Early versus late consultant review

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

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

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Chapter 19Early versus late consultant review

19. Early versus late consultant review

19.1. Introduction

Traditional models of medicine have often relied on patients being admitted by one of the more junior members of the medical team, then reviewed by a middle grade member, and only reviewed by a consultant several hours later on the ‘post take’ round, which may be the following day or even later in the week. This model has the potential to cause delays in timely investigation, diagnosis, and treatment, or in errors in care, which may translate into delayed discharge from hospital or patient harm. In the last decade several professional organisations have developed pragmatic recommendations for earlier and more frequent consultant review.

Earlier consultant review may allow the less sick patient to go home earlier, possibly even avoiding admission and also allowing earlier recognition of the sicker patient, with earlier institution of effective therapy and possibly decreased mortality. However, earlier discharge may lead to more re-admissions, and earlier reviews may not be effective if relevant tests results are not available. Equally, different age groups and different illnesses may have different results. However, it would seem reasonable that early review by a senior and more experienced doctor should improve the patient’s experience of healthcare.

The guideline committee therefore wanted to know if there was a net patient benefit to having a consultant review patients early in their presentation to hospital, what this might be and whether there was a difference depending on how sick the patient was and what was wrong with them. This would need to be balanced against any potential harm that might occur and how much it might cost.

19.2. Review questions

Is early consultant triage in the ED (Rapid Assessment and Treatment (RAT) model) more clinically and cost effective than later consultant review?

Is early consultant review in the AMU, ICU, HDU, CCU or Stroke Unit more clinically and cost effective than later consultant review?

For full details see review protocols in Appendix A.

Table 1

PICO characteristics of review question.

19.3. Clinical evidence

Eight studies were included in the review¹²^,³²^,⁴¹^,⁶⁷^,⁷⁷^,¹¹⁰^,¹³²^,¹⁵¹ and are summarised below. Evidence from these studies are summarised in the GRADE clinical evidence profile and clinical evidence summary below (Table 3, Table 4, Table 7). See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 3

Clinical evidence summary: Early versus late consultant review in ED: RCT evidence (SWAT versus control).

Table 4

Clinical evidence summary: Early versus late consultant review in ED: observational evidence.

Table 7

Clinical evidence summary: Early versus late consultant review in AMU (Consultant absent versus Consultant present): Cohort study evidence.

We searched for randomised controlled trials (RCTs) comparing the effect of early versus late consultant triage in 5 different settings (ED, ICU, AMU, CCU and stroke units) on patient outcomes.

One RCT⁴¹ was included which was set in the ED and compared the effects of a model of care aiming to implement early senior work up assessment and treatment with no model of care.

Six observational studies¹²^,³²^,⁶⁷^,⁷⁷^,¹³²^,¹⁵¹ were included in the ED. Three of these studies¹²^,⁷⁷^,¹³² were similar in design to the RCT in that an intervention was implemented to facilitate early consultant review, which was then compared to days on which the intervention was not implemented; however, patients were not randomised to treatment. Two of these studies⁷⁷^,¹³² were confounded by the addition of point of care testing to the intervention of early consultant review and were downgraded for risk of bias. One of these studies was confounded by the intervention being carried out on days of peak demand;¹² however this study did adjust for confounding variables.

Two of the 6 observational studies set in ED presented data from naturally occurring situations in which some patients were seen exclusively by consultants due to the absence or reduced availability of junior doctors.³²^,⁶⁷ Outcomes were compared with times when junior doctors were present. One of these studies⁶⁷ was confounded by different triage scores at baseline between the 2 groups and was therefore downgraded for risk of bias.

The final observational study¹⁵¹ set in ED reported the proposed management of patients by junior trainees versus the subsequent effect of the senior review process on patient disposition.

No RCTs set in ICU, AMU, CCU and stroke units were found. One cohort study set in AMU¹¹⁰ was identified.

