Digitisation of emergency medicine: opportunities, examples and issues for consideration

Objectives To provide an overview of the safety and effectiveness of Hospital-at-Home (HaH) according to programme type (early-supported discharge (ESD) vs admission avoidance (AA)), and identify the model with higher evidence for addressing clinical, length of stay (LOS) and cost outcomes. Methods A systematic review of reviews was conducted by performing a search on PubMed, EMBASE, Cochrane Database of Systematic Reviews, Web of Science and Scopus (January 2005 to June 2020) for English-language systematic reviews evaluating HaH. Data on primary outcomes (mortality, readmissions, costs, LOS), secondary outcomes (patient/caregiver outcomes) and process indicators were extracted. Quality of the reviews was assessed using Assessment of Multiple Systematic Reviews-2. There was no registered protocol. Results Ten systematic reviews were identified (four high quality, five moderate quality and one low quality). The reviews were classified according to three use cases. ESD reviews generally revealed comparable mortality (RR 0.92–1.03) and readmissions (RR 1.09–1.25) to inpatient care, shorter hospital LOS (MD −6.76 to −4.44 days) and unclear findings for costs. AA reviews observed a trend towards lower mortality (RR 0.77, 95% CI 0.54 to 1.09) and costs, and comparable or lower readmissions (RR 0.68–0.98). Among reviews including both programme types (ESD/AA), chronic obstructive pulmonary disease reviews revealed lower mortality (RR 0.65–0.68) and post-HaH readmissions (RR 0.74–0.76) but unclear findings for resource use. Conclusion For suitable patients, HaH generally results in similar or improved clinical outcomes compared with inpatient treatment, and warrants greater attention in health systems facing capacity constraints and rising costs. Preliminary comparisons suggest prioritisation of AA models over ESD due to potential benefits in costs and clinical outcomes. Nonetheless, future research should clarify costs of HaH programmes given the current low-quality evidence, as well as address evidence gaps pertaining to caregiver outcomes and adverse events under HaH care.

It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.

The COVID-19 pandemic has led health systems to increase the use of tools for monitoring and triaging patients remotely. In this systematic review, we aim to assess the effectiveness and safety of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. We searched five databases (MEDLINE, Embase, Global Health, medRxiv, and bioRxiv) from database inception to April 15, 2021, and included feasibility studies, clinical trials, and observational studies, including preprints. We found 561 studies, of which 13 were included in our narrative synthesis. These 13 studies were all observational cohorts and involved a total of 2908 participants. A meta-analysis was not feasible owing to the heterogeneity of the outcomes reported in the included studies. Our systematic review substantiates the safety and potential of pulse oximetry for monitoring patients at home with COVID-19, identifying the risk of deterioration and the need for advanced care. The use of pulse oximetry can potentially save hospital resources for patients who might benefit the most from care escalation; however, we could not identify explicit evidence for the effect of RPM with pulse oximetry on health outcomes compared with other monitoring models such as virtual wards, regular monitoring consultations, and online or paper diaries to monitor changes in symptoms and vital signs. Based on our findings, we make 11 recommendations across the three Donabedian model domains and highlight three specific measurements for setting up an RPM system with pulse oximetry.