JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):67-76
Effectiveness of decision tools used to identify adult patients suitable for early discharge from emergency departments: a systematic review protocol Gitte Boier Tygesen1 Sasja Jul Håkonsen2 Lisbeth Uhrenfeldt2,3
1. Department of Emergency Medicine, Horsens Hospital, Denmark 2. Danish Centre of Systematic Reviews: an Affiliate Center of the Joanna Briggs Institute; The Center of Clinical Guidelines – Clearing House, Aalborg University, Aalborg, Denmark 3. Department of Health Science and Technology, Aalborg University, Denmark
Corresponding author: Gitte Boier Tygesen [email protected]
Review question/objective The objective of this systematic review is to identify the best available evidence to determine the effectiveness of decision tools used to identify adult patients suitable for early discharge from emergency departments (EDs). More specifically, the review question is: What is the effectiveness of decision tools in terms of their ability to identify adult patients (> 18) for early discharge from the ED the same day or within 48 hours?
Background Emergency department crowding represents an international crisis that may affect the quality and access of health care. Research indicates that crowding leads to adverse outcomes influencing patient safety, working environment and health economy.1 A systematic review on ED crowding examined literature on causes, effects and solutions which indicates input-, throughput- and output factors to be important. Input factors are non-urgent visits caused by insufficient or untimely access to primary care, frequent-flyer patients and the influenza season. The throughput factors are inadequate staffing and output factors are inpatient boarding and hospital bed shortages.1 The literature states the effect of different interventions that can contribute to diminishing input-, throughput- and output factors by identifying inappropriate, preventable, avoidable or unnecessary
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admissions to ED especially for patients over 65 years.2 Early Screen for Discharge Planning seems to be effective as a decision support tool in identifying and prioritizing patients for early discharge planning intervention. It provides the opportunity for patients to access community resources and assists in successful recovery after hospitalization. This in turn decreases the need for referrals for post-acute services and readmissions.3,4 Adequate and competent staffing seems to contribute to early diagnosis and provision of effective treatment through timely and high quality treatment through teamwork and early senior physician involvement. This might assist in decreasing throughput factors.5,6 A high proportion of patients present in ED or acute medical units are discharged within the same day indicating that admission is not always necessary if the patients can be assessed within ambulatory emergency care settings, including diagnosis, observation, treatment and rehabilitation. Simple scoring systems that predict the likelihood of same-day or early discharge after assessment may be used to assess patients, and can be suitable for ambulatory care management. These systems can thereby release beds for the next patient if patients who do not need a full clinical assessment are identified and discharged earlier in the process. 7 Improving the physician’s ability to identify and safely manage low-risk patients after a brief inpatient treatment period is another aspect and is essential in order to avoid unnecessary use of hospital beds due to a faster but safe early discharge. However, an overview of methods for identifying patients who can be sent home early is lacking.3,8 Different tools to identify patients who can safely be sent home do exist. The tools range from rules based on protocols supported by diagnostic tests and stratifying patients to low or high risk categories, to tools based on studies on adverse outcomes, mortality and readmissions to identify patients with specific symptoms or diseases. The Simple Clinical Score (SCS) is an assessment tool that can be used to identify internal medicine patients with low risk of death suitable for early hospital discharge, early identification of patients with high risk of death requiring care in critical care areas.9 The Ambulatory care score (Amb score) can be used to select ambulatory emergency care patients (AEC) from the medical emergency intake and to identify AEC patients suitable for early discharge. 7 The Manchester triage system (MTS) can be used to distinguish between patients with high and low unadjusted risk of short-term death who will stay in hospital for at least 24 hour, and patients who will return home.10 The HEART (history, electrocardiogram, age, risk factors and troponin) score,11 North American Chest Pain Rule12 and the Asia-Pacific Evaluation of Chest pain Trial are different tools, all with aspects of identifying patients with chest pain who are safe for early discharge and with different diagnostic tests and protocols.13 Glasgow-Blatchford Bleeding Score is superior to pre-Rockall score in identifying patients with suspected upper gastrointestinal bleeding who have a low likelihood of an adverse clinical outcome and can be considered for early discharge.14 There is a need to examine which tools exist to support clinicians' decisions about which patients can be discharged early to ensure quality and safety for patients, determine the effectiveness of these methods and possibly uncover more research needed. The decision support system may help to determine who can safely be sent home early, who will remain in the ED and who should be transferred to specialized departments due to the presumption of prolonged hospitalization. This may
