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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Short-stay units and observation medicine: a systematic review

S Daly, DA Campbell, and PA Cameron.

Review published: 2003.

Link to full article: [Journal publisher]

CRD summary

This poorly reported review assessed the effects of short-stay observation units (SOUs) on the delivery and quality of patient care. SOUs have the potential to improve outcomes, reduce the length of stay, improve the efficiency of the emergency department and improve cost-effectiveness. The review itself and the included studies have methodological limitations, so the conclusions should be treated with caution.

Authors' objectives

To assess the effect of short-stay observation units (SOUs) on the delivery and quality of patient care.

Searching

MEDLINE, CINAHL, Best Evidence and the Cochrane Library were searched from January 1960 to July 2000 for studies published in the English language; the MeSH terms were stated.

Study selection

Study designs of evaluations included in the review

Comparative studies that were graded as either randomised controlled trials (RCTs), non-randomised controlled trials, cohort, case-control or time series studies, according to the U.S. Preventive Services Task Force levels of evidence, were eligible for inclusion (see Other Publications of Related Interest). Articles based on description or opinions (levels III or IV) were excluded. The included studies were RCTs, before-and-after studies and non-randomised controlled trials.

Specific interventions included in the review

Studies of SOUs were eligible for inclusion. The included studies compared SOUs with routine care (including direct admission to hospital). In some studies patients in the SOU were managed using a protocol that was not used for patients receiving routine care, while in some studies the SOU was implemented at a time when the number of hospital beds was increased.

Participants included in the review

The inclusion criteria were not specified in terms of participants. The included studies were of patients with chest pain, asthma (children and adults) and alcoholic pancreatitis, and of patients attending emergency departments.

Outcomes assessed in the review

The inclusion criteria were not specified in terms of outcomes. The review assessed clinical outcomes, length of stay, efficiency of the emergency department, re-presentation to the emergency department, medical admissions, quality of life and patient satisfaction.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

Assessment of study quality

The authors did not state how the papers were assessed for validity. However, the validity of the included studies was discussed using a hierarchical of evidence framework. The authors did not state how the papers were assessed for validity, or how many reviewers performed the validity assessment.

Data extraction

The authors stated that the data were extracted independently, but they provided no other details.

Methods of synthesis

How were the studies combined?

The studies were grouped by outcome and a narrative synthesis was undertaken. The level of evidence for each study was presented in a table under the appropriate outcome measure (with subheadings for improved, no change, worse or decreased).

How were differences between studies investigated?

Differences related to study design and potential confounding factors were discussed in the text of the review.

Results of the review

Twelve studies (9,963 patients overall) were included in the review: 5 RCTs (962 patients), 3 non-randomised controlled trials (1,912 patients) and 4 before-and-after studies (7,089 patients).

Clinical outcomes (2 RCTs): no level I or II studies showed that SOUs improve or worsen clinical outcomes. Both RCTs showed no significant difference between SOUs and usual care.

Length of stay (1 RCT and 1 non-randomised controlled trial): neither study showed that SOUs increased the length of stay. The RCT showed that SOUs plus a 'rapid' protocol reduced the average length of stay compared with routine care. The non-randomised controlled trial showed no difference between SOUs and direct hospital admission.

Efficiency of the emergency department (1 before-and-after study): no level I or II studies showed that SOUs hindered the organisation of the emergency department. The study showed that SOUs reduced the average time in the emergency department for some patient subgroups (chest pain and asthma), but had no effect on the time spent in the department for other subgroups (participants with sickle cell crisis or seizures).

Re-presentation to the emergency department (1 RCT and 1 before-and-after study): the RCT showed no difference in re-presentation rates between treatments for children with asthma, while the before-and-after study showed an increase (3 to 5%) in re-presentations for patients with asthma.

Medical admissions (2 RCTs and 1 before-and-after study): both RCTs showed that SOUs decreased the number of medical admissions. However, the before-and-after study found no difference in initial discharge rates, or the number of patients eventually hospitalised, for patients treated within an observation unit.

Quality of life (1 RCT): the RCT showed that the SOU was associated with an improvement in quality of life measures compared with hospital in-patients.

Cost information

The review also assessed cost-effectiveness. One RCT showed that SOUs significantly reduced costs compared with in-patient care for patients with asthma. The costs were $1,203 with the SOU versus $2,247 for in-patient care.

Authors' conclusions

SOUs have the potential to improve outcomes, reduce the length of stay, improve the efficiency of the emergency department and improve cost-effectiveness. In some of the identified studies it was not possible to separate out the effect of concurrently implemented patient management protocols from the effect of SOUs.

CRD commentary

The review question was clear in terms of the study design and intervention. The inclusion criteria were not specified in terms of participants or outcomes, but the outcomes assessed in the review were stated in the abstract and the text of the review. Several relevant sources were searched and the search terms were stated. Limiting the included studies to those in English may have resulted in the omission of some relevant studies. In addition, no attempt was made to locate unpublished studies, thus raising the possibility of publication bias. The methods used to select the studies and extract the data were not fully described; hence, any efforts made to reduce errors and bias cannot be judged. Validity was not formally assessed, but the included studies were categorised according to study design using a hierarchical evidence framework.

Some relevant information on the included studies was tabulated and additional information was provided in the text. The narrative synthesis was appropriate given the small number of heterogeneous studies. There appears to have been some differences between the studies reported in the text and those reported in the table of included studies (some studies in the tables were not mentioned in the text, and vice versa). The authors discussed some of the limitations of the studies, e.g. the potential confounding of management protocols implemented together with SOUs. Some of the limitations of the review were also discussed. However, in view of these limitations, the authors' conclusions should be treated with caution.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further research is required on a wider spectrum of patients. In addition, the effects of SOUs plus clinical protocols compared with protocols alone should be explored, as should the effect of SOUs on the capacity of emergency departments and hospitals. The authors also stated that key performance measures are required to assess the effectiveness of SOUs.

Funding

The Department of Human Services (Victoria).

Bibliographic details

Daly S, Campbell D A, Cameron P A. Short-stay units and observation medicine: a systematic review. Medical Journal of Australia 2003; 178(11): 559-563. [PubMed: 12765504]

Other publications of related interest

Acute medical admissions: a critical appraisal of the literature. New Zealand Health Technology Assessment Report. Christchurch: NZHTA; 1998. Report No.: 6.

Indexing Status

Subject indexing assigned by NLM

MeSH

Delivery of Health Care /organization & administration; Efficiency, Organizational; Emergency Service, Hospital /economics /organization & administration; Hospital Units /economics /organization & administration; Humans; Length of Stay

AccessionNumber

12003001282

Database entry date

31/12/2004

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 12765504