Table 2.
Results of eligible studies grouped in six thematic categories
| a. Mortality | |||
| Author/year | Measure | Results (outliers vs non outliers) | p |
| Bai AD et al. 20184 | Hazard ratio (HR) | ↑ 3.42 on admission decreases by 0.97 per day | p < 0.0001 |
| Stylianou N. et al. 20171 | Odds ratio (OR) | = outliers are not associated with in-hospital mortality (OR 0.983) | p = 0.773 |
| Serafini F. et al. 20157 | Hazard ratio (HR) | ↑ for outliers in surgical wards (1.8, 1.2–2.5 95% CI) | p < 0.05 |
| Santamaria JD et al. 20148 | 58.158 in-hospital mortality rate | ↑ (2.57% vs 1.12%) | p < 0.001 |
| Stowell A. et al. 2013 10 | Mortality rate at 24 h | ↓ (0.00% vs 0.84%) | p < 0.05 |
| Perimal-Lewis L et al. 20139 | In-hospital mortality rate; in-hospital mortality within 48 h | 4.5% vs 3.5% | p = 0.014 |
| 50.4% vs 22.4% | p < 0.001 | ||
| Perimal-Lewis L et al. 2016 (patients with dementia) 6 | In-hospital mortality rate; mortality rate within 48 h; odds ratio | ↑ (9.6% vs 7.9%) | p = 0.072 |
| p = 0.000 | |||
| p = 0.012 | |||
| ↑ (3.2% vs 1.16%) | |||
| ↑OR 1.973; 95% CI 1.158–3.359) | |||
| Alameda C. et al. 200913 | In-hospital mortality | ↓ (17% vs 22%) | p = 0.412 |
| b. Length of stay (LOS) | |||
| Author/year | Sample ( n ) and measure | Results (outliers vs non outliers) | p |
| Bai AD et al. 20184 | LOS in days | = (5.31 vs 5.97 days) | p = 0.1119 |
| Stylianou N et al. 20171 | LOS in days | ↑ (7 vs 3 days) | p < 0.001 |
| Serafini F. et al. 20157 | LOS in days | = (9.8 vs 10 in internal medicine wards; 13 for both in geriatric wards) | p not reported |
| Perimal-Lewis et al. 20139 | LOS in hours | ↓ (110.7 h vs 141.9 h) | p < 0.001 |
| Stowell A. et al. 201310 | LOS in days | ↑ (8 vs 7 days) | p = 0.04 |
| Alameda C. et al. 200913 | LOS in days | ↑ (11.8 vs 9.2 days) | p = 0.001 |
| c. Readmissions | |||
| Author/year | Measure | Results (outliers vs non outliers) | p |
| Stylianou et al. 20171 | Odds ratio | ↑ (odds at 30 days at univariate analysis not confirmed by multivariate) | p = 0.09 |
| Serafini F et al. 20157 | Rate at 90 days | ↑ (26.1 vs 14.2%) | p < 0.0001 |
| Perimal-Lewis et al. 20139 | Rate at 7 and 28 days | ↓ 1.2 vs 2% at 7 days | p = 0.003 |
| ↓ 2.1 vs 4.9% at 28 days | p < 0.001 | ||
| Stowell A. et al. 201310 | Rate at 28 days | ↑ (27 vs 17%) | p = 0.008 |
| Alameda et al. 200913 | Rate at 30 days | ↑ (15 vs 10%) | p = 0.234 |
| d. Other indicators | |||
| Author/year | Indicator | Results (outliers vs non outliers) | p |
| Serafini F et al. 2015 7 | Type of patients less allocated off-ward | Respiratory patients | Not applicable |
| Stowell A. et al. 201310 | VTE prophylaxis | 42 vs 52% | p = 0.03 |
| Number of blood and imaging tests (SD) | |||
| 5.13 vs 4.59 | Not reported | ||
| 1.65 vs 1.41 | |||
| Perimal-Lewis et al. 20139 | ER length of stay | 6.3 vs 5.3 h | p < 0.001 |
| Discharge summary completion within 2 days | 40.7 vs 61.2% | p < 0.001 | |
| Discharge summary completion within 7 days | 64.3% vs 78% | p < 0.001 | |
| Creamer et al. 201011 | Mean consultation time | 152″ vs 136″ | Not reported |
| 25″ vs 14″ | |||
| Mean discussion time | 18% | ||
| Time spent to traveling between wards | |||
| Alameda et al. 2009 13 | In-hospital morbidity* | 24% vs 18% | p = 0.254 |
| Ashdown et al. 200317 | Rate of canceled surgeries | 14.8% | Not applicable |
| Santamaria JD et al. 20148 | % calls to in-hospital emergency team | ↑ by 53% | p < 0.001 |
| Warne S et al. 201012 | Rate of not administered medications in surgical wards | ↑ (100% vs 74%) | p < 0.001 |
| e. Perceived quality and safety of care | |||
| Author/year | Indicator | Results (outliers vs non outliers) | p |
| Goulding L. et al. 2012–2015 (2, 3) | NA (qualitative study) | Patients and health operators reported many safety threats in outliers | Not applicable |
| f. Safety issues | |||
| Author/year | Safety issues | ||
| Rae B. et al. 200716 | Staff factors: too many consultants—large variation in clinical practice | ||
| Process factors within the control of the service: adverse events; ward rounds miss patients; patients not seen at weekends; lack of communication across disciplines; lack of a diagnosis; all diagnoses not dealt with from the start of the admission; too many patients under a single team; interrupted ward rounds by being paged for non-urgent requests. | |||
| Lepage B et al. 20095 | Emergency department care | ||
| Nurse responsible for finding beds for outlying patients not available | |||
