.88–0.94)).ConclusionsComorbidities, previous exacerbations and hospitalisation, and increased length of stay were significant risk factors for 30- and 90-day all-cause readmission after an index hospitalisation with an exacerbation of COPD.

Objective: To assess the impact of a multi‐strategic, interdisciplinary intervention on antipsychotic and benzodiazepine prescribing in residential aged care facilities (RACFs). Design, setting: Prospective, longitudinal intervention in Australian RACFs, April 2014 – March 2016. Participants: 150 RACFs (with 12 157 residents) comprised the main participant group; two further groups were consultant pharmacists (staff education) and community pharmacies (prescribing data). Data for all RACF residents, excluding residents receiving respite or end‐stage palliative care, were included. Intervention: A multi‐strategic program comprising psychotropic medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months; final audit at 6 months. Main outcome measure: Mean prevalence of regular antipsychotic and benzodiazepine prescribing at baseline, and at 3 and 6 months. Secondary measures: chlorpromazine and diazepam equivalent doses/day/resident; proportions of residents for whom drug was ceased or the dose reduced; prevalence of antidepressant and prn (as required) psychotropic prescribing (to detect any substitution practice). Results: During the 6‐month intervention, the proportion of residents prescribed antipsychotics declined by 13% (from 21.6% [95% CI, 20.4–22.9%] to 18.9% [95% CI, 17.7–20.1%]), and that of residents regularly prescribed benzodiazepines by 21% (from 22.2% [95% CI, 21.0–23.5%] to 17.6% [95% CI, 16.5–18.7]; each, P < 0.001). Mean chlorpromazine equivalent dose declined from 22.9 mg/resident/day (95% CI, 19.8–26.0) to 20.2 mg/resident/day (95% CI, 17.5–22.9; P < 0.001); mean diazepam equivalent dose declined from 1.4 mg/resident/day (95% CI, 1.3–1.5) to 1.1 mg/resident/day (95% CI, 0.9–1.2; P < 0.001). For 39% of residents prescribed antipsychotics and benzodiazepines at baseline, these agents had been ceased or their doses reduced by 6 months. There was no substitution by sedating antidepressants or prn prescribing of other psychotropic agents. Conclusions: The RedUSe program achieved significant reductions in the proportions of RACF residents prescribed antipsychotics and benzodiazepines. Trial registration: Australian New Zealand Clinical Trials, ACTRN12617001257358.

Objective: To evaluate pharmacist-conducted follow-up at home of high-risk elderly patients discharged from hospital. Method: A randomised controlled study, in which medical patients admitted to hospital and fulfilling high-risk criteria (including age 60 years or older and prescribed four or more regular medications) were randomly assigned to an intervention or control group. Patients in the intervention group were visited at home by a pharmacist five days after discharge. The pharmacist educated patients on their medications, encouraged compliance, assessed for drugrelated problems, intervened when appropriate and communicated all relevant findings to community health professionals. The intervention group patients were revisited at home 90 days after discharge to evaluate the outcomes of interventions made on day 5. Patients in the control group were visited at home by a pharmacist 90 days after discharge and provided with an identical comprehensive medication review Results: One hundred and twenty-one patients completed the study. There were no significant differences between the two groups in key clinical and demographic parameters at baseline. A median of three drug-related problems were identified in each intervention group patient at the five day home visit. Ninety days after discharge this had declined to one, compared to two for the control group patients (p < 0.0001). In the intervention group, compliance had improved and was significantly higher than for the control group after 90 days (p < 0.0001). There was a significant decline in the use of nonsteroidal anti-inflammatory drugs by the intervention group patients. Forty-five per cent of the control group patients had unplanned readmissions to hospital during the 90 days following discharge compared to 28% of the intervention group patients (p = 0.05). The intervention program was well-received by patients and their general practitioners. Recommendations from the pharmacist were implemented by general practitioners in 79% of cases. Conclusion: A pharmacist-conducted follow-up at home of high-risk elderly patients discharged from hospital is valuable in identifying and addressing drug-related problems and reducing the risk of readmission to hospital.