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help to reduce crowding and create spaces in the ED for patients who will benefit the most from ED treatment. An initial search in the databases PubMed, CINAHL, Cochrane Library, PROSPERO register, and EPISTEMINIKOS has been conducted and no systematic review on this topic exists or is currently underway. Definitions Emergency medicine Emergency medicine is considered as the superior specialty under which the ED is located. Emergency medicine is the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury. It encompasses a unique body of knowledge as set forth in the "Model of the Clinical Practice of Emergency Medicine". The practice of emergency medicine includes the initial evaluation, diagnosis, treatment and disposition of any patient requiring expeditious medical, surgical or psychiatric care. Emergency medicine may be practiced in a hospital-based or freestanding ED, in an urgent care clinic, in an emergency medical response vehicle or at a disaster site.15 Screening “Screening is the presumptive identification of unrecognized disease or defects by means of tests, examinations, or other procedures that can be applied rapidly”. 16(p11) In this review, an evaluation will be made on decision tools identifying patients at risk before symptoms occur or are exacerbated, which predict the likelihood of early discharge. Examples are tools for risk stratification to identify patients who might potentially benefit from early discharge and decision tools, risk stratification score, protocols or models to facilitate early discharge of low risk patients. Early discharge Early discharge is defined as discharge in the same day or within 48 hours.17 Length of stay Emergency department length of stay is defined as the time a patient registers in the ED to the time the patient physically leaves to go home, to another facility or to a hospital bed.18
Keywords Emergency medicine; screening; decision tool; risk score; early discharge; length of stay
Inclusion criteria Types of participants This review will consider studies that include patients over 18 years admitted to the ED. Types of intervention(s) This review will consider studies that evaluate decision tools used to predict early discharge from the ED within same day or 48 hours.
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Examples of interventions are:
The Simple Clinical Score (SCS)
Ambulatory care score
Manchester triage system (MTS)
The HEART score
North American Chest Pain Rule
The Asia-Pacific Evaluation of Chest pail Trial
Glasgow-Blatchford Bleeding Score
Types of outcomes This review will consider studies that include the following outcome measures: Length of hospital stay Early discharge Same day discharge Types of studies This review will consider for inclusion any experimental study design including randomized controlled trials, non-randomized controlled trials, quasi-experimental, and before and after studies.
Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE/PubMed and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Danish, Swedish or Norwegian will be considered for inclusion in this review. Databases will be searched from their inception to December 2015. The search strategy will be constructed and carried out together with a research librarian. The databases to be searched include: PubMed, MEDLINE, CINAHL, Scopus. The search for unpublished studies will include: MEDION, MedNar, Health technology assessment database, turning research into practice (TRIP). Initial keywords to be used will be: Risk assessment/methods, screening tool or instrument, assessment, emergency medicine, emergency service, length of stay (LOS), early discharge, same day discharge, adults, young adults, old*, elderly.
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Population
Intervention
Comparator
Outcome
Patients + 18 years
Risk Assessment/methods
No specific
Length of stay (LOS)
admitted to the
Screening tool or instrument
comparator,
Early discharge Same
Emergency
Assessment
could be
day discharge
Department
normal praxis or a tool/ diagnostic test with same objective
Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBIMAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction Data will be extracted from papers included in the review using the standardized data extraction tool from JBI- MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest The authors have no conflict of interest to declare.
