Exploring prehospital emergency care challenges and interventions to reduce emergency department overcrowding: a qualitative meta-synthesis.

backgroundChallenges within prehospital emergency care (PEC) have significant implications for the provision of emergency department (ED) care. However, ED overcrowding is a prevalent issue with negative impacts on patient outcomes. It can be attributed to multiple factors, such as non-emergency attendances, inaccessible alternative care service pathways (ACSPs) and inefficiencies in emergency medical service operations. ED overcrowding has prompted healthcare systems worldwide to implement interventions. These include tele-triaging, virtual ED and non-conveyance protocols that primarily aim to reduce demand for ED care and increase the supply of alternative services. However, despite such efforts, there remain unaddressed limitations that prevent PEC interventions from being successfully implemented. Moreover, prior studies and reviews have found mixed results, and that ED overcrowding interventions remain underused. Therefore, there is a need for this qualitative systematic review and meta-synthesis to capture the complexities of implementation challenges and identify enablers required to complement PEC interventions.

objectivesThis systematic review and meta-synthesis aims to offer a consolidated overview of PEC interventions intended to reduce ED overcrowding. It focuses on presenting international perspectives on the current challenges these interventions face. The enablers presented in this review could also better inform the actions taken by healthcare systems aiming to implement similar interventions.

methodsA comprehensive search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Web of Science and Scopus was conducted to obtain a set of qualitative studies. Following a quality appraisal with the Critical Appraisal Skills Programme tool, data from the included studies were extracted and meta-synthesised.

resultsA final 21 qualitative intervention-based studies were included. Through these studies, four themes were identified: (1) types of PEC interventions to alleviate ED demands and right-site patients, (2) perceived benefits of interventions, (3) challenges in implementing interventions and (4) key enablers for successful implementation of interventions. Our results describe key factors such as the importance of ACSPs and support for PEC healthcare workers in the form of standardised guidelines, as well as education and training.

conclusionWe further discuss how enablers can integrate into current PEC systems to complement the interventions explored. Discussions are concentrated on several key interventions (tele-triaging, virtual ED and non-conveyance protocols) as they were perceived to hold significant potential in addressing PEC challenges and could be further elevated through various enablers. Overall, we could conclude that each intervention needs to be complemented by enablers to optimise its benefits.