Appendix 5: Full Details of the Characteristics of the Included Systematic Reviews,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Covidence #,Study ID,Title,Reviewer Name,Study ID,Title,First Author,Year,Country in which the study conducted,Aim of study,Objectives,Type of study/review,Participant description,Total number of participants,Setting/context,Sources searched,Range (years) , Number of studies included,Types of studies included,Country of origin of incl. studies,Appraisal instruments used,Appraisal rating,Method of synthesis/analysis,Description of Interventions or strategies,Primary outcomes of the patient flow interventions,Secondary Primary outcomes of the patient flow interventions,Challenges impeding patient flow,Root causes,Outcomes of barriers/challenges,Other findings,Significance/direction,Heterogeneity,Comments 892,Preston 2017,What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review,Consensus,892,"What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review",Louise Preston,2017,UK,To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes,"What is the evidence for the range of different approaches to the management (identification and service delivery interventions) of frail older people within the ED? Is there any evidence of their potential and actual impact on health service and patient-related outcomes, including impacts on other services used by this population and health and social care costs? What specific approaches to the management of frail older people exist within the ED? What evidence is there that these approaches to management within the ED could influence attendance and/or reattendance rates in frail older people, hospital admission and/or readmission rates in frail older people, patient-centred outcomes in frail older people and costs to the health service? What evidence is there that these approaches to management within the ED could influence other health service outcomes (as reported in the literature and as mentioned as important by the clinical academics/topic experts) and is there evidence of any unintended outcomes (such as the displacement of care) as a result of how frail older people are managed in the ED?",Systematic mapping review,Frail and high risk older people and general populations of older people (aged > 65 years),Not reported,Emergency Department,"MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Management Information Consortium and PROSPERO",2005-2016,120 (103 papers and 17 reviews),"Peer-reviewed articles (103), conference abstracts, systematic reviews (17)","USA, Australia, UK, Italy, Canada, Ireland, Switzerland, Netherlands, Singapore, Hong Kong, Spain, Sweden, France, Belgium, Germany, New Zealand, South Korea, Taiwan, Turkey","Formal assessment not done Instead carried out bespoke assessment of the evidence base mapped in our review using three methods: 1. an examination of the research designs used and the strengths and limitations of those designs 2. an examination of the self-reported limitations included in the articles relating to frail or high-risk older people 3. an assessment of the relevance of the evidence to the contemporary UK NHS setting.","Not done No report/rating of bespoke assessment reported ",Tabular and narrative synthesis; by intervention type,"Diagnostic tools to identify frailty (n=7)(ISAR, BRIGHT, FRESH, CFS, EGS, ED screening tool) Diagnostic tools to screen for frailty-related issues (n=7)(MMSE/CAM, Ottawa 3DY, Brief Alzheimer's Screen, SBT; care-giver-completed AD8; SIS; TRST; Mini-Cog) Prognostic tools to measure risk of adverse events in the ED (n=5) (BGA, REMS/HOTEL, ESI, Delirium prediction rule, CTAS) Prognostic tools to measure risk of adverse events on discharge (n=18) (ISAR, TRST, modified ISAR, Runciman questionnaire, Rowland questionnaire, Rapid screening assessment, ESI, Silver Code, TUGT, GRAY, SHARE-FI, two-item screening tool) Individual or team changes to ED staffing (n=21) Changes to the physical infrastructure of the ED (n=11) Care delivery and assessment interventions (n=18)","Outcomes measured: Patient outcomes: ADL decline; appropriate/correct admission/discharge/referral; appropriate/correct diagnosis; appropriate/correct medication; frailty; long-term care placement; morbidity; mortality; return to home (for how long?); and satisfaction with the ED Health service outcomes: Admission to acute care; admissions avoided; attendance or reattendance at the ED; bed occupancy rates; costs/resource utilisation; discharge rates; ED returns/readmissions; ED waiting times; and length of stay Flow outcome measures: 28-day ED reattendance, readmission and mortality; hospital LOS for patients admitted; admission to inpatient beds; admissions avoidance; admissions; ED revisits; LOS; 4-hour-ED target; discharge location and discharge rates; admission location and admission rates; readmission rates; rehospitalisation; change in functional status; ICU admission rate; composite outcome; multiple ED returns/admissions following index episode 1 study before-and-after found decrease in re-presentations after introduction of the ISAR tool, possibly due to increase in referrals to community-based services. Staffing initiatives: - 1 study did not show difference in admission rates/revisit rates/readmission rates in those who received EDCC intervention (emergency department care coordinator) - 1 study - geriatric nurse liaison - preventable admissions in high-risk patients were reduced, although admissions were increased in those with less severe presentation, perhaps because of underlying problems identified; LOS in ED was increased. - 1 study - geriatric aged care nurse did not significantly reduce admission or LOS. - 1 study - geriatric nurse liaison intervention group had significantly improved outcomes compared with control group with hospitalisation, 30-day readmission rates and LOS. Team initiatives: - 1 study - CCT - regression modelling showed non-significant decrease in re-presentation and readmission rates over 3 years - 1 study - ED geriatric medicine liaison service - mean LOS significantly shortened, no adverse effect on repeat attendance or readmission. - 3 studies into care coordination team - 1 study - intervention group slightly increased ED reattendance rate, much higher risk of hospital readmission; 1 study - no difference in LOS (median 88 vs 87hr); 1 study - 72% admission to inpatient beds in intervention vs 74.4% for control (borderline significance) - 1 abstract - geriatric liaison team undertaking CGA in ED - LOS reduced by 4.8hrs - 1 study - frail intervention therapy team (FITT) - 11.5% increase in patients presenting to ED, 59% increase in patients discharged, 42% increase in patients transferred to a ward in <9hrs - 1 study - CCT in Australia reduced proportion of patients admitted - 1 study mobile geriatric team - geriatric recommendations were associated with early discharge from ED - 1 study - acute care of the elderly (ACE) service - 459 out of 662 inappropriate admissions were avoided over 10 months Physical infrastructure of the ED (1 study each): - frailty unit - over 2 years fall in bed occupancy rates, fall in mortality, unchanged rates of readmission - ACE unit - increase in same-day discharge, mixed findings on LOS, no significant findings in 7- and 30-day readmission - emergency frailty unit (EFU) - increased ED attendances, admission rates fell (69.6% to 61.2%), readmission rates decreased (4.7% vs. 3.3% at 7 days; 12.4% vs. 9.2% at 30 days; and 19.9% vs. 26.0% at 90 days) - ED observation unit - initial increase in admissions followed by decrease in admissions and LOS. - GED - significantly fewer admissions post introduction - senior ED - decreased admissions but not ED returns or LOS - rapid access centre - shorter LOS when patients admitted through RAC and discharged earlier - senior ED - significant decrease in admissions from 55.5% to 51.2% Care delivery interventions: - 4 studies - non-significant decrease in admissions and in LOS with comprehensive geriatric assessment (CGA) - geriatric assessment pre-discharge - lower ED reattendance rate, lower 12-month hospitalisation","Improved patient experiences Achieving better outcomes Lower costs ",,,,"Overall evidence for diagnostic accuracy of tools for identifying frail older people is limited. ISAR valid and reliable screening tool and accurate predictor of death, ED revisit, hospital admission at 6-months follow-up. Repeat visits in older persons seemed to be most accurately predicted with Rowland questionnaire Rapid screening assessment provides rapid and accurate method for identifying older patients in ED likely to return to ED. CGA effective at decreasing functional decline, ED readmission and possibly nursing home admission in two systematic reviews.","No overall evidence base was assessed and no statistical analysis done so inconclusive evidence. Purpose was not to examine effectiveness of interventions. Improvements in care of frail older people have the potential to improve both patient and health service outcomes.",No measure given; heterogeneous body of evidence.,"Examples of the types of interventions that might reduce demand on EDs include preventing ED admission through ambulatory triage, referring older people directly to a ward, a medical assessment unit or elderly care unit, delivering appropriate care within a home/community setting (a nursing home or their own home) and preventing readmissions when older people are discharged from acute medical care through interventions delivered in the home. [these are not examined in the review, only discussed]." 888,Malik 2018,The impact of geriatric focused nurse assessment and intervention in the emergency department: A systematic review,Consensus,888,The impact of geriatric focused nurse assessment and intervention in the emergency department: A systematic review,M. Malik,2018,Other: Ireland,"To systematically review the impact of geriatric focused nurse assessment and intervention in the ED on hospital utilisation in terms of admission rate, ED revisits and length of hospital stay (LOHS)","To appraise the impact of geriatric focused nurse assessment and interventions in the ED in terms of admission rate, ED revisits, and length of hospital stay (LOHS)",Systematic review,"Patients from ED including admitted and discharged patient with no follow-up assessment in community; Study participants were of both sexes ≥65 years who underwent a geriatric focused nurse assessment/intervention in ED’s or following discharge",Total not reported; mean sample size 761 participants,"EDs of university based hospitals, general hospitals, university affliated tertiary hospital, tertiary cardiac hospital and medical school affliated public hospital in urban setting","Cochrane, Medline, CINAHL, Embase, Scopus and Web of Knowledge","Inclusion: 1990-2016 Studies: 1996-2015",9,seven RCTs and two prospective pre/post-intervention designed studies,"Canada, Australia, Denmark, Scotland, USA",Evidence based librarianship (EBL) critical appraisal tool,If overall validity of study (yes/total) is > 75% or (no+ unclear/Total) is < 25% then study is valid; RIsk of bias tool on Revman used for RCTs,Tabular summaries; narrative synthesis was conducted on data considered to be unsuitable for meta-analysis ,"Nurse assessment using a disease management risk scale Patients received CGA by an ANP specialising in geriatrics and a multidisciplinary approach to identify unresolved medical, healthcare, social needs Effectiveness of a nurse care management and discharge coordinator for elderly patients who were discharged from ED's where satisfaction with discharge recommendations, adherence with discharge instructions, coordination and provision of healthcare services was assessed","The impact of geriatric focused nurse assessment and interventions on hospital admission rates Two meta-analyses were conducted; the first comprised RCTs that measured outcome at day 30 post-intervention and one prospective pre and post-intervention study that measured outcome data at day 14 post-intervention. Pooled data did not demonstrate a difference in hospitalisation among study groups (OR 0.90; 95% CI: 0.71 to 1.13; p = .36; I2 = 0%). A second meta-analysis was conducted with data gathered at day 14, day 120, day 180 and 18 months post-intervention. Pooled data did not indicate a difference in hospitalisation between study groups (OR 0.84; 95% CI:0.70 to 1.02; p = .08; I2 = 35%).","Significant reduction in total admission at day 30 in one study Readmission rates post-intervention statistically significantly lower than pre-intervention Meta-analysis (two RCTs): no difference in readmission rates between study groups LOHS - no difference between groups in two studies ED revisits - reduced in post-intervention period in one study. Meta-analysis on four studies - no difference in ED revisits between groups.",,,,,Risk screening patients in ED did not allude to more positive outcomes with regard to hospitalisation.,I-squared ranged from 0-62% in meta-analyses performed, 887,Hughes 2019,Emergency Department Interventions for Older Adults: A Systematic Review,Consensus,887,Emergency Department Interventions for Older Adults: A Systematic Review,Jaime M. Hughes,2019,United States,"How effective are emergency department (ED) interventions in improving clinical, patient experience, and utilization outcomes in older adults (age ≥65)?","To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. ",Systematic review ,Older adults >/=65,Not reported,Emergency Department,"MEDLINE (via PubMed), Embase, CINAHL, PsycINFO, ClinicalTrials.gov, Scopus","Inclusion: Inception-2017 Studies: 1996-2017",15 studies (17 articles),"9 randomised (8 randomised studies, 1 cluster-randomised study), 6 non-randomised (5 non-randomised studies, 1 controlled before-after study)","OECD countries: Australia, Canada, Europe, USA",Cochrane EPOC; GRADE criteria,"Randomised studies: 2 high risk, 3 unclear risk, 3 low risk, 1 NA for objective outcomes; for patient-reported outcomes 4 high risk, 3 unclear risk, 2 low risk Non-randomised studies: 5 high risk, 1 low risk for objective outcomes; for patient-reported outcomes 2 high risk, 4 NA","Summary tables When quantitative synthesis was possible, we used random effects models to synthesize dichotomous out- comes (ie, hospitalization at or after the ED index visit, ED return visit) using risk ratios, and the mean difference (MD) for continuous outcomes (ie, quality of life [QOL]). ","Discharge planning; care management; medication management/safety Intervention components: assessment; referral + follow-up; bridge design","Outcome measured: unclear which outcome was primary No pattern of interventions on hospitalisation at the index visit. 1/3 randomised studies on hospitalisation after ED index visit found significant effect of intervention. 3/3 randomised studies found no effect on ED return visit","Functional assessment QOL Patient experience Hospitalization at or after ED index visit ED return visit When considering the interventions collectively, we found a small benefit on functional status but no overall effect on ED return visit(s) or subsequent hospitalization",,,,Using a combination of interventions (two or more) may be associated with greatest effects on clinical and utilization outcomes,"Statistical analysis, but findings not easily applicable given vagueness of intervention descriptions. Planned formal subgroup analyses of moderator variables (eg, intervention strategy, individual intervention components), but there were too few studies to conduct these analyses","I-squared for effect of ED interventions on hospitalisation after index visit = 63.2%. I-squared for effect of ED interventions on ED return visit = 0.9%", 886,Cassarino 2019,Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: A systematic review,Consensus,886,Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: A systematic review,Marica Cassarino,2019,Other: Ireland,"To synthesize the totality of evidence relating to the impact of early assessment and intervention by Health and Social Care Professional teams on quality, safety, and effectiveness of care in the ED"," 1) to explore the impact of early assessment or intervention conducted by interdisciplinary teams with two or more HSCP members in the ED on the qual- ity, safety and cost-effectiveness of care of adults presenting to the ED; 2) to define the content of the assessment or intervention delivered by the HSCP team",Systematic Review,Adults >/= 18 years who present to the ED for care (inclusion criteria); All studies focused on adults >/= 65 years old,"273,886",Emergency Department,"CINAHL, Embase, the Cochrane Library, MEDLINE","No restrictions on inclusion criteria Studies - 2002-2013",6,"three non-RCTs, one CBA and two RMSs",Australia,"Cochrane Collaboration's Risk of Bias Tool Cochrane Effective Practice and Organisation of Care (EPOC) risk of bias criteria were employed to assess the risk of bias of interrupted time series and repeated measures studies ","High, unclear, low","Narrative/qualitative synthesis; meta-analysis not possible due to heterogeneity, and subgroup analysis with funnel plot assessment not undertaken. ","use of interdisciplinary Care Coordination Teams - early assessment or interventions conducted in the ED by interdisciplinary teams comprising one or more HSCP members (two or more of: PT, OT, medical SW, clinical pharmacist, speech and language therapist). Here, ‘early assessment and intervention’ refers to proactive assessment and intervention by the HSCP team following ED triage with/without assessment by a medical professional","ED LOS --> not measured by any studies Reduced rates of hospital admissions Improved referrals to community services Increased satisfaction with safety of discharge (both in patients and staff) Improved health-related quality of care Hospital LOS --> reduced rate of hospital admission by 2% in 2/3 studies; no significant difference in hospital LOS after admission from the ED between ED-based CCT assessment vs routine medical assessment; lower odds of hospital admission from ED for older patients with MSK conditions or angina; decrease by 1.7% in hospital admissions in pre-post; no significant differences in hospital LOS Number of ED revisits --> not reduced in CCT group",Achieving better outcomes (via improved quality of care),,,,None of the studies included investigated ED length of stay or cost effectiveness,Limited evidence to support the effectiveness of HSCP interventions in terms of significant reductions in rates of hospital admissions (three studies); findings mildly meaningful but did not measure primary outcome.,"No measure of heterogeneity given; too heterogeneous for meta-analysis in terms of study designs, health conditions and outcomes reported.", 885,Berning 2020,Interventions to improve older adults' Emergency Department patient experience: A systematic review,Consensus,885,Interventions to improve older adults' Emergency Department patient experience: A systematic review,Michelle J Berning,2020,United States,Improve patient experience in ED,To summarize interventions that impact the experience of older adults in the emergency department (ED) as measured by patient experience instruments.,Systematic Review,Older adults (>/= 65 years),3163,Emergency Department,"Ovid Central, Ovid EMBASE, Ovid MEDLINE, PsycINFO; Clinicaltrials.gov","Inclusion - Inception to January 2019 Studies - 1996-2018",21,"Randomised controlled trials, quasi-experimental studies (nonrandomized), observational studies, before-after observational studies","USA, UK, Australia, Sweden, Canada, Korea, Scotland","GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the confidence in the evidence available. Risk of bias assessed using a modified Cochrane Collaboration Bias Appraisal Tool for RCTs, a modified Newcastle-Ottawa Scale tool for quasi-experimental and observational studies, and a modified tool for evaluating the methodological quality of case reports and case series. ","GRADE Risk of bias was high for 13 studies, moderate for 4, low for 4 ","Summarised in tables and text; meta-analysis not possible due to heterogeneity in study population, intervention strategies, measurement of patient experience, and limited quality of evidence; sensitivity analysis performed excluding high risk of bias studies","Specialist interdisciplinary team; Care coordination program; ""No wait"" Policy; Nurse case management; Nurse discharge coordinator; Discharge planning program led by geriatric nurse practitioner; Identification of elderly patients at high risk for readmission & Multidisciplinary Geriatric and Palliative (GAP)-ED Team; Geriatric assessment & referral to community/healthcare resources; Care coordination team; Home health visitor",Patient experience only outcome reported on --> no reporting on readmission rates/admission to hospital/length of hospital stay/readmission to ED/unscheduled ED visits/hospitalisation rates at all.,"Primary studies also evaluated the following patient flow outcomes but none were not reported on in the systematic review: - Readmission rates - Staff experience including ED physician experience - Health-related quality of life - Hospitalisation rates/Admission to hospital - Unplanned readmission rates to ED or hospital; unplanned ED revisits - Wait time - Length of hospital stay - Service use rates",N/A - not discussed in article,Different needs of older adults compared to population with complex medical conditions,,,No patient flow direction,"Not reported, but significant heterogeneity in study population, intervention strategies, measurement of patient experience, and the limited quality of