Acknowledgements We are grateful to Line Jensen (MA) for her language revision and Karin Friis Velbæk for her help with systematic searches.
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References 1. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-36. 2. Guitares AR, Uhrenfeldt L, Meyer G, Mann E. Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review. BMC Geriatr. 2014;14:80. 3. Holland DE, Knafl GJ, Bowles KH. Targeting hospitalised patients for early discharge planning intervention. J Clin Nurs. 2013 Oct;22(19-20):2696-703. 4. Bull MJ. Discharge planning for older people: a review of current research. Br J Community Nurs. 2000;5(2):70-4. 5. Walley P, Silvester K, Mountford S Health-care process improvement decisions: a systems perspective.Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(1):93104. 6. Shetty A, Gunja N, Byth K, Vukasovic M. Senior Streaming Assessment Further Evaluation after Triage zone: a novel model of care encompassing variousemergency department throughput measures. Emerg Med Australas. 2012;24(4):374-82. 7. Ala L, Mack J, Shaw R, Gasson A, Cogbill E, Marion R, Rahman R, Deibel F, Rathbone N. Selecting ambulatory emergency care (AEC) patients from the medical emergency in-take: the derivation and validation of the Amb score. Clin Med. 2012;12(5):420-6. 8. Collins SP, Lindsell CJ, Jenkins CA, Harrell FE, Fermann GJ, Miller KF, Roll SN, Sperling MI, Maron DJ, Naftilan AJ, McPherson JA, Weintraub NL, Sawyer DB, Storrow AB. Risk stratification in acute heart failure: rationale and design of the STRATIFY and DECIDE studies. Am Heart J. 2012;164(6):825-34. 9. Subbe CP, Jishi F, Hibbs RAB. The Simple Clinical Score: a tool for benchmarking of emergency admissions in acute internal medicine. Clin Med. 2010;10(4): 352-7. 10. Martins HMG, De Castro Dominguez Cuña LM, Freitas P. Is Manchester (MTS) more than a triage system? A study of its association with mortality and admission to a large Portuguese hospital. Emerg Med J. 2009;26(3):183-186. 11. Six AJ, Cullen L, Backus BE, Greenslade J, Parsonage W, Aldous S, Doevendans PA, Than M The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013;12(3):121-6. 12. Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, Shapiro NI, Glynn T, Nowak R, Safdar B, Peberdy M, Counselman FL, Chandra A, Kosowsky J, Neuenschwander J, Schrock JW, Plantholt S, Diercks DB, Peacock WF. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol. 2013;168(2):795-802.
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13. Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet. 2011;377(9771):1077-84 14. Le Jeune IR, Gordon AL, Farrugia D, Manwani R, Guha IN, James MW. Safe discharge of patients with low-risk upper gastrointestinal bleeding (UGIB): can the use of Glasgow-Blatchford Bleeding Score be extended? Acute Med. 2011;10(4):176-81. 15. American college of Emergency Physicians definition of Emergency medicine [internet]. Revised and approved by the ACEP Board of Directors June 2015, April 2008, April 2001 [Internet]. [cited 2014 June 18]. Available from: http://www.acep.org/Content.aspx?id=29164 16. Wilson JMG, Jungner G. Principles and practices of screening for disease. Geneva, Switzerland:
World Health Organization; 1968. Public Health Papers No. 34. [internet]. [cited 2014 June 18] Available from: http://whqlibdoc.who.int/php/WHO_PHP_34.pdf 17. St Noble VJ, Davies G, Bell D. Improving continuity of care in an acute medical unit: initial outcomes.QJM. 2008 Jul;101(7):529-33. 18. Gardner RL, Sarkar U, Maselli JH, Gonzales R. Factors associated with longer ED lengths of stay. Am J Emerg Med. 2007 Jul;25(6):643-50.
