Direct discharge of patients with simple stable musculoskeletal injuries as an alternative to routine follow-up: a systematic review of the current literature

Abstract

Purpose There is growing evidence that patients with certain simple stable musculoskeletal injuries can be discharged directly from the Emergency Department (ED), without compromising patient outcome and experience. This study aims to review the literature on the effects of direct discharge (DD) of simple stable musculoskeletal injuries, regarding healthcare utilization, costs, patient outcome and experience. Methods A systematic review was performed in Medline, Embase, CINAHL, Cochrane Library and Web of Science using PRISMA guidelines. Comparative and non-comparative studies on DD of simple stable musculoskeletal injuries from the ED in an adult/paediatric/mixed population were included if reporting ≥ 1 of: (1) logistic outcomes: DD rate (proportion of patients discharged directly); number of follow-up appointments; DD return rate; (2) costs; (3) patient outcomes/experiences: functional outcome; treatment satisfaction; adverse outcomes; other. Results Twenty-six studies were included (92% conducted in the UK). Seven studies (27%) assessed functional outcome, nine (35%) treatment satisfaction, and ten (38%) adverse outcomes. A large proportion of studies defined DD eligibility criteria as injuries being minor/simple/stable, without further detail. ED DD rate was 26.7–59.5%. Mean number of follow-up appointments was 1.00–2.08 pre-DD, vs. 0.00–0.33 post-DD. Return rate was 0.0–19.4%. Costs per patient were reduced by €69–€210 (ranging from − 38.0 to − 96.6%) post-DD. Functional outcome and treatment satisfaction levels were ‘equal’ or ‘better’ (comparative studies), and ‘high’ (non-comparative studies), post-DD. Adverse outcomes were low and comparable. Conclusions This systematic review supports the idea that DD of simple stable musculoskeletal injuries from the ED provides an opportunity to reduce healthcare utilization and costs without compromising patient outcomes/experiences. To improve comparability and facilitate implementation/external validation of DD, future studies should provide detailed DD eligibility criteria, and use a standard set of outcomes. Systematic review registration number: 120779, date of first registration: 12/02/2019.

Health Care Professionals’ Experiences With a Mobile Self-Care Solution for Low Complex Orthopedic Injuries: Mixed Methods Study

“…Most health care professionals considered DD a safe alternative to face-to-face follow-up, leading to a perceived reduction of SHU. This finding is consistent with previous articles, which concluded that DD is safe based on low, comparable complication numbers, with significantly reduced SHU compared to traditional treatment [9,18,33]. The perceived reduction in SHU varied among stakeholders.…”

“…Preliminary efficacy was partly in line with the literature [18,20,33]. Most health care professionals considered DD a safe alternative to face-to-face follow-up, leading to a perceived reduction of SHU.…”

“…The study results show that DD is an acceptable alternative to traditional follow-up for health care professionals. Health care professionals reported similar, high satisfaction scores with treatment as previously reported patient satisfaction scores for similar protocols [18,33]. To further improve health care professionals' satisfaction scores, health care professionals in this study suggested a short numerical feedback system to monitor injury recovery remotely (eg, recovery questions after 3 months).…”

“…This complexity is widely recognized in eHealth and eHealth evaluation frameworks [15][16][17]. The organizational and logistic benefits and patient satisfaction scores following DD have been well described in the literature [18][19][20]. However, the social aspects of the DD protocol for health care professionals remain underreported [21].…”