As no studies reported patient and/or carer satisfaction, data relating to ‘did not wait to be seen’ patients were analysed as a surrogate marker, but downgraded for indirectness to the protocol.

Table 2

Summary of included studies.

Other outcomes that were unable to be analysed in Revman included: length of stay (for all patients): median 261 minutes (IQR 171, 386) in the SWAT group and median 255 minutes (IQR 177,376) in the control (standard care) group. For discharged patients length of stay was median 206 minutes (IQR 140, 294) in the SWAT group and 208 (IQR 147, 283) in control. For admitted patients length of stay was median 374 minutes (IQR 273-494) in the SWAT group and 381 minutes (IQR 274, 478) in control.

19.3.1. Other outcomes that could not be analysed in Revman

Table 5

Clinical evidence summary: Early versus late consultant review in ED: observational evidence.

19.3.2. Clinical investigations

One study⁶⁷ reported the number of clinical investigations per patient.

Table 6

Clinical evidence summary: Early versus late consultant review in ED: observational evidence.

19.3.3. Unplanned readmissions

One study³² reported that 7.9% (6.5-9.3%) of patients who had been seen during the consultant shift returned to ED within 7 days versus 8.1% (7.4-8.9%) of those seen during the middle grade doctor shift. This paper did not give the number for each group so this data could not be analysed in Revman.

19.3.4. Admissions

One study³² reported that 27.1% (24.2-30.1%) of patients who had been seen during the consultant shift were admitted versus 31.0% (29.6-32.5%) of those seen during the middle grade doctor shift. This paper did not give the number for each group so this data could not be analysed in Revman.

19.4. Economic evidence

Published literature

No relevant economic evaluations were identified.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B

New cost-effectiveness analysis

An original cost-effectiveness analysis was conducted for this topic – see the economic profile table below (Table 8) and Chapter 41 for details.

Table 8

Economic evidence profile: Earlier versus later consultant assessment.

19.5. Evidence statements

Clinical

Emergency departments

Seven papers were identified that assessed early versus late consultant reviews in the emergency department. Six of these studies were observation studies and 1 study was a randomised controlled trial.

One randomised controlled trial comprising 1737 participants evaluated senior work up assessment treatment (SWAT) with non-SWAT treatment and standard care for improving outcomes, in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that SWAT may provide a benefit in increased proportion of patients achieving the National Emergency Access Target (NEAT) (1 study, moderate quality), proportion of admitted patients who met NEAT (1 study, low quality), and proportion of discharged patients who met NEAT (1 study, moderate quality). However, there were more patients admitted (1 study, moderate quality) and fewer patients discharged with early consultant review (1 study, moderate quality).

Six observational studies evaluated early versus late consultant reviews for improving outcomes, in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that early consultant reviews may provide a benefit in reduced length of ED stay, 30 day unscheduled re-admissions, admissions, patients achieving NEAT, discharged patients achieving NEAT, admitted patients achieving NEAT, patients seen within the recommended time and patients who did not wait to be seen (1 study, very low quality). However, there was a possible increase in mortality (1 study, very low quality).

Acute medical units

One observational study comprising 2928 participants evaluated consultant presence versus when the consultant was absent for improving outcomes, in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that consultant reviews may provide a benefit in reduced length of stay and proportion of patients discharged on the same day. There was no effect on mortality during admission. However, there was a possible increase in the proportion of patients discharged within 24 hours and readmitted within 1 week for the same clinical problem. The evidence was graded very low quality for all outcomes.

Economic

An original cost-utility analysis found that Rapid Assessment and Treatment in the Emergency Department (RAT) was not cost-effective (increased costs with no quality-adjusted life-years gained). This analysis was assessed as directly applicable with potentially serious limitations.

An original cost-utility analysis (simulation model) found that Rapid Assessment and Treatment in the Emergency Department (RAT) dominated compared to usual care. This analysis was assessed as directly applicable with potentially serious limitations.