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Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message
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Appendix II: Data extraction instruments MAStARI data extraction instrument
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Effectiveness of decision tools used to identify adult patients suitable for early discharge from emergency departments: a systematic review protocol Gitte Boier Tygesen1 Sasja Jul Håkonsen2 Lisbeth Uhrenfeldt2,3
1. Department of Emergency Medicine, Horsens Hospital, Denmark 2. Danish Centre of Systematic Reviews: an Affiliate Center of the Joanna Briggs Institute; The Center of Clinical Guidelines – Clearing House, Aalborg University, Aalborg, Denmark 3. Department of Health Science and Technology, Aalborg University, Denmark
Corresponding author: Gitte Boier Tygesen [email protected]
Review question/objective The objective of this systematic review is to identify the best available evidence to determine the effectiveness of decision tools used to identify adult patients suitable for early discharge from emergency departments (EDs). More specifically, the review question is: What is the effectiveness of decision tools in terms of their ability to identify adult patients (> 18) for early discharge from the ED the same day or within 48 hours?
Background Emergency department crowding represents an international crisis that may affect the quality and access of health care. Research indicates that crowding leads to adverse outcomes influencing patient safety, working environment and health economy.1 A systematic review on ED crowding examined literature on causes, effects and solutions which indicates input-, throughput- and output factors to be important. Input factors are non-urgent visits caused by insufficient or untimely access to primary care, frequent-flyer patients and the influenza season. The throughput factors are inadequate staffing and output factors are inpatient boarding and hospital bed shortages.1 The literature states the effect of different interventions that can contribute to diminishing input-, throughput- and output factors by identifying inappropriate, preventable, avoidable or unnecessary
doi: 10.11124/jbisrir-2016-1801
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JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):67-76
admissions to ED especially for patients over 65 years.2 Early Screen for Discharge Planning seems to be effective as a decision support tool in identifying and prioritizing patients for early discharge planning intervention. It provides the opportunity for patients to access community resources and assists in successful recovery after hospitalization. This in turn decreases the need for referrals for post-acute services and readmissions.3,4 Adequate and competent staffing seems to contribute to early diagnosis and provision of effective treatment through timely and high quality treatment through teamwork and early senior physician involvement. This might assist in decreasing throughput factors.5,6 A high proportion of patients present in ED or acute medical units are discharged within the same day indicating that admission is not always necessary if the patients can be assessed within ambulatory emergency care settings, including diagnosis, observation, treatment and rehabilitation. Simple scoring systems that predict the likelihood of same-day or early discharge after assessment may be used to assess patients, and can be suitable for ambulatory care management. These systems can thereby release beds for the next patient if patients who do not need a full clinical assessment are identified and discharged earlier in the process. 7 Improving the physician’s ability to identify and safely manage low-risk patients after a brief inpatient treatment period is another aspect and is essential in order to avoid unnecessary use of hospital beds due to a faster but safe early discharge. However, an overview of methods for identifying patients who can be sent home early is lacking.3,8 Different tools to identify patients who can safely be sent home do exist. The tools range from rules based on protocols supported by diagnostic tests and stratifying patients to low or high risk categories, to tools based on studies on adverse outcomes, mortality and readmissions to identify patients with specific symptoms or diseases. The Simple Clinical Score (SCS) is an assessment tool that can be used to identify internal medicine patients with low risk of death suitable for early hospital discharge, early identification of patients with high risk of death requiring care in critical care areas.9 The Ambulatory care score (Amb score) can be used to select ambulatory emergency care patients (AEC) from the medical emergency intake and to identify AEC patients suitable for early discharge. 7 The Manchester triage system (MTS) can be used to distinguish between patients with high and low unadjusted risk of short-term death who will stay in hospital for at least 24 hour, and patients who will return home.10 The HEART (history, electrocardiogram, age, risk factors and troponin) score,11 North American Chest Pain Rule12 and the Asia-Pacific Evaluation of Chest pain Trial are different tools, all with aspects of identifying patients with chest pain who are safe for early discharge and with different diagnostic tests and protocols.13 Glasgow-Blatchford Bleeding Score is superior to pre-Rockall score in identifying patients with suspected upper gastrointestinal bleeding who have a low likelihood of an adverse clinical outcome and can be considered for early discharge.14 There is a need to examine which tools exist to support clinicians' decisions about which patients can be discharged early to ensure quality and safety for patients, determine the effectiveness of these methods and possibly uncover more research needed. The decision support system may help to determine who can safely be sent home early, who will remain in the ED and who should be transferred to specialized departments due to the presumption of prolonged hospitalization. This may