evidence, precluded conducting a meta-analysis","Studies used both patient experience or satisfaction questionnaires, but none of the studies have validated its tools in the ED setting Questionnaires might be overestimated due to gratitude bias" 883,AM 2022,Access block: A review of potential solutions,Consensus,883,Access block: A review of potential solutions,Michael Frommer AM,2022,Australia,Solutions to access block; present recommendations for evidence based access block solutions for piloting and/or implementation in Australia and Aotearoa New Zealand,"To answer: • What solutions (interventions, initiatives or programs) were proposed or described? • For what settings were they proposed or described, and how were these settings relevant to the Australian and/or Aotearoa NZ health system? • Was sufficient detail provided to assess their feasibility, and if so, were they potentially feasible to consider adopting in Australia or Aotearoa NZ? • Were some or all of the interventions piloted or implemented? • Were some or all of the interventions (and/or their implementation) audited or evaluated? If so, were they found to be effective? What was the strength of the evidence from these studies? • Were any cost estimates provided? If so, what were the cost implications? • To what extent were the interventions scalable or transferrable to other settings, and what was the evidence for this? What key features of interventions might facilitate or inhibit scalability or transfer?",Scoping Review,Not reported - however patients in ED,N/A - not reported,Emergency Department,CINAHL; Medline; Embase; Web of Science,2000-2022,199 assessed for eligibility - unclear how many included in the end as not detailed in PRISMA diagram or elsewhere in paper,"Qualitative studies, quantitative studies","Australia, Europe, North America, Japan, Taiwan, Hong Kong, Singapore, South Korea, South America",N/A,N/A,Not stated however narrative synthesis,"Increasing inpatient bed capacity or freeing beds - admitting fewer people/decreasing LOS as inpatients/speeding up discharge process/over-capacity protocols/discharge lounges Using short-stay units and acute medical or surgical units Minimising delays for patients being admitted Introducing ED time targets Pre-ED interventions Interventions within ED (triage and streaming systems, process improvement programs, increasing size of EDs, increasing staff numbers/modifying types/mix, modifying decision-making responsibilities of staff re patient disposition Four broad types: 1. Increasing inpatient bed capacity in hospitals across the health system, and initiatives to free inpatient beds 2. Diverting patients with acute medical or surgical conditions to acute care units separate from mainstream inpatient services 3. Initiatives to minimise delays in assessing and processing ED patients who are to be admitted 4. The imposition of time targets for patients' transit through EDs","Have evidence to support them: Increasing inpatient bed capacity or freeing beds (most effective) Using short-stay units and acute medical or surgical units Minimising delays for patients being admitted Introducing ED time targets Do not work/do not have evidence to support: Pre-ED interventions Interventions within ED (triage and streaming systems, process improvement programs, increasing size of EDs, increasing staff numbers/modifying types/mix, modifying decision-making responsibilities of staff re patient disposition","Improved clinical experiences Improved patient experiences Lower costs","Online pre-ED triaging - factors associated with number of patients who present to ED (volume of presentations to ED) Hospital overcapacity","Two main drivers of access block: 1 - hospital overcapacity, with a mismatch of bed numbers to population needs – access block would cease to be a problem if hospital bed occupancy were reduced to about 85% from currently prevalent occupancy levels of 95-105%. 2 - a widespread lack of integration across the interfaces between EDs and inpatient services, and between inpatient services and other clinical services across the health system.",,"Four types of solutions can reduce the incidence and/or duration of access block. 1. The most effective solution is to increase inpatient bed capacity and free inpatient beds so that bed occupancy is reduced from the present level (typically 95%-plus), with an initial target of 90%, aiming for 85% 2. The establishment of short-stay units, acute medical units and acute surgical units clearly helps to diminish the numbers of admitted patients waiting in EDs, provided that these units have adequate staff and funding and are not used as holding wards 3. Access block can be reduced by expediting patients’ transition through the ED / inpatient service interface 4. Health system-wide time targets for admitted and non-admitted patients’ transit through EDs are ","Clinically relevant and important. For some interventions, in favour of reducing access block; for other interventions that do not work, the opposite. No statistical analysis done.",Heterogeneity not reported.,"Major difficulty raised was researchers' use of outcome variables which are often imprecisely defined and do not reflect outcomes of practical importance (as per authors of this study) - i.e. measuring ED length of stay across admitted and non-admitted patients (better would be to seperate out these statistics) Gap in literature is on patient perspectives" 882,Zepeda-Lugo 2020,Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review,Consensus,882,"Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review",Carlos Zepeda-Lugo,2020,Other: Mexico,To evaluate the effects of lean healthcare (LH) interventions on inpatient care and determine whether patient flow and efficiency outcomes improve,"To determine whether LOS, TOT, TAT, OTS, boarding time, discharge times, and readmission rates are improved with a LH intervention. To review the changes in satisfaction of patient and staff. To classify, organize, and summarize evidence regarding the effects of LH on efficiency and patient flow outcomes within inpatient care.",Systematic review,Not specified but assume to be patients in hospital (unclear if excluded paediatric populations) ,Not reported ,"Public and private sectors Operating/ surgical units, ED, intensive care units ","PubMed-Medline, CINAHL, The Cochrane Library, Scopus, Web of Science, and Ebsco. Grey literature on OpenGrey, Grey Literature Report, Google Scholar, and ProQuest",Inclusion - 2002-2019,39,"Randomized controlled trials (RCTs), controlled before–after, and quasi-RCT studies, case-control, cohort, and pre–post studies.","USA, Taiwan, Spain, UK, Saudi Arabia, Italy, India, Netherlands, Lebanon",Cochrane's ROBINS-I (Risk of Bias in Non-randomized studies of interventions) ,"72% moderate risk of bias; the rest serious risk of bias; None critical or low risk",Narrative review; standardised forms to tabulate and organise collected data; comparative summary of findings for main outcomes using measures of effect.,"Lean principles Studies that used similar interventions such as six sigma, rapid improvement event, or Baystate Patient Progress Initiative were also included ","Primary ED flow outcomes: Boarding time, readmission rates Boarding time decreased in 4/4 studies measuring it; 2.1h was longest reduction time, resulting in boarding time of 5.5h. Readmission rates - none of 9 studies reported increase post-intervention; 7 of these studies reported no change at 30 or 90 days; 2 studies reported statistically significant reduction in readmission rates","Other outcomes less relevant to ED: - hospital LOS - perioperative on-time starts, turnover time, turnaround time - patient and staff satisfaction - perioperative process - lean healthcare Staff and patient satisfaction improved","Availability of beds is key to reducing the boarding time by improving inpatient discharge timing Not only do premature and delayed discharges worsen health outcomes but also increase costs ",,,,"Studies’ heterogeneity and the risk of bias prevented us from carrying out a meta-analysis to determine causal relationship. Limited usefulness in this study on ED flow given focus is on inpatient interventions",Not reported; heterogeneity prevented a meta-analysis being performed,Findings not ED specific 881,Manning 2023,A systematic review to identify the challenges to achieving effective patient flow in public hospitals,Consensus,881,A systematic review to identify the challenges to achieving effective patient flow in public hospitals,Larissa Manning,2023,Australia,To uncover the challenges related to patient flow from a whole public hospital perspective and identify strategies to overcome these challenges,"To answer the questions: What are the common issues that affect patient flow in public hospitals? What tools and strategies have been implemented to improve patient flow in Public hospitals?",Systematic review,Patients in public hospitals - not specifically stated,Not reported,Public Hospitals (not ED specific),"Medline, Emcare, PubMed",2015-2020 inclusive,24,"Quantitative, Qualitative, Mixed method, systematic review","USA, UK, England, France, Australia, Canada, Austria, Netherlands",16-item quality assessment tool (QATSDD),Score based on 16 questions (scale 0-3) - Scores ranging from 7 to 37. The total score achievable was 42 for qualitative and quantitative studies and 48 for a mixed method approach.,Thematic analysis,"No real interventions, purpose of study was to investigate strategies related to patient flow "," A total of 5 themes were generated in relation to patient flow. These include: (1) Teamwork, Collaboration & Communication, - lack of communication between teams and poor collaboration leads to a breakdown in interprofessional working - strategies to improve: formation of huddles and bed management meetings (2) Public hospitals as complex systems, - strategies to improve: use a whole systems approach (3) Timely discharge, - need for early discharge to minimise overcrowding and bottlenecks in ED - strategies to improve: ‘Plan-Do-Check-Act (PDCA) cycle to improve discharges (4) Policy, Process and Decision-making, and - leverage machine algorithm learning (5) Resources- Capacity and demand. - strategies to improve: having the data, resources available and processes in place that can inform decision making and create capacity. ","Achieving better outcomes Improved clinical experiences ","Teamwork, collaboration and communication - lack of communication between teams, performance driven coordination and referral-related barriers; Complexity of public hospitals and variability that can occur daily; Late discharges/discharge delays; Ineffective flow processes & fragmented bed management process; Resources and mismatch between capacity and demand.",,,"Formation of huddles & bed management meetings - one study: significant decrease in hospital boarding times after implementation; second study: 'plan of the day huddles' improved communication & patient flow across units. Multidisciplinary approach - early discharge identification, daily huddles, early discharge recognition improved discharges from 8.8% to 15.8% in 10 months. Other interventions: dedicated slots in diagnostic services for discharging patients, improved communication, eliminating pending exams, identifying discharges the day before, prioritising laboratory tests, coordinating discharge medication processes and utilising case management. Another study - increasing availability of early results on hospital wards - did not have discharges occurring earlier in the day but discharges were increased. Further interventions - education campaigns on the safety implications of reducing hospital boarding times, afternoon huddles and web-based dashboards to display real-time discharges by noon; criteria led discharges. Simulation to identify optimal discharge time targets to improve performance which both identified benefits of early discharges on patient flow performance targets. Multidisciplinary approach and communication increases effective decision-making around patient flow. Patient Admission Prediction Toll (PAPT) and workflow guidelines - identified ideal occupancy rate for hospitals as 85% and increased admissions without increasing occupancy. Real-time demand capacity (RTDC) management analytical tool had some accuracy. An electronic dashboard which monitors patient flow can provide information required to make timely decisions and implement process early to facilitate effective flow.",Not done,N/A,Whole systems approach required to improve patient flow in public hospitals - meaning that need engagement and collaboration of the multidisciplinary team to work towards common goals 809,Voaklander 2022,Interventions to improve consultations in the emergency department: A systematic review,Consensus,809,"Interventions to improve consultations in the emergency department: A systematic review",Britt Voaklander,2022,Canada,To describe and evaluate the effectiveness of interventions to improve the ED consultation process.,To describe and evaluate the effectiveness of interventions to improve the ED consultation process.,Systematic review,"Patients presenting to ED requiring an ""ED Consultation"" to a specialist team.","Sample size ranged from 136 - 71,051; not recorded for all studies so could not total ",Emergency Department,"Medline OVID, PubMed NCBI, EMBASE OVID, SCOPUS Elsevier, Dissertation & Theses Global, EBM Reviews/Cochrane Library Wiley, Global Health OVID, and CINAHL EBSCOhost Grey literature on: Clinicaltrials.gov, Google Scholar Conference abstracts published in Annals of Emergency Medicine, the Canadian Journal for Emergency Medicine, Academic Emergency Medicine, and Emergency Medicine Journal from 2014–2020 were hand searched. ","Inclusion: inception-2021 Studies: 2004-2021",35,"Before/after study design (n = 25, 71%); controlled before/after design (n=1), including: Before-after, RCT, retrospective cohort, interrupted time series, prospective cohort, controlled before-after","USA, Canada, South Korea, Singapore, Thailand, Taiwan, India, Ireland, Turkey",Methodological Index for Non-Randomized Studies (MINORS) tool. ,"Scores comparative studies on 12 methodological items from 0 to 2 (0= not reported; 1 = reported but inadequate; 2 = reported and adequate) for a maximum score of 24. Median MINORS score was 14/24","Narrative review, tabular and descriptive data, meta-analysis calculating Mantel–Haenszel mean difference (MD), weighted mean differences (WMDs), and odds ratios (ORs) with 95% confidence intervals (CIs) using a random-effects model. Subgroup analysis could not be completed due to incomplete reporting. Sensitivity analysis was conducted.","Interventions to improve consult responsiveness (11 studies): - specific time in which the consultant was expected to start or complete the consultation (5 studies); - specific time in which consultants were expected to arrive to an admission decision (1 study); - reminder messages via SMS to consultant or residents/staff of service if specified time target was not met (2 studies) - use of instant messaging like WhatsApp for communication between ED physician & consultant (2 studies) - audits and feedback (5 studies), of which 2 studies also provided educational sessions to staff Interventions to improve access to consultants in ED (9 studies): - addition of specialised care team (9 studies) - of which 5 studies implemented surgical specialised care team, 2 of which specified increased availability of surgeon to provide non-trauma surgical consults; 3 studies - psychiatric care team, of which 1 had psych resident in ED from 9am-8pm and 1 had comanagement model where ED care shared between ED physician and psych liaison Interventions to expedite ED consultations (8 studies): - e.g. emergency physicians assessment & request consultation at triage before assessment/bed space (2 studies); promoting earlier consultation requests (3 studies); screening tools (2 studies) Interventions to bypass ED consultations with direct admission (7 studies)","Primary outcome measured: Consult responsiveness Consult response time - assessed in 6/11 studies on interventions to improve consult responsiveness, with 4/6 reporting significant decrease in consult response time in intervention group vs control between 10% to 71% - assessed in 3 studies on interventions to improve access to consultants, with 2 reporting significant decrease in consult response time with reductions of -41.50 and -49.20min; 1 study reported decrease but not statistically significant - assessed in 3 studies on interventions to expedite ED consultations, with 3 studies reporting significant decrease in consult response time; 2 reporting between 41% and 13% decrease among discharged patients","Secondary outcomes measured: Proportion of patients consulted Proportion of patients admitted to hospital following a consultation ED LOS Consultation duration reduced Reduction in door-to-consultation - 8 studies in interventions to improve consult response time; 7 studies significant decrease in ED LOS with intervention, between 39% to 4.2%; 4/4 before-after studies - significant reductions in ED LOS but heterogeneity high - 3 studies in interventions to improve access to consultants, all significant decrease in ED LOS - 5 studies in interventions to expedite ED consultations; 4 found significant decrease in ED LOS; 1 increase in ED LOS for palliative care consultation in ED vs consultation after ICU admission - 6/6 studies on interventions to bypass ED consultations had reduced ED LOS",,,,"Some studies took advantage of evolving technology (e.g., the use of SMS to share relevant patient information) and while these e-health strategies have the potential to be low-cost interventions to improve consult responsiveness, health care providers will need to ensure that any messaging platforms are compliant with privacy and data protection legislations.",Statistically significant findings from meta-analysis results,"Heterogeneity in interventions to improve consult responsiveness was high (I2= 91%) for proportion of patients admitted to hospital following a consultation and high (I2= 99%) in four before-after studies for ED LOS. Heterogeneity in interventions to bypass ED consultations was high (I2=99%) in six before-after studies in ED LOS. High heterogeneity was a limitation listed by authors.", 713,Shepherd 2022,"Radiographer-led discharge for emergency care patients, requiring projection radiography of minor musculoskeletal injuries: a scoping review",Consensus,713,"Radiographer-led discharge for emergency care patients, requiring projection radiography of minor musculoskeletal injuries: a scoping review",Jenny Shepherd,2022,UK,To scope all radiographer-led discharge (RLD) literature and identify research assessing the merits of RLD and requirements to enable implementation,,Scoping review ,"Radiographers with advanced training in projection radiography or image interpretation for the appendicular skeleton; Patients attending the ED with minor MSK injuries of the extremities","Range from 5-497, with modelling extending up to 1,303 Totals could not be done given not all studies reported.",Emergency Department,"MEDLINE, Embase, CINAHL, Scopus, Google Scholar, The Radiography journal, sources found through Public Health England, Imaging and Therapy in Practice magazine and the University of Exeter Repository","Inclusion criteria: 2000-2017 Studies: 2007-2018",7,"Audit, pilot studies, discrete event simulation modelling study, feasibility study, survey, mixed methods study",UK,N/A - scoping review,N/A - scoping review,"Narrative synthesis. Descriptive-analytical approach, charted under headings and tabulated.","Radiographer-led discharge - radiographers discharging patients with normal x-rays, although giving basic treatment advice was also stated in 4 of the studies ","Quantitative outcomes: Reduced length of stay in ED Recall and re-attendance to ED Qualitative outcomes: Radiographer questionnaire used snowball sampling across hospitals with an estimated 30% response rate 6 studies --> significant LOS reduction using RLD; - 17% (21min) mean RLD LOS reduction - 61% (82min) LOS reduction with RLD and after RLD treatment referral reduction of 41% (63min) - X-ray to discharge LOS 72% reduction - X-ray to discharge LOS 12.9min reduction","Lower costs Improved patient experiences (reduction in image interpretation errors improving recall and re-attendance rates) -> this could improve patient outcome and decrease likelihood of litigation ED recall and re-attendance rate within 28 days of original attendance --> significant reductions. - 1 study - RLD re-attendance rate 2.62%, either not clinically significant or unrelated, while standard practice were 7.06% of which 1.75% were clinically significant; same study - odds ratio of re-attending with same injury through standard discharge compared with RLD was 8.36 (95% CI 2.05 to 34.08) (study may be underpowered). - 1 study - RLD re-attendance rates of 1.75% compared to 13.1% and 8.6% for junior doctors nad NPs respectively. - 1 study - no patients re-attending, one patient recall with no change in management with RLD.",,,,"Radiographer hot reporting cost effective with significant reduction in interpretive errors compared to ED clinicians. Potential for increased efficiency in the minor MSK patient pathway and capacity for ED staff was recognised",Clinically relevant & important; studies identified statistically significant results but very small sample sizes.,No measure of heterogeneity given. Limited evidence base with 7 RLD studies of varying sample sizes and heterogeneity,"Reasons why RLD not widely implemented: 1) Concern of litigation 2) Less supportive work environment could impede role development (departmental cultural issues) 3) radiographers preferred commenting on images to RLD 4) Would need very consistent use of protocol-driven process" 711,Sharma 2020,The role and contribution of nurses to patient flow management in acute hospitals: A systematic review of mixed methods studies,Consensus,711,The role and contribution of nurses to patient flow management in acute hospitals: A systematic review of mixed methods studies,Shrawan Sharma,2020,UK,To explore nurses' roles and their contributions to maintaining patient flow in acute hospitals through emergency departments,"To investigate different facets of the nursing role and contribution to patient flow management, To explore nurses’ experiences of flow processes, and To identify flow barriers and enablers from nurses’ perspectives.",Systematic review of mixed methods studies,Nurses in ED; ED patients,Not reported,Emergency department,"PubMed, CINHAL, BNI, ASSIA and SCOPUS Grey literature searched for in Google Scholar Manual searching of the references in the included studies was undertaken to compensate for any deficiencies of the indexing of terms due to the limited value of ‘protocol-driven search strategies’ in the mixed method review.","Inclusion: Inception to 2019 Studies: 1993 - 2019",34,"Mixed studies (qualitative, quantitative and mixed method) 31 primary studies and 3 systematic reviews exploratory (n=5), ethnography (n=2), quasi-experimental before-and-after (n=13), cross-sectional/comparative (n=3), qualitative (n=1), grounded theory (n=2), action research (n=1), descriptive (n=2), randomised controlled trials (RCT; n=1), pragmatic randomised cluster (n=1) and systematic reviews (n=3)","USA, UK, Canada, Australia, Iran, India, Italy, Netherlands, Sweden",CASP tool (score out of 10),19 high quality; 11 moderate quality; 4 poor quality,Narrative synthesis ,"Various nursing roles - operational roles, focusing on maintaining patient flow through bed management and bed allocation - strategic roles, accentuate mitigation of flow barriers such as process-related factors and supporting non-clinical activities - expanded roles, focusing on clinical activities to support admission, treatment and discharge process","Outcome measures: Both the role and function of nurses, as well as their experiences and perspectives of the patient flow process, and Investigated nurses’ contribution to patient flow in terms of length of stay (LOS), triage time, and other associated performance data LOS Triage time ED crowding Patient experiences Operational roles --> no outcomes discussed Strategic nursing roles (12 studies): - Nurse navigators --> reductions in ED LOS in many studies. 