Review article: Emergency department models of care in the context of care quality and cost: A systematic review

Abstract

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Overcrowding in emergency departments: A review of strategies to decrease future challenges

“…Moreover, it should be considered in studies and decision-makings that access to ED is an issue at a strategic government level, whereas throughput efficiencies are being addressed at a local operational level. [51]…”

“…Numerous studies have shown that these units can effectively reduce mortality, the LOS, and access block, as well as improve staff and patient satisfaction. [51]…”

“…Local context, organizational factors, and cost-effectiveness analysis of ED models necessitate additional methodological approaches with a sharper focus on outcomes of quality, patient and staff satisfaction, and economic and ethical issues. [51] Strategies for managing throughput ED patient flow should focus on the following issues: patient acuity levels, prolonged ED evaluations, inadequate inpatient bed capacity, a severe shortage of staff, problems with access to on-call specialists, and the use of ED by those with no other alternative to medical care, such as the uninsured. [52] Consequently, further studies must employ a systematic approach to evaluating the most likely way to success.…”

Understanding ED performance after the implementation of activity‐based funding

“…With high fixed workforce costs (ie, salary and wages) and small marginal costs (ie, consumables, pathology, and radiology), ED budgets had been historically average cost based, aggregated, and capped with adjustments calculated as the additional workforce (ie, inputs) required to meet rising demand. This is reflected in the considerable variation in how specific EDs value their available resources with many different models of care reported in the literature …”

Emergency department crowding: Time to shift the paradigm from predicting and controlling to analysing and managing

“…Due to considerations of space, this paper cannot provide a comprehensive review of existing models. A recent review discusses ED models of care in the context of care quality, care effectiveness, and cost (Wylie et al, 2015).…”