An original cost-utility analysis found that extended consultant hours on the Acute Medical Unit were not cost-effective (ICER: £39,200 per QALY). This analysis was assessed as directly applicable with minor limitations. This analysis was assessed as directly applicable with potentially serious limitations.

19.6. Recommendations and link to evidence

Recommendations	10. For people admitted to hospital with a medical emergency, consider providing the following, accompanied by local evaluation which takes into account current staffing models, case mix and severity of illness: Consultant assessment within 14 hours of admission to determine the person’s care pathway Daily consultant review, including weekends and bank holidays More frequent (for example, twice daily) consultant review based on clinical need.
Research recommendation	-
Relative values of different outcomes	Mortality, quality of life, avoidable adverse events and patient and/or carer satisfaction were considered by the committee to be critical outcomes. Early diagnosis, hospital admission, number of diagnostic tests, length of stay, GP visits, referrals from admission, unplanned readmission, discharge and staff satisfaction were considered to be important outcomes. The committee considered that avoiding readmission was likely to be particularly important for people who have a chronic condition as this has an impact on mortality and also could have an impact upon psychological wellbeing and the ability to maintain independence.
Trade-off between clinical benefits and harms	Emergency Department A single RCT was identified. The committee decided that the Senior Work up Assessment and Treatment (SWAT) intervention had most similarities to current systems in the NHS (Rapid Assessment and Treatment [RAT]) compared to the non-SWAT intervention because for consultants to work effectively, they need the support of a team and therefore seeing patients alone would not be productive. Indeed, in the UK, consultants do not normally see patients in isolation. The comparison of SWAT versus control data suggested that SWAT may provide a benefit in increased proportion of patients achieving the National Emergency Access Target (NEAT), which is to be seen and discharged from the ED within 240 minutes of triage; proportion of admitted patients who met NEAT; and proportion of discharged patients who met NEAT. However, there were more patients admitted and fewer discharged with early consultant review. The committee surmised that early consultant review might, in some circumstances, be disadvantageous if it took place before definitive investigations were available which might have permitted safe discharge on later review. Therefore, review prior to all the relevant information being present may result in a greater number of patients admitted. However, the fact that more patients were admitted, although increasing demand, may be a positive step as it may ensure that certain patients receive the inpatient care their condition requires. The presence of a senior decision maker may identify these patients. The committee discussed their experience of the Rapid Assessment and Treatment system (the UK system of immediate consultant triage at presentation to ED). Perceived benefits included more rapid diagnosis, earlier administration of antibiotics and analgesics, and more appropriate triage. However, such outcomes are not normally measured in trials whereas admission, discharge and length of stay are affected by a wide variety of factors, and therefore may not accurately capture the whole effects of early consultant triage. Six observational studies suggested that early consultant review may provide a benefit in reduced length of ED stay, 30 day unscheduled re-admissions, admissions, patients achieving NEAT, discharged patients achieving NEAT, admitted patients achieving NEAT, patients seen within the recommended time and patients who did not wait to be seen. There was a possible increase in mortality but this was discounted by the committee as there was only a difference of 1 case between the 2 groups. No evidence was identified for early diagnosis, quality of life, GP visits, avoidable adverse events, diagnostic test number, patient and/or carer satisfaction, referral from admissions and staff or trainee satisfaction. Acute Medical Unit A single observational study was identified suggesting that early consultant review may provide a benefit in reduced length of stay, and the proportion of patients discharged on the day of admission. There was no effect on mortality during admission; there was a possible increase in the proportion of patients discharged within 24 hours and readmitted within 1 week for the same clinical problem. No evidence was identified for hospital admission, readmission, early diagnosis, quality of life, GP visits, avoidable adverse events, diagnostic test number, patient and/or carer satisfaction, referral from admissions and staff or trainee satisfaction. Stroke patients: No evidence was identified in a stroke care setting. The committee felt that the results from ED and AMU could be extrapolated to