1 study - significant improvement of 87.6min in ED LOS with nurse navigator role; 1 study - reduced time from notification of bed assignment to patient arrival on ward from 104min to 84min with patient flow coordinator; 1 study - decline in ED LOS from 3.6 to 3.4h with emergency journey coordinator (EJC); 1 study - increase in ED LOS after ED ambulance offload nurse (EDAOLN) from 236 to 239min - Nurse roles outside ED --> reduction in LOS in many studies. 1 study - reduced mean LOS from 8.7 to 7.12 days with case manager introduction; 1 study - mean LOS shorter by 1.97 days after medical team coordinator introduced; reduction in ED visit rates to all hospitals decreased from 16.36% to 12.08% with strategic nursing role focused on stroke patients; 1 study - readmission rates static at 6% in pre and post nurse navigator groups. - Reduction in ED waiting times --> 1 study ED waiting time declined from 64.42min to 62.36min; 1 study reduction in waiting time of 54.9min with ED flow coordinator role; 1 study EDAOLN reduced ED waiting times from 34min to 31min. - Reduction in ambulance diversion rates --> 1 study reduced from 13.8hr to 2.8h; 1 study reduced by 11% after introduction of strategic nursing role; Expanded clinical roles (5 studies & 3 systematic reviews): - 1 study: reduced ED waiting time from 75min to 25min; 1 study time to diagnosis and treatment reduced 102.7min to 65.5min; 1 study 75% vs 40% of patients were reviewed within an hour of referral to specialty ward after introduction of expanded nursing roles - nurse practitioner role: 5 studies reduced ED LOS and waiting time; 3 studies no difference in ED LOS","Ambulance diversion rates declined from 13.8 h to 2.8 h Reduced 30 day readmission rates from 9.39% to 3.24% Improved clinical experiences Achieving better outcomes ","According to nursing staff interviewed (qualitatively): Lack of hospital beds Insufficient ED space Staff shortages Prolonged nursing time away from the department escorting patients or performing other non-clinical activities when healthcare assistants were not available contributed to delays. Lack of awareness of systems and processes particularly among temporary or casual staff","Patients referred by GP, multi-trauma patients and patients requiring in-patient beds all caused significant ED crowding Lack of beds for mental health treatment Increase in acutely ill patients requiring prolonged ED LOS was significant factor leading to ED overcrowding Internal factors: staff shortages, training and skills, awareness of flow process, decision-making by seniors. External factors: increasing number of patients attending ED, lack of alternative options including shortages of community beds",,"The effects of emotional labour (conflicts, frustrations) of patient flow processes on nurses are significant and may have unaccounted for transaction costs and consequences that need acknowledging in order to be addressed by managers and policy makers ","Clinically relevant - various nursing roles can contribute to improved patient flow. No synthesising statistical analysis completed however, but findings in individual studies promising.",Not measured, 641,Rasouli 2019,"Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study",Consensus,641,"Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study",Hamid Reza Rasouli,2019,Other: Iran,"To conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals. ","To assess the causes and challenges of ED crowding, the experiences of emergency patients, emergency care providers, and healthcare systems, and the solutions to ED crowding and their consequences since 2007 globally",Systematic Review,Patients and staff in ED - not specifically detailed,Not reported,Emergency Department,"PubMed/MEDLINE, EMBASE ",Inclusion: 2007-2018,106,Peer-reviewed original articles,Not Reported,Critical Appraisal Skills Program (CASP); JBI Meta-Analysis of Statistics Assessment and Review Instrument,"Cutoff of 0.33 points (<33%) meant exclusion from review. No ratings reported.",Narrative synthesis and R 'wordcloud',"Organisation/management level solutions: - involving the executive leadership, implementing of hospital-wide coordinated strategies, strengthening evidence-based management and performance accountability - implementing a coordinated patients transfer networking system (RTNS) - implementing an independent capacity protocol - application of lean principles/Six Sigma in service delivery - forecasting ED crowding Operational level solutions: a) staffing the ED and motivating the staff - pay for performance - allocation of residents/staffing with qualified professionals b) operation level strategies and tactics - evidence-based patient admission - implementing Electronic Blockage System (EBS - triage system) - implementing smoothing strategy - using capacity alert escalation calls - application of Discrete Event Simulation (DES) model - improving leadership of ED - implementing contingency strategy - using management-support multimodal hospital-wide interventions - implementing 4-hour-rule for emergency care - introducing Stat Lab within ED - implementing contingency strategy - using management-support multimodal hospital-wide interventions - using a dashboard to provide real-time information about crowding c) service delivery process - acute care emergency surgery service provision - whole week emergency service delivery - implementing triage by physicians - introducing efficient patient discharging process - high-turnover utility bed management - implementing timely quality care - implementing an improved ED patient flow d) other services - enhanced primary care - optimising translation services e) premises - expanding or opening additional EDs - hallway emergency bed - increasing hospital capacity","Outcomes measured: LOS, LWBS, waiting time, ED bed occupancy, ambulance diversion hours, Introducing pay for performance and assigning ED residents reduces LOS of patients; allocation of residents to ED reduces waiting time and reduces patients LWBS Use of EBS reduced ED crowding and facilitated patient admissions. Applying management-support multimodal hospital-wide interventions decreased ED occupancy and increased four-hour performance without compromising quality of care. Smoothing strategy (properly utilising unused capacity) and using capacity alert escalation calls contributed to reduction of ED crowding by lowering ED bed occupancy rates. Initiating an acute care emergency surgery service, improving the ED patient flow and introducing an efficient patient discharging process reduce the ED bed occupancy and LOS. High-turnover utility bed management can decrease ambulance diversion hours and LOS of patients. Triage by physicians reduced patients LWBS in EDs. Whole week emergency service delivery & implementing Timely Quality Care reduced crowding. Enhancing primary care, optimising translation services concerning patients' issues & engagement on specialists in outpatient environment contribute to reduction of ED LOS and crowding.","Improved clinical experiences Improved patient experiences Lower costs Achieving better outcomes ",,"Causes of ED crowding: - Patient-related factors: being critically ill; age (child and ageing); male gender; lifestyle such as alcoholism - Emergency service delivery related causes: patient flow and emergency care related [delay in discharging admitted patients; severe emergency condition; high proportion of emergency patients; long waiting of emergency patients for diagnostic test results]; staff related [wrong diagnosis; delay of consultants; delay of staff to provide emergency services; delay in transferring patients to inpatient ward; shortage of emergency care providers]; premises and materials of ED-related factors [shortage of beds for admitting emergency patients] - Other hospital services delivery related causes: delay in laboratory and imaging investigations; delay in diagnostic test results/reports; high number of patients in the waiting room of a hospital; reluctance of hospital staff to admit patients from ED.","Adverse consequences of ED crowding: treatment delays; patients LWBS; walkouts due to perceived ED LOS; readmissions, hospitalisation, costs for healthcare; dissatisfaction, adverse outcomes & death Overcrowding --> delay in treatment to patients and risks of not being well examined by healthcare workers High workload --> prolonged service preparation and clinical decision making, increasing patients' LOS",,Not reported,Not mentioned, 605,Pearce 2023,"Emergency department crowding: an overview of reviews describing measures causes, and harms",Consensus,605,"Emergency department crowding: an overview of reviews describing measures causes, and harms",Sabrina Pearce,2023,Canada,"To synthesize the current literature of the causes, harms, and measures of crowding in emergency departments around the world",,Umbrella review,Not reported but would assume patients in ED,Not reported,Emergency Department,"MEDLINE, Embase ","Inclusion: 2010-2022 Studies: 2011-2022 Range of studies within systematic reviews: 1980-2012",13 (744 studies included within those reviews) ,"Systematic reviews (those systematic reviews included studies that were cross-sectional, cohort, case control, quality improvement, quasi-experimental, RCT) ","Canada, USA, Brazil, Australia, Iran, Saudi Arabia, New Zealand, Italy",JBI checklist tool,5 low; 7 moderate; 1 high,"Narrative review with tabular data; No meta-analysis given heterogeneity",Not reported - aim of study was not to identify interventions specifically ,"Outcome measures: Number of patients in waiting room, ED occupancy, and no. of admitted patients in the ED were metrics most frequently linked to ED quality of care (QoC) - 15 crowding measured studied had quantifiable links to QoC Patient flow measures rely on time, nonflow measures evaluate the number of people and utilization of resources: ED LOS - Boarding time Time to diagnostic imaging Time to inpatient bed after being admitted Time in waiting room Time to disposition ED Census - Waiting room patients Number of boarders Percentage of beds occupied by boarders within the department Number of patients in the waiting room Number of ED arrivals Number of hallway patients Number of ambulance diversions (a) Four reviews evaluated the validity of measures used to study emergency depart- ment crowding; (b) Four studies investigated the causes of emergency department overcrowding; and (c) Nine studies evaluated the possible outcomes and harms of crowding in emergency departments ",Achieving better outcomes ,,"Patient presentations and factors impact time spent and crowding in ED - e.g. being critically ill, extremes of age, male gender, social determinants of health. Staff issues - Speed of service delivery to these patients is impacted by ED staff-related factors. ED service delivery factors include a delay to discharge or imaging and lab investigations, increased time to inpatient consultation, staff fatigue, and crowding itself, which causes delay to diagnostic tools and final diagnoses. Inadequate staffing of nurses, high rates of provider burnout, excessive workloads, high staff turnover all associated with throughput causes. System-wide issues - lack of access to primary care and tertiary care; limited access to resources and primary care physicians; boarding of admitted patients","Shortage of inpatient beds --> Boarding of admitted patients Lack of access to primary & tertiary care --> increased low acuity presentations Limited access to resources & primary care physicians --> increase in mental health & addictions presentations","Patient harms include increased risk for morbidity, adverse events, and mortality. Other effects include delayed time to assessment, decreased quality of care, or medication errors which may cumulate in low patient satisfaction. It can also cause increased walkouts prior to receiving care, which may contribute to increased chance of readmission and prolonged time in hospital. No publications had data on the relationship between crowding measures and efficiency or equitable care",N/A,"Heterogeneity made it difficult to standardise results; no statistical analysis conducted. Causes of ED overcrowding are multifactorial with input, throughput and output factors.","The goal of this paper was to synthesize information on ED overcrowding Second paper will be published that will focus on interventions and solutions Includes studies that have already been identified in our umbrella review: - Morley 2018 ""Emergency department crowding: A systematic review of causes, consequences and solutions"" - DiLaura 2021 ""Efficiency measures of emergency departments: an Italian systematic literature review"" - Rasouli 2019 ""Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study""" 585,Ortíz-Barrios 2020,Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review,Consensus,585,"Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review",Miguel Angel Ortíz-Barrios,2020,Other: Colombia,Aims at identifying research papers published in high-quality journals and focused on interventions addressing the above-mentioned leading problems in ED,,Systematic review,Not reported - patients in ED,Not reported,Emergency Department ,"ISI Web of Science, Scopus, PubMed, IEEE, Google Scholar, ACM Digital Library and Science Direct.",Inclusion: 1993-2019,203 papers (1178 studies) ,Not reported,Not reported,Not done,Not done,Unclear but narrative review with graphs and tables,"Various process-improvement approaches, with a mix of single- and hybrid approaches Main techniques: - Simulation - Lean manufacturing - Optimisation - Integer programming - Queuing theory - Regression - CQI - Six Sigma Others: Process redesign Petri nets – including coloured Rapid Entry and Accelerated Care at Triage Pivot nursing Value Stream Mapping Nurse Navigator Resource Preservation Net Iowa Model of Evidence-Based Practice ED dashboard and reporting application Separated continuous linear programming (SCLP) Acute care model Critical pathways Fast track protocols Plan-Do-Study-Act cycle Statistical Process Control Balance Scorecard (BSC) Preference Ratios in Multi-Attribute Evaluation (PRIME) Game Theory Single and bi-objective optimisation models Fuzzy Analytic Hierarchy Process (FAHP) Multi-attribute Utility Theory (MAUT) Dynamic grouping and prioritisation (DGP) Discrete event simulation Non-dominated sorting particle swarm optimisation (NSPSO) Multi-objective computing budget allocation (MOCBA)","Primary outcomes measured: Overcrowding Prolonged waiting time Extended LOS Excessive patient flow time High number of patients who leave the ED without being seen 1 study - continuous quality improvement with critical pathways decreased LOS from 7.52 days to 6.33 days for stroke patients 1 study - MAUT and FAHP developing triage algorithm reduces ED LOS vs ESI triage system 1 study - simulation + queueing analysis decreased median LOS from 192min to 112min 1 study - multidisciplinary lean intervention reduced ED LOS for medicine admissions by 26.4% from 8.7h to 6.4h 1 study - continuous quality improvement (CQI) led to immediate improvements in LOS 1 study - simulation reduced LOS in ED by 30% 1 study - modeled implementation of new treatment pathway led to 68% or 7.2h reduction in patient LOS 1 study - metamodel techniques combined with simulation - total waiting time of ED patients reduced by 48% 1 study - combination of DES, queuing models, heuristic staffing algorithm decreased waiting times by up to 15% 1 study - simulation model reduced average wait by 73.2% 1 study - lean thinking in triage acuity level 3 patients reduced waiting times significantly from 71 to 48min 1 study - LM program reduced patient lead-time from registration to discharge by 17% 1 study - DES model led to increase in NEAT performance by 16% and decreased bed occupancy by 1.5% 1 study - integrated agent-based simulation and ordinary least squares regression led to decreased average LWBS by 42.14% and ED LOS by 6.05% 1 study - LWBS can decrease between 0.66%-2% if additional internal waiting room adopted within ED 1 study - lean effects in hospital A dropped rates of LWBS 8% to 5%; hospital B had 22% decrease in LWBS 1 study - lean healthcare reduced LWBS from 4.1% to 2% in rural EDs and also decreased LOS.","Lower costs Improved patient experiences ",,"Overcrowding - set of mismatches along the supply chain within the healthcare system (inpatient bed availability, demand growth, increased proportion of non-urgent visits). Extended LOS - delays in delivery of lab and/or radiology test results, lack of hospital beds, hospital transfers taking a long time, insufficient medical staff during peak hours Excessive patient flow time - departmental layout, insufficient medical staff, inefficiencies of parallel assisting processes, mismatches between the demand on emergency services and ED capacity. LWBS - restricted ED capacity, long waiting time for triage classification, diversion status",,,"Many promising findings in process improvement towards decreasing LOS and waiting times. Not statistically significant despite large number of studies reported on No appraisal done, no statistical analysis done and thus results are not generalisable.",Not addressed/reported, 547,Morley 2018,"Emergency department crowding: A systematic review of causes, consequences and solutions",Consensus,547,"Emergency department crowding: A systematic review of causes, consequences and solutions",Claire Morley,2018,Australia,"To expand on and provide an updated critical analysis of the findings of peer-reviewed research studies exploring the causes or consequences of, or solutions to, ED crowding ","To critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding",Systematic review,Unclear but involved patients in ED and patients prior to presenting to ED ,Not reported for all studies ,Emergency Department (adult),"Medline, CINAHL, EMBASE, Web of Science ",Inclusion criteria - 2000-2018,102,"Retrospective cohort, retrospective chart review, pre-post, RCT, retrospective time series analysis, prospective observational, mixed methods, exploratory field study, non-randomised controlled trial, prospective observational cohort study, prospective pre-post observational study, retrospective data analysis, retrospective cross-sectional, statistical modelling, prospective interventional, non-comparative survey, secondary data analysis from observational registry, cross-sectional data linkage, retrospective stratified cohort","Singapore, UK, USA, Australia, Finland, Korea, Canada, New Zealand, Holland, Taiwan, Belgium, China, Sweden",Scottish Integrated Guidelines Network (SIGN) critical appraisal tool,59% acceptable quality; 7% high quality; 34% low quality.,Narrative and tabular synthesis,"Input: GP-led walk-in centres/co-located GP; extended GP opening hours; choice of ED; social interventions including education campaigns, financial