Structured approaches to improve patient flow

Frontline healthcare professionals can use structured quality improvement processes to improve patient flow.

This study aimed to reduce the time taken to transfer critically ill people between the emergency department and the medical intensive care unit at one hospital in the US. The team used the clinical microsystems approach to map out existing practice. They determined the causes of delays and used PDSA cycles to test changes. Causes of delays included poor coordination between transport and nursing services in transferring patients and delays in identifying and transferring people out of ICU. The interventions put in place reduced transfer time from four hours to two hours. Average hospital length of stay decreased from 10 to eight days.

Reference: Cohen RI et al.  A quality improvement project to decrease emergency department and medical intensive care unit transfer times. Journal of Critical Care. 2015. 30(6): 1331 – 1337

Self-management support helps carers of people with dementia

Professional self-management support interventions can help the carers of people with dementia cope better. Integrating psycho-education into self-management support may be particularly effective. 

Reviewers from the Netherlands examined interventions to support self-management amongst the carers of people with dementia. They searched five bibliographic databases for systematic reviews available as of March 2014. Ten reviews were included. There was evidence of the effectiveness of professional self-management support interventions targeting psychological wellbeing for reducing stress and improving social outcomes. Interventions providing information were found to increase knowledge. There was limited evidence identified about techniques to cope with memory change on coping skills and mood.

In-hospital exercise could help to prevent falls

Exercise programmes in hospital can help improve balance and functional mobility in elderly people which may help to reduce falls.

Researchers from Italy examined the effectiveness of three rehabilitation programmes for elderly people in hospital: group exercise, individual core stability training or balance training with a platform tool. Twenty-eight people who had fallen within the last 12 months were consecutively assigned to one of the approaches for three weeks. All of the interventions were associated with improved balance and mobility.
Reference: Villafane JH et al.  Moving forward in fall prevention: an intervention to improve balance among patients in a quasi-experimental study of hospitalized patients. International Journal of Rehabilitation Research. 2015. 38(4): 313 – 319


Triage service can reduce use of emergency ambulances

A secondary triaging service for ambulance callouts may divert at least one third of cases. 

In Australia a telephone triage service was set up for people who called an ambulance but were at low risk. The service provided alternatives to dispatching an ambulance, such as a doctor or nurse visiting the home. A review of more than 100,000 people supported over a four year period found that this accounted for 10% of all emergency calls for the ambulance service. Abdominal pain and back issues were the most common reasons for calling. Two thirds of patients were referred to the emergency department, but only 28% went by ambulance. The rest went by themselves or using a non-emergency ambulance. The other third of patients were referred to alternative service providers or given advice about care at home.
Eastwood K, Morgans A, Smith K, Hodgkinson A, Becker G, Stoelwinder J. A novel approach for managing the growing demand for ambulance services by low-acuity patients. Australian Health Review. 2015.


Reducing waste and inefficency

It has been suggested that nudges – approaches that steer people in certain directions while maintaining their freedom of choice – might offer an effective way to change behaviour and improve outcomes at lower cost than traditional policy tools.

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Nudges have been applied across a wide range of areas in the UK and globally. However, there is relatively little in the way of coverage of nudge-type behaviour change interventions to health care specifically and some uncertainty about how effective nudges are in bringing about desirable behaviour change.

This review begins to address this gap by:

  1. providing a map of the evidence of the application of nudge-type interventions in health care
  2. considering opportunities for reducing inefficiency and waste in health care.

The review identifies:

  • nudge-type interventions with potential to increase efficiency and reduce waste in health care
  • areas of inefficiency and waste to which nudge-type interventions might be productively applied
  • opportunities and considerations for those looking to introduce nudge-type interventions

Reference: Behavioural insights in health care: Nudging to reduce inefficiency and waste



What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Authors: Turner J, Coster J, Chambers D, Cantrell A, Phung V-H, Knowles E, Bradbury D, Goyder E

Journal: Health Services and Delivery Research Volume: 3 Issue: 43

Publication date: December 2015

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.