stroke patients. Intensive (or critical) care unit: No evidence was identified in an intensive care unit (critical care unit) setting. Studies of resident versus non-resident intensive care specialists were considered too indirect to be employed as substitutes for early consultant review. Given this lack of evidence, the committee considered that studies in ED and AMU patients might be used to inform recommendations relating to the ICU. Overall The committee noted that the effect of early consultant involvement is dependent upon the staffing model, the presenting case mix and the disease process. For example, conditions with a well-defined treatment pathway may benefit more from early consultant involvement if this results in earlier diagnosis and entry to the pathway. In settings where patients are presenting with often unclear disease processes (for example, in an emergency department), the benefit of early consultant involvement might be realised if consultants’ greater knowledge results in earlier diagnosis, or diminished if the diagnostic process is complex. The committee noted that a range of models for early consultant involvement were used in the studies examined, and that the model used within a UK context may differ from those included in the studies. For example, the Rapid Assessment and Treatment model implemented within some emergency department settings in the UK was a model containing a range of interventions, including early consultant involvement. It was felt to be similar but not identical to the SWAT model in the RCT for EDs. Overall, the evidence was mixed but suggested some benefit in outcomes over usual care for the ED and AMU. No evidence was identified to suggest harm in early consultant involvement and the committee were not aware of any negative outcomes that might occur. They therefore chose to make a consensus recommendation to consider early consultant involvement in care of a patient with an acute medical emergency. However, there was insufficient evidence to recommend specific models such at RAT.
Trade-off between net effects and costs	No relevant economic evaluations were identified. Unit costs of staff time, emergency department visits and relevant hospital admissions and stays were presented to the committee. One RCT, described above, set in the emergency department showed that the SWAT arm of the trial was associated with a trend for more patients meeting the 4-hour target; however, there was also a trend for more admissions and less discharges compared to the control arm. The committee felt that without information on the appropriateness of the decisions to admit or discharge, it would be difficult to fully assess the impact of the SWAT model. Anecdotally, the committee felt that the equivalent model in the UK (Rapid Assessment and Treatment or RAT) had shown some clinical benefit in terms of timely diagnosis and treatment. These benefits might be expected to result in saving in downstream costs. For the AMU, the observational study included in the clinical review suggested that there was a reduction in length of stay, which would translate into possible cost saving. The committee noted that the economic impact of early consultant assessment would be dependent on how it could be achieved or implemented in practice. Possible scenarios discussed included increasing the number of consultants, increasing their contracted hours (which might include working out-of-hours or being on-call) or accommodating the required changes in the consultants’ current rotas by prioritising early patient assessments over other duties, which can be undertaken by other staff members. The committee commented that the most likely scenario in large hospitals is that consultant rotas could be tailored to accommodate prioritising assessing patients given current capacity levels and the limited number of NHS consultants, which precludes the possibility of recruiting more consultants. However, this may not be feasible in smaller hospitals. New cost-effectiveness analyses were conducted for 2 areas of early consultant assessment with the results presented to the committee. A cohort model and a simulation model were built to assess the cost-effectiveness of early consultant assessment. Both models used inputs from bespoke data analysis, national data and treatment effects (primarily length of stay reduction and modest reductions in adverse events) that were informed by the above review but elicited from the committee members. The full model write up can be found in Chapter 41. Rapid Assessment and Treatment in the Emergency Department (RAT) The models compared RAT in the ED with no RAT. RAT involves an immediate assessment by a consultant in the ED, using additional resources in terms of consultant time at an incremental cost to normal care. Both models found that RAT was cost increasing with assumed no impact on quality of life, hence no gain in quality-adjusted life-years. The committee noted that RAT is a costly intervention a, with additional consultant time for all ED major patients. An optimistic sensitivity analysis found RAT to cost £98,000 per