disincentives, redirection. Throughput: Split ESI 3 on presentation; earlier physician assessment, including physician-led/supported triage; fast-track/flexible care area; shorter turnaround-times for laboratory tests; ED nurse flow coordinator; bedside registration; nurse initiated protocols; earlier inpatient consultation; increased ED bed numbers; increased ED staff. Output: active bed management; leadership program/support; implementation of nationally mandated, timed patient disposition targets; ED staff direct admit rights; admitting team prioritise ED admissions; alternative admission policies; increased inpatient beds and staff.","Outcomes measured: ED LOS LWBS DNW (did not wait) Hours of ambulance bypass/diversion Hours of access block/boarding hours Proportion of presentations meeting patient disposition targets (4-hour target) Input: - 19% lower wait time for category 2 patients in EDs with a co-located GP; reduction of 8.3% in GP-type presentations to adult EDs with a GP walk-in-clinic on demand for ED care. - increased GP opening hours --> 17.9% decrease in weekend ED attendances; 19% fall in admissions in elderly, 29% reduction in elderly cases arriving by ambulance; 26% reduction in self-referrals with minor problems; decrease of presentations by 8.2% in category 4 and 5 (low acuity). - public education campaigns effective but presentations reverted to pre-campaign levels when campaign finished; financial disincentives for non-emergencies reduced presentations when the fee exceeded the fees charged by primary health care clinic; redirection of non-emergencies initially successful but adverse public relations so discontinued. Throughput: - 7/8 papers on early physician assessment had significant decreases in ED LOS, 4/8 had decreases in patients LWBS or DNW; one study - team triage, quick registration process, improving 'front-end operations' - significant increase in EDLOS for cat 2-4 patients as rise in diagnostic radiology; 5 studies looked at physician in triage - all found reduction in EDLOS post implementation, but one - only for patients who were then discharged, one - increase in boarding time, one - decrease in LWBS, two - reductions in hours on ambulance bypass - significant reductions in 2/2 papers for ATS cat 4 patients only with fast track and flexible-care areas; geographically separating US cat 3 patients with low variability showed significant decrease in EDLOS for cat 3+cat 4 discharged patients. - reducing lab test turnaround-times showed significant reduction in EDLOS in 4/4 studies. - senior nurse flow coordinator led to 4.9% increase in number of patients meeting NEAT targets, as did nurse navigator. - bedside registration concurrent with physician evaluation - decrease in time from triage to treatment room allocation for all patients initially; 3/6 nurse-initiated protocols significantly reduced mean EDLOS in one study; text reminders about wait times decreased median LOS by 36mins; increase in ED size with no changes to staffing ratios increased ED boarding significantly while addition of nursing and medical staffing with extra beds decreased median EDLOS. Output: - bed management (bed director + bed manager) --> 98min reduction in EDLOS and reduced time on alert; 21% decrease in ED LOS for admitted patients, 52% reduced mean boarding time. - leadership programs & leadership support - collaborative group introduced a computerised tracking system to ensure the ability for real time tracking of ED admit wait times --> 16% increase in patients transferred to inpatient bed within 60mins of decision to admit; decreases in boarding time, LWBS and hours of ambulance diversion; - targets - one study- hospital education to increase awareness of targets prior to implementation increased number of patients leaving ED within 4-hours post-implementation & reduction in access block but also significant increase in IPLOS and # inter-unit transfers within 48hrs of admission; reduction in % access block and decreased median EDLOS; median EDLOS decreased - reforms e.g. direct admission; limits on response times to ED referrals - decrease in EDLOS - alternative admissions decreased LWBS and hours of ambulance diversion; reduced EDLOS with 'high turnover' unit for ED admissions; reductions in ED LOS with providing ED with extra assistance from hospital leaders/specialists during times of crowding; 34min increase in ED LOS when full capacity protocol operational but 92% decrease in hours of ambulance diversion","Patient effects - poor patient outcomes (e.g. for patients with chest pain) Increased mortality Delayed assessment and care - Crowding associated with delays in time to receive analgesic and antibiotic therapy as well as delays in patients receiving their usual 'home' medications Increased IPLOS Risk of readmission Reduced patient satisfaction Exposure to error - Frequent medication errors (including administration of incorrect and contraindicated medications, during times of crowding) Staff effects - Non-adherence to best practice guidelines (including increased time to assessment of pain and/or delays in administration of analgesics) Increased staff stress Increased violence towards staff System effects - Increased inpatient length of sty Increased ED LOS ","Inputs: presentations with more urgent and complex care needs; increase in presentations by the elderly; high volume of low-acuity presentations; access to primary care; limited access to diagnostic services in community. Throughput: ED nursing staff shortages; presence of junior medical staff in ED; delays in receiving test results and delayed disposition decisions. Output: access block; ICU and cardiac telemetry census.","Increases in types of ED presentations, limited access to primary care and access block for patients requiring admission, inadequate staffing, low acuity presentations, increase in presentations by patients with complex and chronic conditions including the elderly","Poorer patient outcomes and inability of staff to adhere to guideline-recommended treatment Treatment delays Increased mortality ",Number of studies identified financial costs associated with the interventions but did not provide any cost benefit analysis ,Clinically relevant - mix of direction with different interventions. No statistical analysis done.,"Not reported; Many solutions have been trialled and modelled with varying success, but there is a mismatch between identified causes of crowding and initiatives implemented in efforts to resolve the problem. Elderly patients with complex, multi-morbid conditions represent increasingly important driver of ED crowding.", 503,Maninchedda 2023,Main Features and Control Strategies to Reduce Overcrowding in Emergency Departments: A Systematic Review of the Literature,Consensus,503,"Main Features and Control Strategies to Reduce Overcrowding in Emergency Departments: A Systematic Review of the Literature",Mario Maninchedda,2023,Other: Italy,"To identify the characteristics of the problem, analyzing the proposed strategies aimed at improving patient flow, delay in services provided and overcrowding of emergency departments","To identify overcrowding features, and to analyze the proposed strategies aimed at improving the flow of patients, the delay in services provided and the ED overcrowding",Systematic review,Patients ≥ 13 years of age,N/A,Emergency Department,"PubMed, Scopus, Web of Science","Inclusion - 2012-2022 Studies - 2012-2021",19,"Descriptive study, observational study, prospective study, undeclared","Belgium, Brazil, USA, Canada, China, Hong Kong, Israel, South Africa, UK, Taiwan, Turkey",N/A,N/A,Narrative and tabular summary with graphs although not explicitly stated,"Grouped the solutions proposed in five categories: work organization, investment in primary care, creation of new dedicated professional figures, work and structural modifications and implementation of predictive simulation models using mathematical algorithms","Outcomes measured: ED measurement scales - ED LOS, LWBS, Door to Evaluation Time Work organisation - optimisation of staff & resources already present, earlier identification of subtle presentations of life threats, earlier starting of diagnostic testing, earlier administration of important therapies, real-time information on ED overcrowding, creating a tool that predicts waiting times to inform patients, reducing the number of potentially avoidable diagnostic tests and treatments performed, discharging patients before noon, re-evaluating all patients staying in hospital for 14 days or more to facilitate their discharge. Investing in primary care Creation of new dedicated professional figures and reorganisation of patient flow - e.g. the patient partner; or a rapid evaluation unit (RAU), medical evaluation, complete registration at the patient’s bed after medical visits and nursing services, patient stabiliza­tion and start of treatment; or a clinical assistance, a professional figure in charge of managing the flow of incoming patients, entrusting them in an orderly and efficient way to doctors and doing administrative tasks. Structural works and modifications - increased beds in internal medicine wards; reorganization of internal spaces to ensure first patients’ evaluation, using hallway beds/chairs and enlarging the triage area dedicated to emergency; ED vertical flow model with fold-down horizontal stretchers and replacing them with multiple chairs that allowed for the assessment and medical management in an upright sitting position. Use of dynamic modeling - Dynamic Grouping and Priority Algorithm (DGP), identifies the most appropriate patient groups for hospitaliza­tion, assigning them a priority level based on patient information and organization of the ED in real time; Discrete event simulation (DES); Simul8 can generate solutions to help healthcare managers improve ED overcrowding and predict patient's requests for admission and ED waiting time; Dynamic System with virtual simulation models to develop & test solution strategies before implementation","Clinical experiences Patient experiences Cost ","Input - population aging with increased demand for hospitalisation; difficulties in accessing urgent healthcare services; distorted information provided by mass media; bad health education; mismanagement of treatable diseases at home; lack of seasonal disease prophylaxis; increase of the poor population with consequent difficulty to face health costs; failed intervention on ED frequent users. Throughput - failure to optimise triage activities; architectural limits of ED department; excessive practice of defensive medicine; efficiency of diagnostic services; health care understaffing; collaboration lack between health personnel. Output - hospital bed shortage; failure to identify available beds; shortage of hospital discharge rooms; delayed and prolonged discharge; lack of social services to facilitate difficult patients' discharge","Multiple characteristics of overcrowding Structural causes (shortage of physical ED space), human cases (increase in unscheduled access, inadequate ED access, increase of elderly people, increased demand from patients for specialised care, rising burden of chronic disease, excessive diagnostic test demand, defensive medicine) , Managerial cases (rising ED closures, increased patients waiting to be hospitalised, insufficient numbers of health workers, lack of availability of beds, flow patients' bed management, ambulance diversion, mismanagement resources allocation, limited access to primary care, reduced health funding, inability to discharge patients, delayed services and consultations) ","Outcomes on patients: increased in hospital death, increased patients who left without complete assessment, increased patients leaving the emergency room without being seen, increased patients' pain and suffering, patient dissatisfaction, inbed delay patients, delay in identification and treatment Outcomes on healthcare workers: increased of the preventable medical mistakes, health workers burnout, decreased quality of care, work related stress Outcomes on system: maximum waiting time for medical exam > 4 hours, prolonged ED LOS, rising health care cost, ambulance diversion, waste of medical resources",,Not statistically significant ,Not assessed, 455,Leduc 2021,The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review,Consensus,455,"The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review",Shannon Leduc,2021,Canada,To identify existing programs where allied healthcare personnel are the primary providers of the intervention and to evaluate their effectiveness and safety ,"To determine, among long-term care patients, what is the effectiveness and safety of interventions that evalu- ate and treat patients on site, avoiding unscheduled transport to the ED. A secondary objective was to determine what additional patient and system impacts occurred when these interventions were implemented, such as changes to health-related quality of life, frailty measures or functional status, paramedic response times and hospital offload delay measures",Systematic review,Adult patients living in long term care centres,N/A,RACF/long-term care facilities,"Medline, Embase and CINAHL Grey literature: clinicaltrials.gov, PROSPERO, the Central Registry of Controlled Trials as well as the reference lists of included studies",2013-2018,22,"4 were RCTs, 19 were observational studies ","United States, Canada, Scotland, Norway","Cochrane Risk of Bias tool for randomized control trials Newcastle-Ottawa scale for non-randomized studies","2/4 RCTs had high risk of bias; 1 had low, and one had some concerns. Quality assessment scores of observational studies ranged between 2 and 9; median 6.5",Narrative synthesis/review,"Care provider other than physician targeting reduction of patient transports to ED by treating patient on-site, for any condition. 5 categories of interventions: 1 - providing some form of advanced nursing care like nurse practitioners/advanced practice nurses. 2 - set of tools called Interventions to Reduce Acute Care Transfers (INTERACT) 3 - end-of-life issues 4 - condition-specific interventions (eg dehydration, infection) 5 - extended care paramedics for acute illnesses. Intervention providers were: paramedics, physician assistants, nurse practitioners, advanced practice nurses, registered nurses, other nursing ","In 17 studies measuring hospitalisation, all but one of the 21 interventions reported a decrease. Only 12 interventions demonstrate statistical significance. 13/13 studies reported a decrease in ED visits, and 16/ 17 reported a decrease hospitalization in the intervention groups. Advanced Nursing: In one study, registered nurses reported that 78% of patients they treated for acute issues avoided ED visit. Another - 43% of acute issues managed by a nurse practitioner avoided transport to the ED. (Both were self-report measures according to if the nurse felt an ED visit was avoided). NPs providing care through Evercare - 2.4 hospital admissions per 100 enrollees monthly vs 4.6 in control group. In pilot program with NPs and PAs assessing patients through telemedicine, 69% of cases that would have been sent to ED previously were treated at the care centre. INTERACT: Reductions in hospitalisation were higher in those that were more engaged (14-24%) vs non-engaged (0-6%). Observational study - 50% reduction in hospitalisations per 1000 resident days & relative reduction of 36% in potentially avoidable hospital admissions. 17% reduction in hospitalisation rates when used across 30 nursing homes. No significant difference when it was applied in 264-centre randomised trial. Relative reduction of 11.2% in all cause hospitalisations & 18.9% in potentially avoidable hospitalisations in another study. End-Of-Life: 7% reduction in hospital admission in last 8 weeks of life. Patients who had earlier consults had hospital admission rate 13.2% lower than those without. Condition specific: Pneumonia - 12% fewer were admitted to hospital vs control group. Dehydration - 44% decrease in hospitalisations for dehydration or infection from 37% treated onsite to 81% treated onsite. Extended care paramedics: 29.3% decrease in ED transfers; Less likely to be admitted when seen by emergency paramedic (16.8% vs 39.8%). ","Secondary outcomes measured: Patient adverse events (functional status, relapse, mortality, LOS) Out of Hospital Impacts Cost impacts Relapse - 2 studies: in first, 2.8% of patients required unexpected emergency care within 48hrs; in second, patients treated by extended care paramedics had 11% fewer relapses than those treated by emergency paramedics. Length of stay - all studies measuring LOS reported decrease, ranging from 0.2 to 1.2 days fewer. ",,,,"Many of the interventions, although good initiatives, were pilot projects or quality improvement projects and very few evaluated their interventions against a comparator group","The 22 included studies differed in terms of patient conditions, interventions and study designs making meta-analysis inappropriate; clinically relevant, however.",Not assessed,No study evaluated patient preferences or experiences and very few reported on adverse events. 430,Kirkland 2019,A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?,Consensus,430,"A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?",Scott William Kirkland,2019,Canada,"To examine the effectiveness and safety of pre-hospital and ED-based diversion strategies on ED utilisation, non-ED healthcare utilisation and patient outcomes compared with standard emergency care responses","To examine the impact of interventions designed to either bypass the ED or direct patients to other alternative care after ED presentation",Systematic review,"Patients seeking ED care patient transport to the ED, standard emergency medical service (EMS) assessment, or attending and being assessed by an ED physician; primarily low-acuity ED patients",N/A - Unclear as % of patients eligible was not reported for each study,Pre-emergency department (ambulance service) or Emergency department,"Medline, Embase, Cochrane Library, PsycINFO, CINAHL, Social Services Abstracts and ProQuest Dissertations and Theses Global Grey literature: Google Scholar, Health Services Research Projects in Progress, Health Services/Sciences Research Resources, National Centre for Biotechnology Information Bookshelf and ClinicalTrials.gov Reference lists of included studies and conference proceedings from the Society for Academic Emergency Medicine (2008–2017) and the Canadian Association of Emergency Medicine (2008–2017) ","Inclusion criteria: 1990-2016 Studies: 2002-2017",15,"randomised/controlled trials or controlled cohort studies (retrospective or prospective) 10 were clinical trials, 5 observational cohort studies ","England, USA, Scotland, Wales, Sweden ",Newcastle-Ottawa Scale; Cochrane Risk of Bias Assessment tool,"Clinical trials: high or unclear RoB Cohort studies: moderate quality","Unadjusted pooled statistical analyses; Meta-analyses; Tabular format","pre-hospital or ED based diversion interventions Pre-hospital diversion: Paramedic practitioner + ambulance crew to assess and treat at the scene Paramedic evaluation and transport to a detoxification facility Ambulance crew transport to a minor injury unit Ambulance crew referral to community-based falls service ED-based diversion: Deferred to on-site primary care clinic PED nurse","Primary outcomes: number of visits to ED 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%). Variation among studies. Many patients triaged as able to be diverted and not requiring ambulance transfer refused diversion.","patient diversion to, or utilisation of, non-ED-based settings for care (eg, assistance at the scene of the emergency, referral to primary care); hospitalisation; serious adverse events (eg, death, ICU admission); and patient quality of life (eg, health status). Additional outcomes of interest— namely, the percentage of patients considered eligible for diversion, the percentage of patients diverted, compliance with the diversion strategy, patient refusal of diversion and cost-effectiveness—were extracted a posterior",,,,No conclusive evidence regarding the impact of diversion strategies on ED utilisation and subsequent healthcare utilisation.,Ultimately evidence lacking to either support or refute effectiveness and safety of this practice.,"Meta-analysis of four pre-hospital diversion studies: I-squared 86% for ED attendance. Meta-analysis of three pre-hospital studies: I-squared 0% for subsequent ED attendance", 399,Jeyaraman 2021,Interventions and strategies involving primary healthcare professionals to manage emergency department overcrowding: a scoping review,Consensus,399,Interventions and strategies involving primary healthcare professionals to manage emergency department overcrowding: a scoping review,Maya M Jeyaraman,2021,Canada,To conduct a scoping review to identify and summarise the existing literature on interventions involving primary healthcare professionals to manage emergency department (ED) overcrowding ,"The main objective was to identify and summarise existing literature on the interventions and strategies involving PHCPs (family physicians/general practitioners (GPs), nurse practitioners (NPs) or nurses with expanded role) to manage ED overcrowding",Scoping review,"Adult and paediatric patients in ED (although most studies did not specify the type of ED); Primary Healthcare Professionals (PHCPs: GPs, nurse practitioners or nurses with expanded role). ",Not reported,Emergency Department in urban and rural areas ,"Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) database Search of grey literature