doi: 10.11124/jbisrir-2016-1801
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2016;14(1):67-76
help to reduce crowding and create spaces in the ED for patients who will benefit the most from ED treatment. An initial search in the databases PubMed, CINAHL, Cochrane Library, PROSPERO register, and EPISTEMINIKOS has been conducted and no systematic review on this topic exists or is currently underway. Definitions Emergency medicine Emergency medicine is considered as the superior specialty under which the ED is located. Emergency medicine is the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury. It encompasses a unique body of knowledge as set forth in the "Model of the Clinical Practice of Emergency Medicine". The practice of emergency medicine includes the initial evaluation, diagnosis, treatment and disposition of any patient requiring expeditious medical, surgical or psychiatric care. Emergency medicine may be practiced in a hospital-based or freestanding ED, in an urgent care clinic, in an emergency medical response vehicle or at a disaster site.15 Screening “Screening is the presumptive identification of unrecognized disease or defects by means of tests, examinations, or other procedures that can be applied rapidly”. 16(p11) In this review, an evaluation will be made on decision tools identifying patients at risk before symptoms occur or are exacerbated, which predict the likelihood of early discharge. Examples are tools for risk stratification to identify patients who might potentially benefit from early discharge and decision tools, risk stratification score, protocols or models to facilitate early discharge of low risk patients. Early discharge Early discharge is defined as discharge in the same day or within 48 hours.17 Length of stay Emergency department length of stay is defined as the time a patient registers in the ED to the time the patient physically leaves to go home, to another facility or to a hospital bed.18
Keywords Emergency medicine; screening; decision tool; risk score; early discharge; length of stay
Inclusion criteria Types of participants This review will consider studies that include patients over 18 years admitted to the ED. Types of intervention(s) This review will consider studies that evaluate decision tools used to predict early discharge from the ED within same day or 48 hours.
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Examples of interventions are:
The Simple Clinical Score (SCS)
Ambulatory care score
Manchester triage system (MTS)
The HEART score
North American Chest Pain Rule
The Asia-Pacific Evaluation of Chest pail Trial
Glasgow-Blatchford Bleeding Score
Types of outcomes This review will consider studies that include the following outcome measures: Length of hospital stay Early discharge Same day discharge Types of studies This review will consider for inclusion any experimental study design including randomized controlled trials, non-randomized controlled trials, quasi-experimental, and before and after studies.
Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE/PubMed and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Danish, Swedish or Norwegian will be considered for inclusion in this review. Databases will be searched from their inception to December 2015. The search strategy will be constructed and carried out together with a research librarian. The databases to be searched include: PubMed, MEDLINE, CINAHL, Scopus. The search for unpublished studies will include: MEDION, MedNar, Health technology assessment database, turning research into practice (TRIP). Initial keywords to be used will be: Risk assessment/methods, screening tool or instrument, assessment, emergency medicine, emergency service, length of stay (LOS), early discharge, same day discharge, adults, young adults, old*, elderly.
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2016;14(1):67-76
Population
Intervention
Comparator
Outcome
Patients + 18 years
Risk Assessment/methods
No specific
Length of stay (LOS)
admitted to the
Screening tool or instrument
comparator,
Early discharge Same
Emergency
Assessment
could be
day discharge
Department
normal praxis or a tool/ diagnostic test with same objective
Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBIMAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction Data will be extracted from papers included in the review using the standardized data extraction tool from JBI- MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest The authors have no conflict of interest to declare.
