17 Oct Short Stay Units May Save Money For Health Care Systems
MedicalResearch.com Interview with:
James Galipeau PhD
Ottawa Hospital Research Institute
Ottawa, Ontario, Canada
Medical Research: What is the background for this study?
Dr. Galipeau: Overcrowding in emergency departments (EDs) is becoming more and more commonplace in Canada. The issue of overcrowding is complex and multidimensional with three distinct but interdependent components: input, throughput (processing), and output. At the processing level, one solution to overcrowding that has emerged is the establishment of observation/short stay units.
A short-stay unit is a physical location in a hospital, usually in close proximity to the ED. Patients needing treatments or observation that may take several hours to resolve (e.g., blood transfusions, diagnostic testing, arranging social services) can be accommodated in a short-stay unit without occupying ED beds or needing to be admitted. In theory, ED-based short-stay units can lessen ED overcrowding by influencing outcomes such as ED wait times and hospital costs (if patients are moved from the ED to inpatient care).
Although a recent report by the American College of Emergency Physicians recommends pursuing the use of short-stay units to alleviate ED overcrowding, there is a lack of evidence syntheses summarizing their effectiveness, safety, and value for money. Our objective was to conduct a systematic review to evaluate the effectiveness and safety of ED short-stay units compared with care not involving short-stay units.
Medical Research: What are the main findings?
Dr. Galipeau: Ten reports of five studies are included, all of which compared short-stay units with inpatient care. None of the included studies actually measures outcomes related to all patients admitted to short-stay units—they are all only snapshots of a narrow subset of patients who were treated via specific protocols within the general short-stay units (e.g., asthma, chest pain).
There is limited evidence regarding the effectiveness and safety of short-stay units. Various conditions (e.g., acute coronary syndrome, myocardial infarction) and non-condition-specific outcomes (e.g., length of stay, readmission) were measured across studies. Most outcomes were reported by one study, while the remaining outcomes were reported by two to four studies. Of the non-condition-specific outcomes, four studies reporting the outcome of deaths found none. Three of the four included studies reporting length of stay found a significant reduction among short-stay unit patients, and one of the two studies reporting readmission rates found a significantly lower rate for short-stay unit patients. Overall, few and small studies, as well as other quality issues, limit the ability to make conclusions as to whether or not ED-based short stay units are effective compared with inpatient care.
All four economic evaluations indicated that short stay units were a cost-saving intervention compared to inpatient care from both hospital and health care system perspectives. Results were mixed for outcomes related to quality of care and patient satisfaction. Although economic evidence suggests that a short-stay unit is a cost-savings option, the statistical and econometric methods used to compare cost data were poorly described.
Medical Research: What should clinicians and patients take away from your report?
Dr. Galipeau: Currently there is no clear universal definition of what a short-stay unit is, or should be. The heterogeneity between these units suggests they are often conceived and designed to meet very local, specific challenges in flow related to practice patterns and specifics of the population served, and perhaps funding rules or opportunities as well. Therefore, specific metrics and outcomes might depend heavily on individual characteristics of how a particular SSU is set up (e.g., what kind of extra resources are made available to this SSU). Including outcomes such as reductions in cost, length of stay, and satisfaction are important from a hospital, system, and patient point of view, respectively and suggest a well thought out evaluation.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Galipeau: We would encourage future research on the general effectiveness of short-stay units in addition to more research dealing with specific conditions in the context of a general short-stay unit. However, what is more important is that a set of generalizable key outcomes, such as death, length of stay, readmission, and problems with care processes, be included to assess effectiveness of short-stay units across conditions. It would make sense to develop a core set of outcomes, as per the Core Outcome Measures in Effectiveness Trials (COMET) initiative. Additionally, full economic evaluations of short-stay units are suggested in order to justify whether the costs of implementation are worth the outcomes compared to usual care.
Effectiveness and Safety of Short-stay Units in the Emergency Department: A Systematic Review
James Galipeau PhD1,*,Kusala Pussegoda MSc1,Adrienne Stevens MSc1,Jamie C. Brehaut PhD2,Janet Curran PhD3,Alan J. Forster MD, FRCPC1,2,Michael Tierney4,Edmund S. H. Kwok MD, FRCPC, MHA2,4,James R. Worthington MD, FRCPC4, Samuel G. Campbell MBBCh5 and David Moher PhD1,2