sources: Canadian Foundation for Healthcare Improvement (www.cfhi-fcass.ca), Institute for Healthcare Improvement (www.ihi.org), Agency for Healthcare Research and Quality (www.ahrq.gov), NHS Improvement (https://improvement.nhs.uk), International Society for Quality in Health Care (www.isqua.org), Health Quality Ontario (www.hqontario.ca), Saskatchewan Health Quality Council (https://hqc.sk.ca), Health Quality Council of Alberta (www.hqca.ca), BC Patient Safety & Quality Council (https://bcpsqc.ca), Australian Commission on Safety and Quality in Health Care (www.safetyandquality.gov.au), and Health Quality & Safety Commission New Zealand (www.hqsc.govt.nz).","Inclusion - Inception to 2020 Studies - 1981-2020",268 studies (274 reports),"22 RCTs, 9 non-randomised trials, 112 cohort studies (prospective or retrospective), 4 case-control studies, 27 cross-sectional studies, 76 pre-post studies, 14 interrupted time series, 4 mixed-methods studies.","USA, UK, Canada, Australia, Netherlands, Switzerland, Sweden, France, Italy, South Korea, China, New Zealand, Saudi Arabia, Taiwan, Belgium, Brazil, Finland, Oman, Portugal, Spain, Singapore",Not done given scoping review ,Not done given scoping review ,Descriptive statistical analyses; did not summarise the data quantitatively (meta-analyses); reported using graphs and tables,"Interventions and strategies involving primary healthcare professionals (PHCPs: general practitioners (GPs), nurse practitioners (NPs) or nurses with expanded role) to manage ED overcrowding The reported interventions were either ‘within ED’ (48%) interventions (eg, PHCP-led ED triage or fast track) or ‘outside ED’ interventions (52%) (eg, after-hours GP clinic and GP cooperatives). PHCPs involved in the interventions were: GP (32%), NP (26%), nurses with expanded role (16%) and combinations of the PHCPs (42%). The ‘within ED’ and ‘outside ED’ interventions reported outcomes on patient flow and ED utilisation, respectively. Within ED interventions: 1) Area within ED staffed by PHCPs to manage lower acuity ED patients streamlined at triage 2) PHCPs located next to ED (sharing common triage with ED) to manage lower acuity ED patients streamed at triage as well as self-directed patients 3) PHCPs located at ED triage to manage lower acuity ED patients 4) PHCPs fully integrated within the ED to manage ED patients along with the ED team PHCP triage interventions involved: ‘see and treat’ lower acuity patients, diverting low-acuity patients to adjacent/co-located primary care centre or after-hours primary care centre, or the triage nurse was given increased authority to order diagnostic investigations or initiate a specified protocol Within-ED interventions involved: low acuity patients streamlined at triage to a PHCP working alone within ED (eg, rapid medical assessment units, fast-track units or emergency care access points for management); PHCPs working in conjunction with the emergency physician and the rest of the ED team in the interpretation of diagnostic imaging, management of lower acuity or in some cases higher acuity patients, and in discharge process. Outside-ED interventions: increasing after-hours primary care, free access to primary care for the uninsured, adjacent or co-located primary care clinic for lower acuity patients, introduction of a patient-centred medical home that addresses primary care needs of patients, implementation of GP cooperatives (out-of-hours primary healthcare in one centrally located practice), urgent care collaborations between the GP and ED, GP-led walk-in centres, PCP blended fee for service, hospital-integrated general practice for emergency care services, integrated emergency posts where care is provided by both ED and GPs, rural health clinics and advanced access primary care with timely access","Outcomes measured: ED visits, ED LOS, LWBS, patient satisfaction, patient safety, ED workup time, time to provider initial assessment, number of patients diverted to primary care, ED cost savings, ED utilisation 62% of studies reported positive impact on ED utilisation; 28% reported no impact; 9.7% reported negative impact. 73.6% - positive impact on ED LOS 77.1% - positive impact on LWBS 62.1% - positive impact on patient satisfaction 84.6% - positive impact on time to provider initial assessment 62.5% - positive impact on ED workup time","Lower costs Improved patient experiences",,,,"The geographic area in which these studies were conducted, and the type of healthcare systems vary widely across the included studies and may influence how these results can be interpreted",Statistical analysis of primary studies indicate significance and clinically relevant - in favour of PHCP interventions in ED,Not reported on, 398,Jeyaraman 2022,Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis,Consensus,398,Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis,Maya J Jeyaraman,2022,Canada,"To identify, critically appraise and summarise evidence on the effectiveness of employing PHCPs at ED triage to improve ED patient flow metrics","To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes",Systematic review & meta-analysis,"PHCPs, ED patients (adult and paediatric)",Not reported,"Emergency department, in urban or rural settings, or both","Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) Also searched the reference lists of all the included publications for additional relevant studies ","Inclusion: inception to 2020 Studies: 1993-2020",40 studies (44 papers),"Pre-post intervention (13), randomised controlled trials (10), observational retrospective cohort studies (8), controlled before-and-after studies (4), quasi-randomised trials (1), observational prospective cohort studies (3), cross-sectional observational studies (1)","Saudi Arabia, Oman, UK (including England), USA, Canada, Australia, France, China, Netherlands",National Institute for Health and Care Excellence (NICE) quality appraisal tool for quantitative studies of intervention ,82.5% (33) low quality; 17.5% (7) moderate quality,"A meta-analysis of mean differences (MD) in ED times with 95% CIs was planned a priori to derive pooled summary estimates. Heterogeneity among included studies was quantified and tested using I2 (I2 statistic and χ2 statistic, respectively. Narrative review; effect estimates using forest plots when meta-analysis was not possible.","PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage Nurse triage- plus NP team triage GP team triage","Primary outcome: time to provider initial assessment Overall, PHCP led triage interventions improved ED patient flow metrics ED LOS: 8 RCTS reported a significant decrease in ED LOS; 3 CBAs reported significant decrease in ED LOS; 3 retrospective cohorts reported significant decrease in ED LOS; 8 pre-posts all reported decrease (5 significant 3 non-significant); 1 quasi-RCT and 1 cross-sectional observational reported no significant differences; 1/3 prospective observational cohorts had significant decrease but 2/3 had non-significant decrease. ","Secondary outcomes: time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction Improved patient experiences Lower costs (cost of adding an NP could be far less than adding an ED MD)","Many factors such as patient acuity, EMS traffic/volume and referral patterns often dictate the degree of ED crowding and each ED has their own ‘signature’.",,,"PHCP-led triage interventions significantly decrease the ED LOS and lead to improvements in key ED patient flow metrics such as PIA, proportion of patients who LWBS, triage time, ED visits and patient satisfaction","The evidence on effectiveness of nurse triage-plus model came mostly from moderate quality studies (RCT or CBA) and showed significant decrease in PIA, ED LOS, and an improved patient satisfaction. Some studies were statistically significant; overall clinically relevant, in favour of employing primary HCPs in ED triage reducing ED LOS","8 RCTs: I-squared 0% 3 CBAs: I-squared 51% 3 retrospective cohorts: I-squared 37% 8 pre-post studies: I-squared 99%",Least available evidence was for the GP team triage model 365,Hong 2020,The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review,Consensus,365,The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review,Michael Hong,2020,Canada,To understand the association between improved access to after-hours primary care and both ED and primary care utilisation,To examine the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency departments and primary care utilization,Systematic review ,General population including paediatric patients,Not reported,"Emergency department, after-hours primary care","CINAHL, EMBASE, MEDLINE, and Scopus Additional studies were identified by scanning the reference list of initial references included for review and forward citation tracking of articles using Google Scholar ",Inclusion: inception to 2020; unclear publication year of studies,20,"cross-sectional studies comparing patients with and without access to after-hours primary care and (ii) pre-post design studies evaluating the impact of access to after-hours primary care before and after implementation of some initiative to improve access to after-hours primary care.","US, Australia, Belgium, England, Ireland, the Netherlands, Canada, Italy, Scotland ",Not detailed,Not detailed,Narrative review,Improved access to after-hours primary care and ED utilisation ,"After-hours primary care and Emergency department utilization Impact of opening an after-hours primary care clinic during evenings and/or weekends Impact of extension of primary care clinic hours Impact of reorganization of primary care from smaller groups to larger cooperatives Impact of opening these GPCs on ED utilization Mixed findings from cross-sectional studies: Patients with PCP who offered extended services on weekends/evenings over 2 years less likely to visit ED by 1.9%. Patients with access to after-hours primary care less likely to use the ED compared to those without such access. Association between lower likelihood of ED utilisation greater for practices open for longer hours & more nights/week; significant reduction in ED utilisation for adult practices that offered >/=12hrs of weekday evening services (RR 0.80) and for paediatric practices offering weekday evening services >/= 5 nights/week, with no association between weekend hours & ED utilisation. Finding of improved access to after-hours primary care reducing ED utilisation not consistent; one study found likelihood was the same for patients with non-emergency conditions. 3/5 cross-sectional studies found significant reduction in ED utilisation ranging from 2% to 50%. Pre-post designs: Introducing after-hours clinic available during weekends reduced non-urgent ED visits but not semi-urgent. Statistically significant reduction in non-urgent ED visits by 8.2% but increase in urgent ED visits by 1.6%. Evening after-hours clinic 40% reduction in number of semi-urgent ED visits/month but no difference in non-urgent and urgent. Primary care emergency centre & after-hours primary care walk-in clinic did not lead to difference in ED utilisation. Extension of primary care services outside regular hours associated with reduction in semi-urgent ED visits between 5-19%; no statistically significant reduction in non-urgent ED visits. Primary care services expanded into weekend reduced semi-urgent ED visits by 19.9%. Implementation of GPCs in 2 studies found reduction in ED utilisation from 8% (in-hours) to 53% (after-hours). Proportion of self-referrals to ED dropped. In Belgium no difference in ED utilisation with GPCs, but if located within local ED associated with fewer ambulance admissions & self-referrals. Financial incentives for PCPs - reduced inappropriate admissions 10-15% in Italy; small reduction in Canada. 3/5 studies comparing patients with access to after-hours primary care vs those without found significant reductions in ED utilisation ranging from 2-49% during weekday evenings but no effects on weekends. 10/15 studies looking at interventions to improve access to primary care found significant evidence of reduction in non-urgent or semi-urgent ED visits from 2-54%."," Lower costs (two studies examined impact of financial incentives for primary care physicians on ED utilization...financial incentive for GPs was effective in limiting the ED utilization and resulted in a reduction of inappropriate admissions between 10-15%","Inappropriate ED utilisation/visits; low-acuity patients diverted to ED setting, perhaps secondary to patients unaware of availability of primary care outside of regular working hours",Difficulty obtaining primary care access/lack of primary care availability,,"The results of cross-sectional studies were mixed. Patients with a primary care physician who offered extended services on weekends and evenings over two years were less likely to visit the ED by 1.9% Patients with access to after-hours primary care were less likely to use the ED compared to those without such access in both adult and paediatric practices.","Some primary studies within the reviewed articles were statistically significant however not statistical analysis was done Improved access to after-hours primary care was typically associated with increased primary care utilization but had mixed results on ED utilization. Mixed effects of opening an after-hours primary care practice, but extension of clinic hours for existing primary care clinics effective in reducing ED utilisation. Overall promising results in favour of decreased LOS but needs more research for significance",No measure reported; results noted to be heterogeneous.,"Better access to after-hours primary care may lead to increased primary care utilisation, but the impact of this access on ED utilisation was mixed. Most evidence being lower-quality evidence from cross-sectional studies and non-controlled pre-post design studies " 352,Hesselink 2019,Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review,Consensus,352,Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review,Gijs Hesselink,2019,Other: Netherlands,"To systematically review the effectiveness of interventions targeting the older adults in reducing ED crowding, and identify core characteristics shared by successful intervention models",,Systematic review,Older adults (≥ 60 years of age),Not reported,Hospital and community settings including ED and ambulance,"PubMed (including MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, EMBASE and PsychInfo Grey literature: online archives/ bibliographies of three high-impact journals in the field of emergency care (i.e. Annals of Emergency Medicine, Injury, Academic Emergency Medicine)","Inclusion: 1990 and 2017 Studies - 1996-2016",16,"eight were RCTs, 2 were non-RCTs, and 6 were CBAs","US, Canada, UK, Australia, Singapore","Risk of bias criteria for Cochrane Effective Practice and Organisation of Care (EPOC) reviews",12 studies high risk of bias; 2 studies low risk of bias; 2 studies moderate risk of bias,"Tabular form, qualitative assessment, set of core elements identified; meta-analysis intended but not completed due to high heterogeneity","Geriatrician or geriatric pharmacist embedded within the ED, or ED staff with geriatric expertise to facilitate more efficient and effective care for older adults Care and disposition planning by regular ED staff or nurse liai- sons to ensure continuity of care after a patient’s discharge from the ED ED-based geriatric assessment to improve a timely recognition and treatment of geriatric problems specific units or zones with dedicated space and beds to address the specific emergency needs of older adult ‘acute frailty zone’ within the ED – with early access to geriatrician-led multidisciplinary input and CGA – that replaced the pre-existing geriatrician in-reach service ‘acute frailty zone’ within the ED – with early access to geriatrician-led multidisciplinary input and CGA – that replaced the pre-existing geriatrician in-reach service","Outcome measured: ED LOS ED throughput time: - One CBA study - reduction in ED LOS for patients treated at geriatric trauma unit vs control group - Two studies (1xRCT, 1xnRCT) - significant longer LOS for same intervention. ED revisits: - 9 studies - decrease in ED revisit rates in intervention groups vs controls - 1 study - increase in number of revisits **however, study summary reports 11 with no statistically significant effects on ED revisits, 1 with sig increase and 1 sig decrease**","Time until patients are reviewed by a geriatrician - Time reduction between patient admission and geriatric review Ambulance diversion, waiting time or count, patient leaves before treatment, ED occupancy level, time to consultation or ED room/bed placement, ED LOS, ED boarding time or count, ED return visits or ED staff stress level",Management of older adults in the ED often requires more time and resources compared to younger adults; ED crowding by older adults; ED physicians and nurses are not well trained in geriatric emergency medicine,,,"The combination of initial triage of older adults by the ED physician and multidisciplinary care – according to time-efficiency goals – within a specific hospital-based geriatric emergency unit contributes to a reduced LOS of older adults in the ED Older adults treated in an emergency care setting with an embedded geriatrician receive more timely geriatric assessment compared to an in-reaching geriatrician service","Limited significance statistically, but important and meaningful as a base on which to build using future research. The poor methodological quality, the differences in intervention types and used outcome effects, and the validity of used outcome measures hinder the demonstration of robust evidence to support these interventions. Inter-study heterogeneity and poor methodological quality ","Heterogeneous treatment effect - I-squared >70%, preventing meta-analysis", 320,Grant 2020,Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review,Consensus,320,Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review,Kiran L. Grant,2020,Canada,"To review, categorise and evaluate interventions to reduce preventable long-term care facility transfers to ED","To answer: What interventions are most effective at reducing prevent- able transfers from long-term care facilities to EDs?",Scoping review,"Not reported, however based on setting can assume residents in long term care facilities and patients in ED ","80,791 (total of all studies except one that did not have a sample size)","ED and long-term care facilities in urban settings One study was conducted in a public rural long-term care facility, and one study was conducted in public long-term care facilities across a mixture of urban and rural environments. Six studies were conducted in private, urban long-term care facilities","Medline, EMBASE, CINAHL","Eligibility criteria - no limits Studies - 1988-2018",26,"RCT, pre-post design, observational, prospective cohort design, quasi-experimental pre-post, retrospective cohort study, cross-sectional study, cluster RCT, cluster randomized controlled trial, observational time-series study, non-randomized controlled trial",Not reported,"National Heart, Lung, and Blood Institute (NHLBI) quality assessment tools were used to assess the included studies ","11 rated good, 14 rated fair, 1 rated poor",Tabular summary; narrative review,"Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Telemedicine Outreach teams Interdisciplinary care Integrated approaches - INTERACT (interventions to reduce acute care transfers) program; multidisciplinary care rounds; patient management algorithms; telephone consultations Quality improvement program with feedback and audits on quality indicators and resident health status Medicare incentives RACF education Transfer document to bridge communication gaps during transfers","Outcome measures: ED transfers Telemedicine - 3 studies: results ranged from non-significant decrease in transfers of 4.4% to significant 8.8% reduction in transfers. Outreach teams - 3 studies: 1 - mobile nurse team that identified at-risk patients and attended emergency consultations, reducing ED transfers by 10%; 1 - RACF staff could request in-house services by emergency nurse with GP supervisor, reducing ED transfers by 17%; 1 - NP-led outreach team providing direct care in long-term care facilities found no change of ED transfers between teams led by NPs vs physicians. 2 studies: extended-care paramedic programs = 31% and 62% reduction in ED transfer rate. 1 study: NP visits to long-term care facilities q60 days associated with 8% decrease in ED transfers. 