| Inaccurate or out-of-date information about bed occupancy in the hospital | |||
| Best compromise between outlier’s pathology and outlying ward’s specialty not taken into account at disposal decision time | |||
| Outlying ward contact, called by emergency department before transfer agreement, varying from ward to ward (duty doctor, charge nurse, nurse) | |||
| Person in charge of admission agreement in outlying ward not contactable | |||
| Wrong information given to outlying wards about outlying patients | |||
| Emergency department contact for outlying patients not known by outlying wards or appropriate specialty wards | |||
| Appropriate specialty staff not informed of hospitalization of outliers who should be in their charge | |||
| Transfer from emergency department to outlying ward | |||
| Final diagnosis or final clinical assessment not made in emergency department, potentially resulting in transfer of patients in unstable condition; emergency department porters not available for patient transfer; bad communication between emergency department and outlying wards about time of transfer; bad communication between emergency department and porters regarding name of outlying ward; patient transferred to outlying ward without medical record | |||
| First day of hospital care | |||
| Final diagnosis or final clinical assessment not entered into emergency department medical record | |||
| Medical or nursing records varying from department to department | |||
| No medical record used for outlying patients | |||
| Bed not yet available at time of admission to outlying ward | |||
| Delayed admission of patients scheduled for non-urgent problems or elective procedures | |||
| Doctors in outlying wards not aware of new outliers hospitalized in their wards | |||
| No defined contact in outlying wards (nurse, charge nurse, or doctor) to call a specialist doctor in appropriate specialty ward | |||
| No traceability of calls from outlying wards to specialist doctors; in appropriate specialty wards, no identification of specialist doctors responsible for care of outlying patients falling within their sphere of competence | |||
| Specialist doctor in appropriate ward not easily contactable; lack of information or prescription from a specialist doctor in appropriate ward to nurses and doctors in outlying ward; no specialist medical and nursing care; diagnostic tests not ordered by a doctor from appropriate specialty; no specialist interpretation of diagnostic tests performed on outlying patients; no specialist information given to outlying patients and their families; no systematic meeting or information transmission between doctors in outlying wards and doctors in appropriate specialty wards; inappropriate nursing care provided to outlying patients | |||
| Care in outlying ward from the second day of hospitalization until the day before discharge | |||
| No specialist follow-up; results of diagnostic tests not systematically transmitted to a specialist doctor in appropriate ward; no specialist information given to outlying patients and their families | |||
| Day of discharge | |||
| Information about discharge and follow-up of outlying patients not given by a specialist doctor from the appropriate ward | |||
| Information in medical record and discharge documents not completed by a specialist doctor from the appropriate ward | |||
| Transport forms and prescriptions not completed by a specialist doctor from the appropriate ward | |||
| Follow-up of outlying patients not scheduled by specialist doctors from appropriate wards | |||
| g. Solutions | |||
| Author/year | Solutions | Results | p |
| Novati R. et al. 20175 | Algorithm supporting rational outward allocation of patients and difficult discharges | Outlier days fell from 6.3 to 5.4% | p = 0.000 |
| Lepage B et al. 200914 | Identification of medical doctor and nurse coordinator for outliers, use of standardized medical records | Not reported | Not applicable |
| Gilligan S et al. 200716 | “Physician of the week”, discharge facilitator, “quick and sick” ward | Reduction of Hospital-Standardized Mortality Rate (HSMR) | Not reported |
| Rae B. et al. 200715 | Discharge planning, increase of transfers from general internal medicine to geriatrics, implementation of a consultant-led ward round 7 days a week | Outlier bed crises solved | Not applicable |
*Intra-hospital infection (urinary, respiratory, bacteremia, or others beginning 48 h after admission), intra-hospital hemorrhage (digestive, urinary, or others), and intra-hospital venous thromboembolism