QALY gained – far from being cost effective. The main impact of RAT is likely to be on hospital flow, not taken into account by the cohort model. The simulation model saw a reduction in 4-hour breeches from 10% to 8%. The committee concluded that RAT is a costly intervention that is probably not cost effective in general, although it might still have a positive impact on hospital flow in hospitals operating at sub-optimal levels of efficiency within the emergency department. Extended hours for consultants in Acute Medical Units (AMU) The model compared consultant assessment available in the AMU 08:00-18:00 with consultant assessment available in the AMU 08:00-22:00. Therefore, the intervention involves the presence of a consultant to assess and treat on the AMU for an additional 4 hours in the evenings, 7 days a week. This uses additional resources in terms of consultant time at an incremental cost to normal care. The results of the cohort model found that extended hours on the AMU was cost increasing with a small impact on quality-adjusted life-years. However, the QALYs gained were not large enough in the base case or optimistic sensitivity analysis to allow an incremental cost-effectiveness ratio under the £20,000 threshold, £45,500 per QALY gained in the base case and £25,500 in the optimistic treatment effects sensitivity analysis. The committee noted the results of the cohort model with an ICER close to the £20,000 threshold in the sensitivity analysis. However, they also noted that extended hours in the AMU was likely to have an impact on hospital flow, not taken into account by the cohort model. However, the AMU could not be properly assessed by the simulation model because too many runs would be required. The committee noted that the intervention allows earlier decision making, potentially avoiding an overnight admission or facilitating earlier discharge. They also noted that extended hours in the AMU could have a positive impact on the hospital flow and patient outcomes, and therefore may be cost-effective at local level. However, extended hours to the AMU should only be implemented alongside local evaluation. Conclusion The committee felt that early consultant assessment could be cost effective in some settings. It is associated with some clinical benefit and, in some settings, the cost might be completely offset by savings from increased efficiencies in the hospital pathway. However, it was agreed that this would not be the case nationwide and any intervention should only be implemented at the local level alongside evaluation. For some Trusts, the resource impact of this recommendation will be more hours of consultant time in the AMU and other high care units. This should be partially offset by reduced length of stay and fewer complications. Some Trusts might want to disinvest in RAT, which would mean savings in terms of ED consultant staff time. There are benefits of early consultant assessment that were not captured in the model and are difficult to quantify, including impact on quality of life from quicker diagnosis and more appropriate location of/better quality of death. Overall, the evidence was not very strong and therefore the committee felt that neither immediate consultant assessment, such as RAT, nor extended hours could be recommended. However, there is still a need for consultant assessment at the earliest practical opportunity. Current pragmatic recommendations from professional organisations recommend initial consultant review within 14 hours for patients admitted to acute medical units [Society for Acute Medicine{ ACT2015}, and within 12 hours for patients admitted to intensive care units [UK Faculty of Intensive Care Medicine{FICM2016}]. The committee concluded that in the absence of definitive evidence, these professional recommendations were reasonable, but should be subject to local audit and evaluation.
Quality of evidence	Emergency department: One RCT was identified which was based in Australia and was graded low to moderate quality due to risk of bias and imprecision. The committee considered whether the study was applicable to a UK setting as in a non-UK setting, patients may present more frequently to secondary care as a first contact. However, the committee chose not to downgrade this study for indirectness as the model was applicable. The observational evidence was all graded as very low quality due to lack of randomisation and the presence of additional confounders, such as the intervention group also receiving point of care testing in addition to early consultant review. Acute medical unit: One observational study was identified and the outcomes were graded as very low quality due to risk of bias, imprecision and indirectness. There were some baseline differences in the conditions for which patients in both groups were being assessed and multivariate analysis had not been carried out. No evidence was identified for stroke care, intensive care or critical care units. Original health economic modelling was assessed to be directly applicable but still had potentially serious limitations due to the treatment effects being based on expert opinion, albeit conservative and informed by the guideline’s systematic review. Due to the quality of the evidence the committee decided to make a cautious recommendation for providers to consider consultant review within 14 hours.