1 study: NP visits reduced ED transfers by 47.6%. Interdisciplinary care - 5 studies: One - geriatric NP and physician assessed patients on RACF admission and took call reduced ED transfers by 17%; One - full-time team composed of physician and mid-level provider (PA or NP) provided call, reduced ED transfers by 75%; One - MDT introduction non-significant reduction in ED transfers of 12%; One - weekly in-house GP clinic with nursing support associated with 70% decrease in ED transfers. One - care team consisting of geriatricians and nurses - 10.2% decrease in ED transfers. Integrated approaches - INTERACT (interventions to reduce acute care transfers) program: 8 studies - 2 studies no significant reduction in hospitalisation rates/readmission rates/ED transfers but one found reduced hospital transfers by 30%; multidisciplinary care rounds: 3 studies - did not report significant reductions in ED transfer rate; multi-modal approach ""Care by Design"" with weekly on-site visits, interdisciplinary care teams & access to extended care paramedic programs reduced ED transfers by 36% in one study. Quality improvement program with feedback and audits on quality indicators and resident health status: 1 study - average ED transfer reduction of 26.1% Medicare incentives: average ED transfer reduction of 75%. RACF education - 1 study: no change in hospital transfer Transfer document to bridge communication gaps during transfers - nonsignificant 1.6% reduction in 30-day hospital admission rate.","Achieving better outcomes (better quality of life) Lower costs ",,,,Reducing preventable transfers from long-term care facilities to EDs improves patient care ,"Clinically relevant - many interventions identified that could reduce preventable transfers from nursing homes. Unifying statistical analysis not completed, however results reported from individual studies. ",Not reported, 319,Grant 2020,Throughput interventions to reduce emergency department crowding: A systematic review,Consensus,319,Throughput interventions to reduce emergency department crowding: A systematic review,Kiran L. Grant,2020,Canada,To evaluate and summarise the results of studies describing ED throughput interventions,"To answer: What throughput interventions are most effective at reducing ED length of stay and left without being seen left with- out being seen rates?",Systematic review,"Unclear, however given setting is the ED then patients in ED",Not reported,Emergency Department,"Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials","Inclusion: inception to 2020 Included articles: 1996-2020","99 in qualitative synthesis, 2 in quantitative synthesis (meta-analysis)","RCT, pre-post, prospective cohort, case review, retrospective observational, case-control, cross-section, clinical trial, chart review, cluster RCT, prospective observational ","USA, Canada, Sweden, Australia, Netherlands, Spain, UK, Turkey, Pakistan, Finland, Korea, Jamaica, Taiwan","Cochrane risk of bias tool (version 2) to assess randomized controlled trials and the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tools for other study designs.","19 good, 67 fair, 5 poor (NHLBI) 3 low, 5 some concerns, 0 high risk of bias (Cochrane)",Tabular format; meta-analysis; narrative review,"Triage interventions (physicians in triage; NP or physician-assistant-led triage; team triage; telemedicine triage) Specific patient populations (adding PTs as providers; ED neurologist; Weekday psychiatric rounds; Rh testing protocol) Testing strategies (POC testing or lab-ordering at triage; triage-nurse ordered X-rays according to Ottawa Ankle rules) Alternative ED staffing models (ED scribes; Nurse flow coordinator; NPs or additional physicians) Streaming (Split-flow processes; fast-tracks) Integrated approaches (multiple interventions simultaneously) Other throughput interventions (ED patient tracking system, dedicated early assessment clinical team, computerised order entry, physician transition from contract to fee-for-service payment, computerised provider order entry, electronic documentation systems, automatically assigning patients to physicians by algorithm)","Outcomes measured: LWBS, LOS Triage interventions (6 studies: physicians in triage - LOS changes between -82 and +18mins; 6 studies: physicians in triage - improvement in LWBS; 3 studies - physicians in triage - nonsignificant results; 5 studies: NP or physician-assistant-led triage - LOS changes of -106 to +19min; 1 study: PA-led triage improvement in LWBS; 1 study: NP-led triage nonsignificant results; 5 studies: team triage, LOS improvements of 4 to 34mins; 4 studies - team triage LWBS changes ranging from RR 0.6 to RR 1.7; 2 studies: telemedicine triage - 0.3 and 8min increases in LOS; 1 study: triage liaison provider nonsignificant results) Specific patient populations (3 studies: adding PTs as providers for MSK patients - LOS improvement from 60 to 227min; 1 study: ED neurologist - 30-min LOS reduction and LWBS improvement (RR 0.6); Weekday psychiatric rounds - no change; Rh testing protocol for pregnant women - no change) Testing strategies (12 studies: POC testing - LOS changes from -114 to +8min, but 3 were not significant; 4 studies: POC or lab-ordering at triage - LOS reductions ranging from 22-174min, but only 1 significant; 1 study: triage-nurse ordered X-rays non-significant LOS reduction of 28mins) Alternative ED staffing models (2 studies: ED scribes - LOS reductions of 16-19min; 3 studies: ED scribes - non-significant increases in LOS of 1-10min; 1 study: ED scribes - increased LWBS; 1 study: Nurse flow coordinator - reduced LOS by 87min; 3 studies: NPs or additional physicians LOS changes from +2 to -76min) Streaming (9 studies: Split-flow processes - LOS reductions from 9-60mins; 1 study: split-flow reduces LWBS by 43% RR 0.6; 14/15 studies: fast-tracks - ED LOS reductions from 12-114min; 6/7 studies: fast-tracks - significant reductions in LWBS rates with RR 0.5-0.8) Integrated approaches (multiple interventions simultaneously): 12/15 studies reported significant overall ED LOS reductions from 2-114min; 4/5 studies: LWBS rates significantly improved (RR 0.02-0.8); Other throughput interventions (ED patient tracking system, dedicated early assessment clinical team, computerised order entry, physician transition from contract to fee-for-service payment, computerised provider order entry, electronic documentation systems, automatically assigning patients to physicians by algorithm) - 5/8 studies led to LOS reductions","Improved patient experiences Lower costs ",Not reported,Not reported,Not reported,"Possibility that, in many cases, observed benefits may relate more to enhanced focus on operational improvement (Hawthorne effect) than to specific effects of the intervention.","Streaming and fast track most consistently effective intervention types. Earlier physician or provider assessment at triage is effective. Most studies used observational pre-post designs, which are vulnerable to bias and fail to account for confounders. High levels of heterogeneity precluded data pooling in all but two cases, making robust comparisons within and between intervention categories difficult","No value for heterogeneity given but was assessed using the chi- squared statistic and the I-squared (I2) statistic, and pooled results where appropriate. ", 316,Gottlieb 2021,"Effect of Medical Scribes on Throughput, Revenue, and Patient and Provider Satisfaction: A Systematic Review and Meta-analysis",Consensus,316,"Effect of Medical Scribes on Throughput, Revenue, and Patient and Provider Satisfaction: A Systematic Review and Meta-analysis",Michael Gottlieb,2021,United States,"Answer: How does the implementation of a scribe program affect the throughput, revenue and provider and patient satisfaction?","The primary objective of this study was to evaluate the effect of scribes on throughput, revenue, provider satisfaction, and patient satisfaction",Systematic review & meta-analysis,"Medical scribes, patients in ED","Greater than 562,682 patient encounters","Emergency Department, specialty clinics, primary care clinics, mix of primary and specialty clinics","PubMed, Scopus, the Cumulative Index of Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature database, Google Scholar, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials Manually searched all conference abstracts for the American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine, and the Canadian Association of Emergency Physicians.","Inclusion criteria: inception to March 2020 Studies included: 2010 to 2020",39,"five studies were randomized controlled trials, 23 studies were prospective nonrandomized studies, 10 studies were retrospective, and 1 study had both prospective and retrospective components.","USA, Canada, Australia","Assessed for risk of bias using the Newcastle-Ottawa scale or Cochrane Risk of Bias Tool for retrospective and prospective nonrandomized studies and the Cochrane Collaboration Risk of Bias Tool for randomized controlled trials Study quality was assessed with the Grading of Recommendations, Assessment, Development, and Evaluation criteria Sub-group analysis planned between ED versus non-ED studies",,Meta-analysis and a priori subgroup analysis & sensitivity analysis with funnel plots,Use of medical scribes in both the emergency department and non-ED setting,"Outcomes measured: patients per hour 17 Studies: Patients treated per hour increased from 1.95 to 2.25 with a scribe 10 Studies: RVUs per encounter - increased from 2.39 to 2.53 7 Studies: RVUs per hour increased from 4.34 to 4.89 9 Studies: Time to disposition - similar between groups with 184.18 vs 178.44 7 Studies: In clinic setting, LOS shortened from 32.06min to 26.32min 6 Studies: LOS did not differ between groups. 4 Studies: ED LOS for admitted patients not affected by scribe 5 Studies: ED LOS for discharged patients not affected by scribe","Secondary outcomes: time to disposition, clinic length of stay, ED length of stay, ED length of stay for admitted patients, ED length of stay for discharged patients, relative value units (RVUs) per hour, RVUs per encounter, provider satisfaction, and patient satisfaction Improved patient experiences Improved clinical experiences Lower costs ",,"The factors involved in ED length of stay can be complex and involve many additional factors, such as consultations, laboratory testing, imaging, and medical interventions",,"Scribes improved RVUs per hour, RVUs per encounter, patients per hour, provider satisfaction, and patient satisfaction. Scribes also decreased the length of stay among clinics but did not influence length of stay or time to disposition in the ED setting We also identified improved provider satisfaction in the majority of studies. Although we were unable to perform a meta-analysis on these data because of differences in the scales used, this is supportive of an additional benefit beyond the metrics listed earlier","Overall scribes did not reduce LOS or time to disposition in ED setting. Statistical analysis performed with Revman and StataMP was used to assess publication bias.","Significant heterogeneity between studies. I-squared patients per hour (ED): 99%","Nearly half of the studies noted an increase in patient satisfaction, whereas none reported a decrease Cost and potential harms to patients was not assessed" 315,Gottlieb 2021,Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician,Consensus,315,Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician,Michael Gottlieb,2021,United States,To review the medical literature to determine the utility of triage-ordered testing and to offer evidence-based recommendations to emergency physicians.,Do triage nurse-ordered laboratory tests and imaging reduce LOS among ED patients? To what degree do triage nurse-ordered laboratory tests and imaging correlate with physician ordering?,Literature review,Triage nurse; (also ED patients but not explicitly reported),Not reported,Emergency Department,MEDLINE/PubMed,"Inclusion - inception to 2019 Studies - 1990-2018",13,"RCTs, systematic reviews, prospective, observational study, prospective study, retrospective study",Unclear,"Grades of Evidence of the articles - grade of evidence based on focus, research design, and methodology by consensus. Grade A, B, C, D and four qualities: Outstanding, Good, Adequate, Poor ","Quality: 1 outstanding; 4 good; 5 adequate; 3 poor Grade: 5 A; 4 C; 4 D",Narrative synthesis ,Triage nurse-ordered laboratory tests and imaging ,"Outcome measured: ED LOS, time to diagnosis ED LOS: 10 studies, of which 7 found LOS decreased, 2 found no effect and 1 found increase.",Achieving better outcomes,,,,"No meaningful decrease in ED LOS as result of intervention (nurse ordering) Hiring more physicians may help to alleviate Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing ",No clinically meaningful decrease in RD LOS from the use of nurse triage orders. Limited significance but in a positive direction towards decreasing LOS,N/A; not discussed,Effect of this intervention is generally small; Limited quality and quantity of evidence 312,Gonçalves-Bradley 2018,Primary care professionals providing non-urgent care in hospital emergency departments,Consensus,312,Primary care professionals providing non-urgent care in hospital emergency departments (Review),Gonçalves-Bradley D,2018,UK,"The aim of this Cochrane Review was to find out whether placing primary care professionals, such as general practitioners, in the hospital emergency department (ED) to provide care for patients with non-urgent health problems can decrease resource use and costs.","To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs)",Systematic Review,"Patients with minor injuries and illnesses; primary care professionals working in hospital EDs including GPs, NPs, emergency physicians","11,463 patients, 16 GPs, 9 emergency NPs, 69 emergency physicians ","Hospital Emergency Departments (Ireland, UK, Australia)","Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund Grey literature: Clinicaltrials.gov, WHO ICTRP for registered clinical trials ","Inception to 2017 (inclusion criteria) Studies: 1995-2015",4,"Randomised trials (1), non-randomised trials (3), controlled before-after studies, and interrupted time series studies","Australia, Ireland, UK","GRADE EPOC Risk of Bias Criteria ","Grade: very low, low, moderate, high All 4 studies included were very low EPOC: low, unclear or high risk of bias ","Narrative summary; post intervention risk ratio or mean difference for intervention versus control groups with associated 95% confidence intervals. Unable to perform subgroup analysis due to insufficient data; Unable to conduct sensitivity analyses. Findings presented as forest plots without summary estimates; RRs calculated & reported",Interventions where patients who presented with non-urgent problems were cared for by primary care professionals instead of regularly scheduled emergency physicians.,"Main outcomes 1. Time from arrival to clinical assessment and treatment for: a. patients with non-urgent problems; b. patients with urgent problems. 2. Total length of ED stay (from time of triage/registration to time of admission or discharge) 3. Admission to hospital Time from arrival to clinical assessment & treatment: one study, little/no difference between. Total length of ED stay: one study, little/no difference between. Admission to hospital: 3 studies - in 2 studies, GPs admitted fewer non-urgent patients to hospital (RR 0.33); in 1 study there was little/no difference in proportion of admissions. Subsequent utilisation of primary care/re-attendance to ED - in 1 study, little or no difference in ED re-attendance.","Other outcomes 1. Diagnostic tests (overall number, cost) 2. Treatments (e.g. counselling, prescriptions, procedures) 3. Consultations or referrals to hospital-based specialists 4. Arrangement of follow-up care 5. Subsequent utilisation of primary care/re-attendance to the ED 6. Patient education for self management or appropriate service use 7. Cost comparison of: a. diagnostic tests/investigations; b. treatment; c. referrals. 8. Health outcomes: a. mortality; b. self reported health status; c. adverse events (return visits to the ED or readmissions) Improved costs (employing GPs to attend to primary care patients in the ED saved significant costs in 1991 costs) ",,High patient attendance; use of EDs for conditions triaged as non-urgent/inappropriate use.,,"Source of bias - GP's work a different number of hours compared to EPs; the difference in work hours could have created a performance bias affecting the number of patients seen, physicians' attitudes towards patients and their practice patterns when deciding on investigations, prescriptions, referrals or admissions Important to note differences in training between countries -in North American studies, EPs are referring to consultants however in Australia the majority of EPs were senior house officers and registrars","Little significance as the evidence was overall weak; most studies did not find evidence in favour for this intervention. Very few studies analysed, meaning that the applicability of it is limited, and overall strength of evidence was weak.","High heterogeneity (I2 >=85%)across studies which precluded pooling data, explained by a variety of study designs, interventions, and outcomes.","Evidence from the four included studies was of very low-certainty overall as the results are inconsistent and safety has not been examined. Cannot be certain if the interventions makes any difference to waiting times or total ED LOS, admissions to hospital, diagnostic tests, treatments given, consultations or referrals to hospital-based specialists, as well as costs " 275,Franklin 2022,Use of Hospital Capacity Command Centers to Improve Patient Flow and Safety: A Scoping Review,Consensus,275,Use of Hospital Capacity Command Centers to Improve Patient Flow and Safety: A Scoping Review,Brian J. Franklin,2022,United States,To characterise the evidence related to hospital capacity command centers and synthesizes current data regarding their implementation," (i) characterize the general nature of the literature related to CCCs, (ii) synthesize available data regarding their usage and impact, and (iii) discuss the potential mechanisms underlying their impact to facilitate further rigorous investigatio",Scoping review,Not reported,"Not applicable, not measuring single participants",Hospital,"PubMed, ABI ProQuest, Grey literature (but source not mentioned)","Inclusion criteria - 2009 to 2019 2015-2019 (included studies)",8,"4 uncontrolled pre-post studies All 8 articles were single-site case studies",USA,N/A,N/A,Descriptive synthesis,"Capacity Command Centers (CCCs): Physical and cross-functional units involving (i) colocation of inter-disciplinary workgroups exerting significant influence over patient flow (e.g., admissions, bed management, environmental services, transfer management, etc.), (ii) use of real-time data integrated from sources including electronic health records, and (iii) management of2 or more processes related to patient flow (e.g., admission services, bed management, interhospital transfer management, patient trans-port, environmental services, etc.)","Outcomes measured: IHT volume; ED boarding Study 1 - Mean ED boarding hours per month decreased by 3036 (from 7047 to 4011); ED LWBS decreased by 2.5% from 6.20% to 3.60%; ED door to provider time decreased by 33 median minutes from 74 to 41; Mean bed request to assign time decreased by 49 mins from 153 to 105. Study 2 - ED boarding time remained flat Study 3 - Median ED boarding time for dept of medicine inpatient beds decreased from 9.7 to 6.3hrs at constant occupancy",Lower costs,,,,,"Outcomes of CCC use positive in the direction of decreasing LOS but number of studies limits use; not statistically significant, no appraisal done, unclear source of grey literature ",Not commented upon,"Some of the grey literature (magazine, analysrt report, press release) is very unclear in regards to study source/ rigor No critical appraisal done " 228,DiLaura 2021,Efficiency measures of emergency departments: An Italian systematic literature review,Consensus,228,Efficiency measures of emergency departments: an Italian systematic literature review,Danilo Di Laura,2021,Other: Italy,To review the literature on the issues encountered in the efficiency of EDs worldwide,,Systematic literature review,Not reported - however looks at patients in ED,Difficult to ascertain as many of the interventions were modelling studies so no true participants,Emergency Department,"PubMed, Scopus, Cochrane Library",2010-2019,28,"Retrospective, prospective observational, modelling studies, quasi-experimental study, pragmatic cluster randomised trial ","USA, Australia, Canada, China, France, Italy, Portugal, Sweden, Netherlands, Germany, UK",N/A,N/A,Descriptive analysis,"ED Telehealth Express Care Service (a combination of new technology, informed consumers, patient-centred care based on a 'virtual visit' with a board-certified EM attending physician located remotely); Full integrated ED information system with patient tracking computerised charting and order entry; Development and implementation of a novel process design - a split flow model consisting of deployment of a novel intake model, implementation of a 16 bed clinic decision unit, expanded point of care testing and dedicated ED transportation services; Introduction of a team of doctors with specific training in EM working full time in the ED, addition of a physician assistant acting as a triage liaison provider, addition of a physician-nurse supplementary triage assistance team, resdesign of ED operational nursing leadership, impact of a multifaceted ED work flow redesign, application of Lean principles of Toyota production system, and three reliability tools and strategies, impact of nine flow designed models obtained by the combination of three ED flow models and three ED physical design typologies; Introduction of a team of doctors with specific training in EM working full time in the ED","Outcome measures: ED LOS Process waiting times Indirect quality indicators to determine overcrowding - left before visit complete, left without being seen, let without being seen by a physician Performance in the EDs (number of patients admitted) Mortality ED Telehealth Express Care Service - Decreased LOS by 24%; Full integrated ED information system with patient tracking computerised charting and order entry - ED LOS decreased by 29%; Long list of different measures in studies measuring LWBS - Improvement in LWBS rate in 90% of studies; Introduction of a team of doctors with specific training in EM working full time in the ED - initial worsening of LWBS, probably due to a different triage system at the same time.",Patient experiences (satisfaction),,,,"Longer ED LOS led to decreased patient satisfaction. Door to physician time (by improving this, strong correlation with LOS improvement and patient satisfaction)",Some interventions were found to decrease ED LOS but overall not statistically significant,Not reported/addressed,"Phenomenon of overcrowding does not represent a burden only for the ER, but for entire hospital and assistance system." 