Acknowledgements We are grateful to Line Jensen (MA) for her language revision and Karin Friis Velbæk for her help with systematic searches.
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References 1. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-36. 2. Guitares AR, Uhrenfeldt L, Meyer G, Mann E. Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review. BMC Geriatr. 2014;14:80. 3. Holland DE, Knafl GJ, Bowles KH. Targeting hospitalised patients for early discharge planning intervention. J Clin Nurs. 2013 Oct;22(19-20):2696-703. 4. Bull MJ. Discharge planning for older people: a review of current research. Br J Community Nurs. 2000;5(2):70-4. 5. Walley P, Silvester K, Mountford S Health-care process improvement decisions: a systems perspective.Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(1):93104. 6. Shetty A, Gunja N, Byth K, Vukasovic M. Senior Streaming Assessment Further Evaluation after Triage zone: a novel model of care encompassing variousemergency department throughput measures. Emerg Med Australas. 2012;24(4):374-82. 7. Ala L, Mack J, Shaw R, Gasson A, Cogbill E, Marion R, Rahman R, Deibel F, Rathbone N. Selecting ambulatory emergency care (AEC) patients from the medical emergency in-take: the derivation and validation of the Amb score. Clin Med. 2012;12(5):420-6. 8. Collins SP, Lindsell CJ, Jenkins CA, Harrell FE, Fermann GJ, Miller KF, Roll SN, Sperling MI, Maron DJ, Naftilan AJ, McPherson JA, Weintraub NL, Sawyer DB, Storrow AB. Risk stratification in acute heart failure: rationale and design of the STRATIFY and DECIDE studies. Am Heart J. 2012;164(6):825-34. 9. Subbe CP, Jishi F, Hibbs RAB. The Simple Clinical Score: a tool for benchmarking of emergency admissions in acute internal medicine. Clin Med. 2010;10(4): 352-7. 10. Martins HMG, De Castro Dominguez Cuña LM, Freitas P. Is Manchester (MTS) more than a triage system? A study of its association with mortality and admission to a large Portuguese hospital. Emerg Med J. 2009;26(3):183-186. 11. Six AJ, Cullen L, Backus BE, Greenslade J, Parsonage W, Aldous S, Doevendans PA, Than M The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013;12(3):121-6. 12. Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, Shapiro NI, Glynn T, Nowak R, Safdar B, Peberdy M, Counselman FL, Chandra A, Kosowsky J, Neuenschwander J, Schrock JW, Plantholt S, Diercks DB, Peacock WF. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol. 2013;168(2):795-802.
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13. Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet. 2011;377(9771):1077-84 14. Le Jeune IR, Gordon AL, Farrugia D, Manwani R, Guha IN, James MW. Safe discharge of patients with low-risk upper gastrointestinal bleeding (UGIB): can the use of Glasgow-Blatchford Bleeding Score be extended? Acute Med. 2011;10(4):176-81. 15. American college of Emergency Physicians definition of Emergency medicine [internet]. Revised and approved by the ACEP Board of Directors June 2015, April 2008, April 2001 [Internet]. [cited 2014 June 18]. Available from: http://www.acep.org/Content.aspx?id=29164 16. Wilson JMG, Jungner G. Principles and practices of screening for disease. Geneva, Switzerland:
World Health Organization; 1968. Public Health Papers No. 34. [internet]. [cited 2014 June 18] Available from: http://whqlibdoc.who.int/php/WHO_PHP_34.pdf 17. St Noble VJ, Davies G, Bell D. Improving continuity of care in an acute medical unit: initial outcomes.QJM. 2008 Jul;101(7):529-33. 18. Gardner RL, Sarkar U, Maselli JH, Gonzales R. Factors associated with longer ED lengths of stay. Am J Emerg Med. 2007 Jul;25(6):643-50.
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Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message
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Appendix II: Data extraction instruments MAStARI data extraction instrument
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