Other considerations	The committee noted that, in practice, many of the competencies required to implement a model of early consultant review may be delivered by other members of healthcare staff. However, it is the knowledge or expertise that the consultant brings to the assessment that is crucial. Consultants do not work in isolation and need support of other staff; therefore to implement, this will require reconfiguration of rotas and changes in the availability of healthcare professionals. The committee were aware of observational evidence across a range of healthcare settings which was not included in the review because of either the availability of higher quality evidence or because it did not meet the inclusion criteria for the review. The committee noted that this observational evidence supported their recommendations for early consultant involvement in these settings. Although no evidence was found on patient and/or carer satisfaction, the committee noted that it was probably the preference of patients to be seen quickly, spend minimal time in ED and AMU and receive an accurate assessment of their condition with appropriate admission and discharge decisions. The committee was interested in how early the consultant review should be to demonstrate an improvement in clinical outcome. The definitions for an early consultant review as presented in the evidence was highly variable, most of which were unclear and vague. For example, one study defined an early consultant review as a review within 24 hours, whereas another study defined an early consultant review as when a consultant was present 4 days out of 5 during the working week from 9am-5pm. The committee referred to the RCP’s Acute care toolkit 4 and the Society for Acute Medicine clinical quality standards: Delivering a 12-hour, 7-day consultant presence on the acute medical unit which includes the following 2 key recommendations: During the period of consultant presence on AMU, all newly admitted patients should be seen within 6 to 8 hours, with the provision for immediate review as required according to illness severity. A newly admitted patient must be seen by a consultant within 14 hours after arrival on AMU. The committee also noted that national standards published by the Faculty of Intensive Care Medicine and UK Intensive Care Society (Guidance on the Provision of Intensive Care Services⁵⁰) recommend that all patients receiving intensive care should be reviewed in person by an intensive care consultant within 12 hours of admission. It was felt by the committee that, although there was no evidence from other acute care units such as the CCU, HASU or ICU, this way of working could be extrapolated to those centres. Indeed, in some of these units it is already occurring, that is, PCI in ST elevation MI which is often performed by a consultant cardiologist, or the delivery of thrombolysis in patients with stroke being covered by a consultant stroke thrombolysis rota. The Academy of Royal Colleges provided a report called the benefits of consultant delivered care². In this report they highlighted the benefits of consultant delivered care: Rapid and appropriate decision making Improved outcomes More efficient use of resources GPs access to the opinion of a fully trained doctor Patient expectation of access to appropriate and skilled clinicians and information Benefits for the training of junior doctors. Achieving the benefits of consultant-delivered care for all patients requires greater consultant presence in hospitals than at present, and therefore changes to models of service delivery and the working patterns and practices of consultants will be required. The Academy of Medical Royal Colleges also produced a report in 2013, Seven Day Consultant Present Care Implementation Considerations. This report reaffirmed the findings of the previous report but also looked at daily consultant review. It also reaffirmed the important financial impact and the reconfiguration of rotas that would be required. As part of the implementation of 7 day services, hospital trusts are expected to meet 10 clinical standards produced by NHS England. The standards were drawn up by the national medical director, Sir Bruce Keogh, and his colleagues at NHS England in 2013, informed by an Academy of Medical Royal Colleges report published in 2012. Trusts are expected to meet 4 priority standards by the end of this financial year. The standards are: Time to first consultant review—patients should be seen as soon as possible but within at least 14 hours Inpatients should have 7 day access to a range of diagnostics Inpatients should have access to a range of key interventions All acute patients must be seen and reviewed by a consultant twice daily. Therefore, the natural progression of the NHS in England is to deliver earlier and consistent consultant input into the patient journey.