210,DeFreitas 2018,Interventions to improve patient flow in emergency departments: an umbrella review,Consensus,210,Interventions to improve patient flow in emergency departments: an umbrella review,Loren De Freitas,2018,UK,To provide a comprehensive analysis of the evidence from existing systematic reviews on the interventions that improve ED patient flow ,Aim to summarise the evidence from systematic reviews on the interventions that improve patient flow in EDs,Umbrella review,"Not reported; patients but also physicians, nurses, providers","Not available for all studies listed, given it was an umbrella review, however >2 million",Emergency Department,"Medline via Ovid (1946 to present), EMBASE (1974 to July 2016), CINAHL (1982 to present), Cochrane Library, JBI for Systematic Reviews and Implementation reports, Proquest OpenGrey and Google Scholar searched for grey literature ","Inclusion criteria - 2000 and 2017 Included reviews ranged from 2006 to 2016",13,Systematic Reviews,"Country of origin based on primary studies, not on systematic review United States, Australia, Canada, Germany, Korea, France, New Zealand, Saudi Arabia, Singapore, Sweden, Switzerland, Turkey, Jamaica, Singapore",AMSTAR 2 - low/moderate/high quality,Majority moderate to high quality based on AMSTAR 2 score,Results summarised and presented in tabular form by narrative synthesis,"Full capacity protocols Computer provider order entry Scribes Streaming Fast track Triage Diagnostic services: Point-of-care testing, Advanced triage Assessment & Short Stay Units: Rapid assessment zones, Short stay units, Medical assessment units Nurse-directed interventions: Nurse practitioner, Triage nurse ordering, Nurse-requested X-rays, Clinical initiative nurse Physician-directed interventions: Physician-assisted triage, Triage liaison physicians, Senior doctor triage, Team triage Administrative and organisational interventions: Multifaceted (reorganisation, coordinators, staffing numbers, longer opening hours), System-wide interventions, Staffing changes/ED staffing/reorganisation Miscellaneous: Dedicated ED radiology staff, Electronic board tracking, Bedside registration","Outcome measures: ED LOS, reduction in waiting time Full-capacity protocols: ED LOS decreased: 18.9 vs 13.9 hours. Computerised provider order entry: Review 1 - 2 studies each showed decreases and increases in ED LOS; Review 2 - 2 studies showed decreased LOS; one study showed increased LOS; Review 3 - Decreased door to physician, physician to disposition decision, disposition decision to discharge times. Scribes: No difference in ED LOS; No difference in provider to disposition time; Increase in number of patients seen per hour by 0.17. Streaming: Median reduction in ED LOS of 0.5min; Median reduction in waiting time of 31min. Fast track: Review 1 - Median reduction in ED LOS of 27min; Median reduction in waiting time of 24.5min; Review 2 - 15 studies showed improvement in ED LOS; two studies showed no difference; 8 studies showed decreased waiting times; one study showed an increase; Review 3 - ED LOS decreased; Waiting times decreased. Triage: Waiting time decreased in 2; increased in 3 studies. POC testing: Review 1 - Median reduction in ED LOS of 21min; Review 2 - ED LOS decreased; Review 3 - ED LOS decreased. Advanced triage: ED LOS decreased. Rapid Assessment zones/pods: ED LOS decreased; Physician initial assessment time decreased. SSU: Decreased ED LOS for treat and release patients. Medial assessment unit: Mean time from medical assessment to decision: 170.2mins (unclear if increased or decreased). Nurse practitioners: ED LOS decreased in 5 studies, 3 studies showed no difference; Waiting time decreased in 5 studies, 4 studies showed no difference. Nurse practitioners/clinical initiative nurse: ED LOS decreased in four studies, one study showed no difference. Waiting time decreased in 4 studies; one study showed no difference. Triage nurse ordering: ED LOS decreased; physician initial assessment time decreased. Nurse-initiated X-rays; Median reduction in ED LOS/waiting time of 10min. Physician-assisted triage: ED LOS decreased; Waiting time decreased. Triage liaison physician: ED LOS decreased in 2 RCTs; Physician initial assessment time decreased. Senior doctor triage: ED LOS decreased in 3 RCT; ED LOS increased in 1 RCTs; 12 non-RCT; median decrease in ED LOS of 26min; Waiting time decreased in 2 RCTs; 11 non-RCTs median decrease in waiting time of 15min. Team triage: Review 1 - ED LOS decreased; Review 2 - reduction in median LOS of 40.5min, median reduction of waiting time of 18min; Review 3 - ED LOS and waiting time decreased. Multifaceted: 7 studies showed decreased ED LOS, 1 study showed increase; Decreased waiting times in all. Staffing changes: ED LOS decreased in 3 studies, no difference in one study; decreased waiting time in 5 studies, one reported increase for urgent cases. ED staffing/reorganisation: ED LOS decreased, waiting time decreased System-wide interventions: Decreased ED LOS with a mean 27min preintervention vs 22min postintervention; Time from arrival to exam room - 27min preintervention vs 22min postintervention; time from exam room to physician - 20min preintervention to 18 postintervention; time from physician evaluation to discharge - 100min preintervention vs 99min postintervention. Electronic tracking board: ED LOS decreased Dedicated ED radiology staff: ED LOS decreased Bedside registration: Time from triage to room decreased; no effect on mean time from room to disposition.","Achieving better outcomes Lower costs ","Physical limitations in the ED, limited human resources and cost-effectiveness could affect implementation of a fast track. ",Not explored,Not explored,,"Given the evidence for most studies was weak, there is little statistical significance, but provides some insight into areas for future research","N/A - given high heterogeneity across the reviews, no additional statistical analyses were conducted ",Overall evidence weak; only one intervention had moderate evidence to support its use which was fast track. 174,Clark 2022,Hospital Access Block: A Scoping Review,Consensus,174,Hospital Access Block: A Scoping Review,Joanne Clark,2022,Australia,To lead one through the patient journey and explore scholarly solutions from a diverse body of literature and methodologies to address bottlenecks in access and care delivery.,"To explore the breadth of health care literature in attempts to identify current strategies that hospitals adopt to improve patient bed flow, reduced access and exit block while optimising patient care",Scoping Review,Not reported explicitly but interventions looked at adult and paediatric populations ,Not reported,Emergency Department,CINAHL; Embase; Proquest; PubMed; Cochrane Libraries,2015-2021,43,"quantitative (n= 23), mixed-methods studies (n= 5), other designs (narrative literature review, scoping review, discussion papers) (n= 14), qualitative (n=1)","Trinidad, Kuwait, Iran, Canada, USA, Australia, New Zealand, Europe, France, China, Sweden, UK",N/A,N/A,Narrative review including tabular format,"Access - Triage Staffing models Point of care testing Fast track Co-location of mental health teams Overcapacity of protocols Short stay units After hours GP or nurse service Care - Interdisciplinary care and information sharing Discharge times 7 days per week service Elective admissions Discharge lounges Electric journey boards Lateral transfers and flexible beds Community - Epidemiology Infrastructure and residential aged care facilities Funding Families and care givers ","Outcomes: ED and inpatient LOS, 4 hour rule, wait time Increasing ED bed numbers --> in 2 studies did not improve access block/LOS Lean initiatives --> fast track systems support patient access to EDs but not hospital throughputs (LOS remains unchanged); SSUs can increase access block when used inappropriately; full capacity protocols support flow of patients awaiting inpatient beds & reduce ED boarding by up to 50%; nurse-led triage demonstrates efficiencies; top-heavy physician-led model demonstrates better throughput efficiencies and discharge rates from the ED; physician-nurse-led triage system appears to be most effective in times of access block. Inpatient care processes --> interdisciplinary team care, 7-day-a-week service model, accountability, discharge-before-noon processes, flexible bed allocations, lateral transfers and health information management systems are effective Elective admissions --> staggered elective admissions & staff rostering supports throughputs during the week. Discharge before noon --> sustainable improvement of 42% discharge rates & no increase in readmission rates; reduces mean ED boarding time of 2.1 hours and ED walk out rates by 32% Discharge lounges --> reduced ED boarding times from 458hrs/month to 368hrs/month Electronic journey boards --> reduced hospital LOS by 4.1 days Lateral transfers/Flexible bed allocation --> improvement in access; however transfer after 4pm linked to 1-day increased LOS",Inpatient care,Lack of beds; access block,"Exit block and delayed discharge --> account for 6% of hospital beds Ageing and growing population",,Physicians were 35% less likely to admit patients with acute abdominal pain in times of peak bed capacity,Clinically relevant and strength to study however quality of studies were not appraised; many interventions useful in improving patient flow,Not discussed, 130,Burgess 2021,The effectiveness of nurse-initiated interventions in the Emergency Department: A systematic review,Consensus,130,The effectiveness of nurse-initiated interventions in the Emergency Department: A systematic review,Luke Burgess,2021,Australia,What is the effectiveness of nurse-initiated interventions on patient outcomes in the emergency department? ,To determine the effectiveness of nurse-initiated interventions on patient outcomes in the Emergency Department ,Systematic Review,"All patients accessing treatment in an ED setting; 12 studies paediatric patients only, 14 studies adult patients only",9144,Emergency Department,"PubMed, CINAHL, Embase, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials; Grey literature - ProQuest Dissertations, Theses, Mednar","Inclusion criteria: 2000-2020 Studies: 2000-2019",26,"Nine were randomized control trials, 17 had a quasi-experimental design","Australia, USA, Netherlands, Hong Kong, Sweden, Canada, Iran, Saudi Arabia",Standardized critical appraisal instruments from JBI for experimental and quasi-experimental studies ,JBI tool for RCTs is 13 item checklist; JBI tool for non-RCTs 9 item checklist ,"Data where possible was pooled in statistical meta-analysis using RevMan. Effect sizes are expressed as odds ratios (for categorical data) or weighted mean difference (for continuous data) and their 95% confidence intervals were calculated for analysis. Where statistical pooling was not possible, findings were presented narratively. ","Nurse-initiated interventions Nurse-initiated pathology, nurse-initiated medications, and nurse-initiated intra-venous fluid therapy. Important to note that nurse-initiated x-rays were excluded as reported in previous systematic reviews ","Outcomes: time-to-treatment; patient reported pain relief; symptom relief; inpatient admission Time-to-treatment favoured nurse-initiated groups in 15 studies; 8/9 found statistically significant reduction in time-to-analgesia Time-to-treatment (beta-agonists and oral steroids) in asthma/COPD - statistically significant reduction in time-to-treatment Nurse-initiated NGT and neonatal jaundice management reduced time-to-treatment. Nurse-initiated interventions reduced hospital admissions in 4/4 studies, with meta-analysis OR of 0.51 (I-square 0%) Waiting times in nurse-initiated vs physician MSK injury not significantly different","Achieving better outcomes ",Delay in time to treatment of conditions including pain or respiratory distress,Nurses unable to initiate treatment including analgesia and treatment respiratory conditions,"Long waits for treatment/prolonged patient waiting time, delayed progression of care",Low adherence to treatment protocols identified in a number of studies - means that clinical practice is sometimes incongruent with research methodology or protocol ,Clinically important and meaningful - positive effect in the sense of improved patient flow,"Clinical (sample or intervention characteristics), methodological and statistical heterogeneity was considered and a random effects model used. Statistical tests for heterogeneity were undertaken including the standard Chi-square and I2 test. Due to the differences in interventions subgroup analyses were also undertaken. Some outcomes too heterogeneous to conduct meta-analysis. I-squared for time to analgesia administration 75%; I-squared for admitted as an inpatient 0%",Nurse-initiated interventions reduced time-to-treatment and hospital admissions for acute respiratory distress as it can lead to earlier resolution of symptoms 111,Brambilla 2022,Analysis of Functional Layout in Emergency Departments (ED). Shedding Light on the Free Standing Emergency Department (FSED) Model,Consensus,111,Analysis of Functional Layout in Emergency Departments (ED). Shedding Light on the Free Standing Emergency Department (FSED) Model ,Andrea Brambilla,2022,Other: Italy,To shed light on the Free Standing Emergency Department (FSED) model and compare it with the traditional Hospital Based Emergency Department (HBED) in international contexts,To gather in a structured way the relevant information from recent scientific literature and case studies in order to learn about the key features of the FSED model in comparison to traditional ED frameworks,Systematic Literature Review,"N/A - review was comparing physical building structures, not participants (comparison of dedicated FSED and Hospital ED zones) ","N/A - review was comparing physical building structures, not participants ",Emergency Department zones,"Medline, CINAHL, Scopus, PubMed, Web of Science",Inclusion criteria - 2000-2021; Studies 2010-present at time of article (2021),23,"Sixteen research articles, two reports, one review, one web article, one conference paper, and one book chapter Seventeen were based on an analysis of literature, data or case studies, while the remaining three used theoretical process and, three were about practical application of strategies","USA, France, Spain, Sweden, Italy",N/A - not detailed,N/A - not detailed,Narrative review and synthesis,"Various functional layouts of EDs describing organisational models, functional layouts, structural and technical features, design features and amenities; different layouts of the ""macro areas"" - including FSED and Hospital ED layout ","The initial outcome will be a meta-synthesis for the qualitative research conducted Unclear if outcome of the paper was simply to synthesize known information on research question, no other clear outcome identified ",Lower costs (although this objective is not explicitly measured in article) ,"Where ED facilities are situated in relation (Imaging and Diagnostic Departments), extra services such as on-call specialist doctor, lab analysis, other extended medical services",,,"Dependant on lay-out of hospital and proximity Also dependant on the percentage of space given to certain areas (highly variable between hospitals) - i.e. family lounges, waiting rooms, cafeteria/restaurant facilities ",Not statistically significant given mix in type of research articles and lack of quantitative analysis or actual outcomes.,N/A,"Some concern that not all included papers were academic literature (book chapter, conference paper, web article) " 109,Boylen 2020,Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review,Consensus,109,Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review,Susan Boylen,2020,Australia,"To identify, critically appraise and synthesise evidence on the impact of professional interpreters on outcomes for hospitalised children from migrant and refugee families with limited English proficiency","To answer: Does the use of a professional interpreter for LEP migrant and refugee families impact on: - Child and/or parent satisfaction with care in hospital? - Children’s hospital length of stay, unplanned readmission rates and non-attendance rates at clinic appointments? - Adherence to treatment, medication errors and adverse events relating to the child in hospital?",Systematic Review,"Limited-English-proficient migrant, refugee or asylum-seeker families with a hospitalized child aged 0 to 18 years, who had used a professional interpreter",1813 families,Hospital setting including ED," CINAHL Plus (EBSCO), MEDLINE (Ovid), PubMed, ProQuest Central (1970-current), Scopus, Web of Science (Clarivate), Embase (Ovid), PsycINFO (Ovid), Sci- ence Direct, APAIS Health, AIHW, AustHealth, Factiva, Multicultural Australia and Immigration Studies (MAIS) Grey literature: ProQuest Dissertations and Theses, TROVE and OIASTER, Conference Proceedings Citation Index-Science 1990-present within Web of Science core collection, and Google Scholar.","Search unrestricted, inception-2018 Studies: 2004-2018",6 papers (4 studies),"All studies were quantitative; Experimental studies, including randomized controlled trials (RCTs) and quasi experimental, observational (cohort and case-control) and descriptive studies",USA,"JBI Critical Appraisal Checklists for Randomized Controlled Trials and Analytical Cross Sectional Studies from JBI SUMARI; GRADE Summary of Findings for certainty","Ratings: high, moderate, low, very low 4 articles - 6/13 quality assessment criteria 2 articles - 6/8 quality assessment criteria ","Standardized JBI Data Extraction Form for Experimental/Observational Studies from JBI SUMARI Findings presented in narrative form as statistical pooling was not possible due to clinical heterogeneity of outcomes reported in the articles.","Use of professional (medical, qualified) interpreters in the ED compared to ad-hoc interpreters","Primary outcomes: LOS in hospital, unplanned hospital readmission rates Lion et al. --> ED LOS of children assigned professional interpretation via video vs telephone = no difference; no difference in ED LOS for patients who were discharged and had been assigned professional telephone and video interpretation. Grover et al. --> LEP professional in-person interpreter had shorter median ED LOS (116 minutes) than those who had professional telephone interpreter (141min) or in-person bilingual physician interpreter (153min); Professional in-person interpreter had significantly shorter time measured from time seen by provider to disposition time compared to professional telephone interpreter group and in-person bilingual physician group (52mins, 72mins, 81mins)","Outcomes related to patient safety - provision of discharge planning, caregiver comprehension Overall parental hospital visit satisfaction Parental satisfaction with interpreter Parental satisfaction with physician Parental satisfaction with nurses Non-attendance at hospital clinic appointments and ambulatory care Child and/or parent satisfaction with care in hospital Adherence to treatment Medication errors (including incorrect prescription, administration, dosage and frequency) Other adverse events related to patient safety (falls, healthcare associated infections, failure to rescue, pressure injuries) Improved patient experiences Achieving better outcomes",Communication challenges and ineffective communication due to language differences causing delays to communication,Not reported,,"Using professional in-person interpreters resulted in a shorter total emergency department throughput time compared to using professional interpreters via telephone Reported greater satisfaction with aspects of care when a professional interpreter service was used compared with ad hoc interpreters","Clinically significant - however insufficient evidence to conclude whether use of professional (medical, qualified) interpreter vs ad-hoc interpreter lead to decreased LOS","No measure of heterogeneity reported but results not able to be pooled due to heterogeneity, and findings presented in narrative form.", 97,Blodgett 2021,Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence,Consensus,97,"Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence",Joanna M. Blodgett,2021,UK,"To identify all studies that examined alternate routes of care for the non-urgent ""intermediate"" patient instead of ED conveyance","1) To identify all studies that examined alternatives to direct ED conveyance for patients triaged by the on-scene emergency medical clinician; 2) To describe all alternative schemes and study outcomes in the identified studies; 3) To assess the quality of the evidence provided",Scoping review,"Non-urgent ""intermediate"" patients, pre-hospital/pre-ED; paramedics",Not reported,Ambulance transfer pre-emergency department,"PubMed, CINAHL, Web of Science and ProQuest Health & Medicine databases Grey literature on the following sites: NHS Evidence, CORE, BL.UK, Open-Grey, and HMIC.","No restrictions in inclusion criteria Studies - 2000-2020",41,"All types including qualitative and quantitative studies, commentaries, protocols and policy statements; excluding literature