[Table, Early versus late consultant review]. - Emergency and acute medical care in over 16s: service delivery and organisation

Review question: Is early consultant triage in the ED (RAT model) more clinically and cost effective than later consultant review?
Objective	To determine if early consultant review at acute presentation improves patient outcomes and reduces rate of admission.
Rationale	Specialists ensure that patients are on the correct treatment pathway, moving along the pathway in a timely manner, and not subject to unexpected delays or complications. The first step in the process, determining the correct diagnosis and initial treatment, needs to be taken in a timely manner, as delays can compromise patient outcomes. The question is at what point is specialist involvement essential? At the point of admission, or following initial review and stabilisation by the other members of the clinical team?
Population	Adults and young people (16 years and over) with a suspected or confirmed AME
Intervention	Early consultant review
Comparison	Later consultant review (any time point that is later than the intervention)
Outcomes	Patient outcomes; Early diagnosis (IMPORTANT) Hospital admission (IMPORTANT) Quality of life (CRITICAL) GP visits (IMPORTANT) Mortality (CRITICAL) Avoidable adverse events (CRITICAL) Diagnostic test number (IMPORTANT) Patient satisfaction (CRITICAL) Length of stay in ED (CRITICAL) Readmission up to 30 days (IMPORTANT) Discharge (IMPORTANT) Referrals from admissions (IMPORTANT) Staff outcomes; Staff satisfaction (IMPORTANT) Trainee satisfaction (IMPORTANT) Carer outcome; Carer satisfaction (IMPORTANT)
Exclusion
Search criteria	The databases to be searched are: Medline, Embase, the Cochrane Library Date limits for search: None Language: English only
The review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Analysis	Data synthesis of RCT data. Meta-analysis where appropriate will be conducted. Studies in the following subgroup populations will be included: Frail elderly People with serious mental illness Being seen by consultant prior AMU in diagnosed patients. In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.
Key papers
Number of clinical questions	Max occupancy 85%, often at 95% ED / RAT model in ED, note time points (not enough staff at moments to implement) (PD ideal world seen within 1 hour by consultant).
HE questions	Crucial to conceptual. RF does diagnostic reviews (out of 10) for HE.

Review question: Is early consultant triage in the ED (RAT model) more clinically and cost effective than later consultant review?

Objective

To determine if early consultant review at acute presentation improves patient outcomes and reduces rate of admission.

Rationale

Specialists ensure that patients are on the correct treatment pathway, moving along the pathway in a timely manner, and not subject to unexpected delays or complications. The first step in the process, determining the correct diagnosis and initial treatment, needs to be taken in a timely manner, as delays can compromise patient outcomes. The question is at what point is specialist involvement essential? At the point of admission, or following initial review and stabilisation by the other members of the clinical team?

Population

Adults and young people (16 years and over) with a suspected or confirmed AME

Intervention

Early consultant review

Comparison

Later consultant review (any time point that is later than the intervention)

Outcomes

Patient outcomes;

Early diagnosis (IMPORTANT)
Hospital admission (IMPORTANT)
Quality of life (CRITICAL)
GP visits (IMPORTANT)
Mortality (CRITICAL)
Avoidable adverse events (CRITICAL)
Diagnostic test number (IMPORTANT)
Patient satisfaction (CRITICAL)
Length of stay in ED (CRITICAL)
Readmission up to 30 days (IMPORTANT)
Discharge (IMPORTANT)
Referrals from admissions (IMPORTANT)

Staff outcomes;

Staff satisfaction (IMPORTANT)
Trainee satisfaction (IMPORTANT)

Carer outcome;

Carer satisfaction (IMPORTANT)

Exclusion

Search criteria

The databases to be searched are: Medline, Embase, the Cochrane Library

Date limits for search: None

Language: English only

The review strategy

Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.

Analysis

Data synthesis of RCT data.

Meta-analysis where appropriate will be conducted.

Studies in the following subgroup populations will be included:

Frail elderly
People with serious mental illness
Being seen by consultant prior AMU in diagnosed patients.

In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.

Key papers

Number of clinical questions

Max occupancy 85%, often at 95% ED / RAT model in ED, note time points (not enough staff at moments to implement) (PD ideal world seen within 1 hour by consultant).

HE questions

Crucial to conceptual. RF does diagnostic reviews (out of 10) for HE.

From: Chapter 19, Early versus late consultant review

Emergency and acute medical care in over 16s: service delivery and organisation.

NICE Guideline, No. 94.

National Guideline Centre (UK).

London: National Institute for Health and Care Excellence (NICE); 2018 Mar.

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