What strategies are used to select patients for direct admission under acute medicine services? A systematic review of the literature
Authors: Evans Samuel , Atkin Catherine , Hunt Austin , Ball Georgina , Cassidy Charlotte , Costley-White Alexander , Toy Louise , Wilding Rebecca , Sapey Elizabeth 
Published: September 2024

Background

Pressures on hospital emergency care services have led to increasing interest in new models of acute care provision. One such model is a medical emergency department where medical patients are triaged directly to acute internal medicine, without assessment by emergency medicine. The evidence for this model of care is unclear.

Design

Systematic review.

Methods

Studies included direct referral pathways to acute internal medicine. The protocol was registered prospectively (Prospero: CRD42023495786). Databases searched included MEDLINE (Ovid), The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE in process, Web of Science, CINAHL, and Embase. Studies had no time or language restrictions. Studies were selected based on inclusion and exclusion criteria, assessed by at least two independent researchers. ROBINS I risk of bias assessment was applied to the selected studies and a narrative synthesis was performed.

Results

From 4405 abstracts, 89 full text articles were screened and 4 were selected for data extraction. Two studies assessed tools to predict the need for a medical admission and two studies assessed the impact of direct referral pathways to medicine. Risk of bias was mixed, and studies were heterogeneous. However, the studies reported a good ability to appropriately select patients for direct referral to medicine and a reduced length of time to medical assessment. There were no differences in other outcomes such as mortality or overall length of stay.

Discussion

The current evidence to support direct admission to medicine, effectively a medical ED, is limited with studies being heterogeneous and of varying quality. Models for patient selection varied, but there was evidence to support accurate, early identification of medical patients and of reduced delays in medical assessment and care.

Conclusion

Given these positive early signs of benefit, more studies are needed to design and evaluate care models such as medical EDs.

Registration

Prospero Registration Number: CRD42023495786.

What is already known on this topic

Direct admission pathways to acute medicine services are used in some centres in the UK with significant variation in how this pathway is provided.

What this study adds

This systematic review is the first comprehensive synthesis of published research on direct admission pathways to internal medicine services. The limited number of studies were heterogenous and of variable quality. Different models for patient selection were included but were assessed, studies demonstrated the ability to identify patients likely to require medical admission, and a reduction in the time to medical admission. More studies are needed to assess how to structure and operationalize a direct admission pathway in the United Kingdom and internationally.

How this study might affect research, practice or policy

Our study highlights the need for further research to help develop optimal pathways to enable patients with acute medical conditions requiring treatment to be reviewed by acute medical teams as soon as possible after presentation, to improve patient care in the context of growing demand for these services.

Strengths and Limitations

- This is the first systematic review of direct admission pathways to medicine.

- The systematic review was conducted using standardised methodology with the protocol prospectively registered on an open access database. There were no date or language restrictions applied.

- The main limitation of the systematic review is the limited number and quality of studies available for inclusion.