reviews, conference abstract, non-English and non-peer reviewed articles","UK, Sweden, Netherlands, USA, Australia, Canada, Ireland",Modified 7-level rating system for the hierarchy of evidence ,Levels 1-7,Narrative synthesis and tabular presentation,"Alternative routes of care for non-urgent ""intermediate"" patient: - Triage protocol to guide ambulance clinician's decision-making, including triage tools leading directly to alternate care route outcomes; series of protocols for specific incidents; and subjective referral of patients triaged as low acuity using traditional triage tools - Referrals to primary care including GP or nurses, urgent care centres, psychiatric/social teams, minor injury units","Outcome measures: patient safety; operational efficiency Improved operational efficiency by decreasing ambulance job cycle times; decreased ED conveyance rates; improving patient documentation; increasing clinic care destinations; decreasing hospital admissions; improving or maintaining patient satisfaction. Not unanimous, however - some found longer job cycle times or no impact on decreasing ED conveyance rates.",Achieving better outcomes,,"Ambulances unable to divert low acuity patients to alternative care sites; Absence of training resulted in lack of confidence in both themselves and system;",,"Mixed evidence as to whether paramedics could accurately and safely triage patients to appropriate level of care Most studies suggested that paramedics were able to accurately triage patients to the correct care pathway (although mixed evidence) Lack of evidence of patient safety ","Important and clinically relevant/meaningful, signs that this can improve operational efficiency and reduced ED conveyance, however most studies lacked rigorous design and evidence of safe outcomes; Not based on statistical significance as was a scoping review",Measures of heterogeneity not reported - high heterogeneity however.,"4 key features of successful interventions: clear triage tools, additional training, formal liaisons and partnerships between ambulatory care, primary care, urgent care centres, minor injury units or psychiatric and social team, need more evidence about patient safety, paramedics, GPs, patients and stakeholders expressed willingness and recognised benefits of this scheme" 92,Bittencourt 2020,Interventions in overcrowding of emergency departments: an overview of systematic reviews,Consensus,92,Interventions in overcrowding of emergency departments: an overview of systematic reviews,Roberto Jose Bittencourt,2020,Other: Brasil,To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments,To investigate the interventions on the throughput component of patient flow,Umbrella Review (an overview of systematic reviews),"Not reported - Patients in the ED including mental health patients, surgical patients",Not reported,Emergency Department,"PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, CAPES periodicals portal, Google scholar for grey literature","Inclusion criteria - 2007-2018 Studies - 2007-2016",15,Systematic Reviews,"UK, China, Canada, Australia, Netherlands, USA, Italy","AMSTAR 2 Tool, with ratings of low/moderate/high quality","3 - critically low 4 - low 6 - moderate 2 - high",Tabular format & descriptive/narrative,"Senior doctor triage - placing a senior doctor at the triage in a hospital ED Team triage - teams composed by at least one physician and nurse, instead of a single nurse Employing a triage liaison physician in ED Triage nurse ordering - authorised to request, from triage, imaging tests, lab tests, ECGs Different triage systems - basic triage vs no formal triage; basic triage with variations on team experience or with different triage criteria; triage with options management by physician vs basic triage Implementation of Acute Medical Units - facility in hospital that acts as focus for acute medical care for patients who have presented as medical emergencies to hospital; designated hospital wards to receive medical inpatients presenting with acute medical illness from emergency departments and/or the community Implementation of rapid assessment zones - areas where patients with acute problems but who are not severely ill and who require limited observation have their investigations started, wait for results and/or receive treatment in a chair or stretcher Implementation of short stay units (SST) - a physical location in a hospital that accommodate patients needing treatments or observation without occupying ED beds or needing to be admitted Employing general practitioners in ED to care for patients with non-urgent health problems Employing nurse practitioners (NPs) in the ED Use of full capacity protocol (FCP) - create a designated area in the hospital to admit patients from ED who need hospitalisation, so they do not wait in the ED itself Use of lean thinking approach for re-designing ED processes","Outcome measured: Patient length of stay Senior doctor triage --> Improvements in ED overcrowding indicators, especially LOS, in most studies Team triage --> No statistically significant improvement in LOS or wait times Employing a triage liaison physician in ED --> TLP reduces LOS and, to a lesser degree, number of patients LWBS Triage nurse ordering --> effective intervention to reduce LOS, especially in case of patients suspected of having a fracture Different triage systems --> Triage vs no formal triage: no significant difference in LOS; Basic triage with different criteria: mental health triage system caused LOS reduction of 17.5mins; Triage with options: 5 non-RCTs found reductions in LOS. Implementation of Acute Medical Units --> Review 1 - Reduced LOS in hospitals in 12/12 studies measuring LOS; Review 2 - Reduced LOS in 4/4 studies measuring LOS, but 3/4 significant; Review 3 - 12/15 studies measuring LOS reported shorter LOS in hospital Implementation of rapid assessment zones --> 1/2 statistically significant LOS reduction; 1 statistically non-significant LOS reduction; Implementation of short stay units (SST) --> 3/4 statistically significant reduction in LOS; 1/4 statistically non-significant reduction in LOS Employing general practitioners in ED to care for patients with non-urgent health problems --> No studies measured LOS; weak evidence; reduction in # hospitalisations Employing nurse practitioners (NPs) in the ED --> Review 1: 5/9 statistically relevant difference in LOS; 4/9 no statistically significant difference in LOS; Review 2: No studies measured LOS Use of full capacity protocol (FCP) --> 1 study measured LOS, had reduction of 5hrs Use of lean thinking approach for re-designing ED processes --> 6/7 studies reduced LOS; 1/7 both increased and reduced LOS depending on where conducted.",Achieving better outcomes ,Triage process; staffing; low acuity patients,"Imbalance between demand and supply of health services A growing lack of public-sector hospital beds; low integration between health care networks, which hamper an integrated healthcare system, and low effectiveness of basic care services.","ED overcrowding, queues, other healthcare unmet needs (lower health care outcomes)","Authors report that the use of physicians in triage was the most successful intervention, with the evidence the most robust.",Statistically significant findings in some interventions positive for reduced LOS,Not reported,Only 2/15 systematic reviews had high quality 85,Benabbas 2020,Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis,Consensus,85,Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis,Roshanak Benabbas,2020,United States,To ascertain the role of triage liaison providers in improving throughput metrics to minimize patient risk and improve safety and quality metrics set forth by CMS,To investigate the impact of triage liaison providers on the ED throughput,Systematic review and meta-analysis,Triage liaison providers; patients in the ED,"329,340",Emergency Departments in the USA,"PubMed, EMBASE, and Web of Science Grey literature: abstracts at opengrey.eu, www.ntis.gov, and clinicaltrials.gov and also went through the scientific meetings of Society for Academic Emergency Medicine, and American College of Emergency Physicians from April 2012 to April 2019.: the Society of Academic Emergency Medicine (SAEM), the American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM). We also searched Opengrey.edu and googlescholar. com","Inclusion: Inception to 2019 Studies: 2001-2019 study range",12,"Randomised control trials, controlled clinical trials, prospective, retrospective, case-control, or before-after studies",USA,"EPHPP (Effective Public Health Practice Project) tool; Tool assessed the quality of studies in 6 domains: selection, design, confounders, blinding, data collection, withdrawals and dropouts Each domain is graded as ""weak"", ""moderate"", and ""strong"" ",66.7% moderate; 33.3% weak quality,"ED-LOS data was pooled using mean difference with random effect model. Where data was reported as median and interquartile range IQR, we calculated the standard deviation (SD) from IQR. Risk Ratio (RRs) for LWBS and LWCA were calculated with random effect model with 95% confidence interval (95% CI). Sensitivity analysis performed Data only pooled if I-square <75%. Meta-analysis conducted",Implementation of triage liaison providers in initiating diagnostic testing and treatment as well as discharging patients if appropriate ,"Outcome measures: ED-LOS, LWBS, LWCA Left without being seen (LWBS): 6 trials into attending physicians as TLPs - pooled RR of 0.62 in meta-analysis (I-square 68%) Left without complete assessment (LWCA): 2 studies, used physician TLPs - decrease in LWCA, RR 0.60 in meta-analysis (I-square 0%) ED-LOS --> 9 studies; in 8 ED-LOS decreased; too heterogeneous to pool data (I-square 98%)",Increased patient satisfaction (improved patient experiences),,,,"Lots of factors that can affect patient's ED-LOS that are completely variable; would be difficult to try to control for all of them Patient's characteristics, time of the day and day of the week, need for laboratory work, imaging, and consults, the occupancy rate of the hospital, the acuity mix of the patients in the ED, nurse and physician staffing, provider hand-offs, number of admission in that shift can all affect ED-LOS Significant medicolegal, financial, and public relations risk for healthcare systems if the patient has an adverse outcome upon leaving ED ","Introduction of TLP resulted in reduction of ED-LOS in 8/9 studies; in reduction of LWCA in 2/2 studies; and in reduction of LWBS in 10/10 studies, therefore statistical significance","Meta-analyses & heterogeneity: LWBS: - 10 studies into patients LWBS had RR of 0.15-0.95 - heterogeneity of I-square 96%, too heterogeneous to pool - of these, 2 trials looking at LWBS had I-square 83% for resident physicians as TLPs & 3 trials looking at LWBS had I-square 92% for NPPs (both too heterogeneous to pool); 6 studies with physicians as TLPS had I-square of 68% LWCA: - 2 studies; I-square 0% ED-LOS had high heterogeneity (9 studies, I-square 98%)","TLP impacts mostly ambulatory patients and patients with medium acuity; Higher acuity patients excluded in most TLP studies - their care is prioritised and having sicker patients in the ED negatively affects LOS of less acute patients because sicker patients are resource intensive; additionally, different providers may have different clinical assessments, so new workup may need to be performed which negates effect of TLP" 83,Beckerleg 2020,Interventions to reduce emergency department consultation time: A systematic review of the literature,Consensus,83,Interventions to reduce emergency department consultation time: A systematic review of the literature,Weiwei Beckerleg,2020,Canada,"To identify what interventions have been tried to reduce consultation to decision time and, in turn, ED length of stay.","To evaluate the impact of workflow interventions on the consultation to decision time and ED length of stay in patients referred to consultant services in teaching centres. To identify any barriers to reducing consultation to decision time. To explore association between consultation to decision time and ED length of stay with patient safety outcomes",Systematic Review,Adult patients (>/= 18 years of age),Not reported,Emergency Department at teaching centre,MEDLINE; EMBASE; Cochrane Central; CINAHL,"Inclusion criteria: 1946-2018 Studies: 2011-2018",9,Retrospective chart review (1/9); observational prospective pre and post study with/without time series design (8/9),"South Korea, Canada, USA",SQUIRE 2.0 checklist,"No cut-offs listed. Each study was categorised as ""poor/fair/good"". Outcomes were 3 poor; 5 fair; 1 good",Descriptive qualitative analysis. Meta-analysis not possible due to heterogeneity in included studies. ,"SMS messaging reminder for delays in consultation process Standardisation of admissions process (form or protocol) Restructuring consultation process - more senior staff contacted first, and then juniors facilitated admissions once disposition decision made Education, audit and feedback - on potential adverse impact of prolonged ED wait times on patient care; decision time data for each resident compiled; Implementation of guidelines - institutional guideline where goal of physician arrival was within 30mins of consultation and disposition decision made within additional 60mins Modification of staffing patterns - dedicated surgeon to provide daytime coverage for non-trauma surgical patients; extension of ED coverage by existing services & addition of physician and advanced practice RN staffed shift","Main outcome measure: ED LOS, consultation to decision time (CTDT) SMS messaging reminder for delays in consultation process --> Consultation to decision time reduced by 101 minutes and ED length of stay by 106 minutes; no change in time to discharge from ED after disposition decision made; proportion of inpatient admissions did not change (Cho et al.); Consultation to decision time reduced by 16mins and ED LOS by 14 minutes; time from admission decision to patients leaving ED decreased by 12mins (Kim et al.) Standardisation of admissions process (form or protocol) --> Consultation to decision time reduced by 79 minutes but ED length of stay did not change (Langheim & Heiligenstein - form); Consultation to decision time reduced by 78 minutes, cost per admission lowered by $36 CAD (Kachra et al. - protocol) Restructuring consultation process --> Consultation to decision time reduced by 179 minutes; ED LOS reduced by 290 minutes; Admission order to ED departure time reduced by 119 minutes (Shin et al.) Education, audit and feedback --> Consultation to decision time decreased by 92 minutes; ED LOS reduced by 40 minutes; time to discharge from ED for admitted patients decreased; time to ED physician assessment & time to consultation request did not change (Soong et al.) Implementation of guidelines --> Consultation to decision time decreased by 21 minutes, sustained beyond 6 months; Time to discharge from ED after submission of admission order decreased by 18 minutes; inpatient discharge time delayed by 50 minutes. Modification of staffing patterns --> consultation to decision time reduced by 54 minutes; ED LOS decreased by 55 minutes (Faryniuk & Hochman); Reduction of 23 minutes in consultation to decision time and reduced cost (Wells et al.) Interventions with highest effectiveness overall: SMS messaging, direct consultation to senior physicians, standardisation of admission protocol, and education with audit & feedback",Achieving better outcomes ,Consultation to decision time; added time from trainees performing assessments and reviewing with more senior staff; other factors that delay consultation time,"Resource intensive interventions (increasing staff, money for educational time and resources); Teaching hospitals - presence of trainees who may take longer to complete assessments/consults",N/A,"No measurement of how interventions may have affected health care providers in terms of distress or anxiety (no mention of improved clinician outcomes) No measurement of how interventions affected patient safety outcomes ","All interventions had a positive impact on one/multiple of: length of stay, time to consultation, consultation to decision time, admission to ED departure time, time from provider response to admission decision, cost. No statistical significance done.","No measure of heterogeneity but significant heterogeneity among interventions reported, so not possible to pool outcome measures","In one study, trainees expressed frustration about being under greater pressure to complete consults quickly. Review authors muse whether interventions might have resulted in distress and anxiety for providers, especially trainees who need to balance learning, patient safety, efficiency and evaluations by supervisors. Quality of studies was fair to poor, due to lack of assessment of process and balancing measures." 58,Austin 2020,Strategies to measure and improve emergency department performance: a scoping review,Consensus,58,Strategies to measure and improve emergency department performance: a scoping review,Elizabeth E. Austin,2020,Australia,To map the research evidence provided by reviews on strategies to measure and improve ED performance,"The review questions addressed were: (1) how is ED performance measured, (2) what are the interventions used to im- prove ED performance and (3) what is the role(s) of pa- tients in improving ED performance, and (4) what are the outcomes attributed to interventions used to im- prove ED performance.",Scoping review,"Clinicians, patients, and/or administrators in the ED",N/A,Emergency Department,"Cochrane Database of Systematic Reviews, Scopus, Embase, CINAHL and PubMed","No date limits on search; Included studies - 2000-2019",77,"Systematic reviews, primary research studies, umbrella reviews, literature reviews, integrative reviews, critical reviews, substantive reviews, integrative literature reviews, rapid reviews, scoping reviews, evidence-based reviews, narrative reviews, narrative literature reviews, meta-analyses","Denmark, Canada, USA, England, Australia, Hong Kong, Sweden, Italy, Iran, New Zealand, Brazil, South Korea, Switzerland",Risk of Bias in Systematic Reviews (ROBIS) tool,"1 reviews were assessed as being low bias, 31 as high bias, and 15 as unclear bias","Narrative synthesis, including numerical statistical summaries, textual commentaries, and tabular and graphical representations","Practices and processes intervention domains: triage, care transitions, process re-design, point-of-care testing, observation units, technology. Triage interventions: having a physician present (aka triage liaison physician), triage team consisting of at least 2 medical personnel (nurse or physician), dedicated triage resources (ie ECG machine and ECG tech), triage education, variations of basic triage, triage protocols, and nurse-led triage service. Care transition interventions: handover tools, bedside registration, discharge planning, discharge communication, process protocols and guidelines, handover training, dedicated offload nurse for triaging and assessing EMS patients, nurse discharge coordinators. Process re-design interventions: clinical guidelines and protocols, patient assignment and referral processes, organisational processes (ie communication, administration), nurse-initiated care processes, clinical decision supports, lean management/lean thinking. Point-of-care testing interventions: laboratory analysis located in ED Observation unit interventions: ED-based observation units including for specific clinical needs such as chest pain and asthma, for processes such as assessment and procedures, for medically stable patients likely to require admission, or further investigation, or management for more than 4 hours, or to manage referrals from GPs. (Rapid Assessment Zones/Pods; Medial Assessment Units; Short Stay Units; Quick Diagnostic Units; ED Managed Acute Care Unit). Technology interventions: computerised clinical support systems, mobile devices, telecommunication technology, computer simulation, eHealth records access. Team composition interventions: Advanced nursing roles - nurse practitioner, clinical nurse specialist, certified registered nurse anaesthetists, clinical initiatives nurse Physiotherapy roles in ED General practitioners in ED Scribes and physician assistants in ED Pharmacy roles in ED Mental health services in ED - liaison mental health services; co-located psychiatry liaison personnel/spaces; psychiatry specialist services Professional development interventions in ED (medical Spanish, customer service skills, staff education/workshops, clinical education)","Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Scoping review, so does not report on outcomes of interventions. Overall outcomes used in primary studies: LOS, ED waiting time, admissions, resource use, treatment follow-up rate, LWBS, DNW, patient/provider satisfaction, costs","Scoping review - does not report on outcomes of interventions. Improved clinical experiences","Periods of crowding, changes such as seasonal increases in demand, and unanticipated events.",Not reported,Not reported,Not reported,Not reported; no statistical measures. Clinically relevant.,Not reported,"Few interventions reported outcomes across all five outcome domains. The published reviews examining the effectiveness of interventions in the ED context might have suffered from publication bias, with negative results less likely to be published. As a result of this publication bias, it is unclear what interventions are unsuccessful or if particular context characteristics result in unsuccessful intervention "