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Appendices

Appendix A. Review protocols

Table 9Review protocol: Early versus late consultant review

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 review in the AMU, ICU, HDU, CCU or Stroke Unit 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 - presenting to GP
Intervention	Early consultant review
Comparison	Later consultant review (any time point that is later than the intervention)
Outcomes	Patient outcomes; Early diagnosis Hospital admission Quality of life GP visits Mortality Avoidable adverse events Number of diagnostic tests Patient and/or carer satisfaction Length of stay in ED Length of stay in hospital Readmission up to 30 days Discharge Referrals from admissions Staff outcomes; Staff satisfaction Trainee satisfaction
Exclusion	None
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.

Appendix B. Clinical article selection

Figure 1Clinical article selection

Appendix C. Forest plots

Emergency Department – RCT evidence

Figure 2Early (SWAT) versus late (standard care): Proportion of patients who met NEAT

Figure 3Early (SWAT) versus late (standard care): Proportion of admitted patients who met NEAT

Figure 4Early (SWAT) versus late (standard care): Proportion of discharged patients who met NEAT

Figure 5Early (SWAT) versus late (standard care): Admissions

Figure 6Early (SWAT) versus late (standard care): Discharged

Emergency Department – Observational evidence

Figure 7Mortality

Figure 8ED length of stay (minutes)

Figure 930 day unscheduled re-admissions

Figure 10Admissions

Figure 11Patients achieving NEAT

Figure 12Discharged patients achieving NEAT

Figure 13Admitted patients achieving NEAT

Figure 14Patients seen within the recommended time

Figure 15Patients who did not wait to be seen

Figure 16Patients who did not wait to be seen

Figure 17Patients who did not wait to be seen

AMU – observational evidence

Figure 18Early versus late (Consultant present versus consultant absent) in AMU: length of stay (days)

Figure 19Early versus late (Consultant present versus consultant absent) in AMU: percent discharged on day of admission

Figure 20Early versus late (Consultant present versus consultant absent) in AMU: percent of patients discharged within 24 hours and readmitted within 1 week for same clinical problem

Figure 21Early versus late (Consultant present versus consultant absent) in AMU :mortality during admission

Appendix D. Clinical evidence tables

Download PDF (560K)

Appendix E. Economic evidence tables

No studies were included.

Appendix F. GRADE tables

Table 10Clinical evidence profile: Early versus late consultant review in ED (SWAT versus standard care control): RCT evidence

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Early (SWAT)	late consultant review (control)	Relative (95% CI)	Absolute	Quality	Importance
Proportion of patients who met NEAT
1	randomised trials	Serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	308/647 (47.6%)	45.6%	RR 1.04 (0.92 to 1.18)	18 more per 1000 (from 36 fewer to 82 more)	⨁⨁⨁◯ MODERATE	IMPORTANT
Proportion of admitted patients who met NEAT
1	randomised trials	Serious¹	no serious inconsistency	no serious indirectness	Serious²	none	56/251 (22.3%)	17.8%	RR 1.26 (0.86 to 1.83)	46 more per 1000 (from 25 fewer to 148 more)	⊕⊕⊝⊝ LOW	IMPORTANT
Proportion of discharged patients who met NEAT
1	randomised trials	Serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	252/396 (63.6%)	62.5%	RR 1.02 (0.91 to 1.14)	12 more per 1000 (from 56 fewer to 87 more)	⨁⨁⨁◯ MODERATE	IMPORTANT
Number of patients admitted
1	randomised trials	Serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	251/647 (38.8%)	37.7%	RR 1.03 (0.89 to 1.19)	11 more per 1000 (from 41 fewer to 72 more)	⨁⨁⨁◯ MODERATE	IMPORTANT
Number of patients discharged
1	randomised trials	Serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	396/647 (61.2%)	62.3%	RR 0.98 (0.9 to 1.08)	12 fewer per 1000 (from 62 fewer to 50 more)	⨁⨁⨁◯ MODERATE	IMPORTANT

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs.

Table 11Clinical evidence profile: Early versus late consultant review in ED: observational evidence

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Early consultant triage	late consultant triage	Relative (95% CI)	Absolute	Quality	Importance
Length of stay (minutes) (Better indicated by lower values)
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	Serious³	none	608	683	-	MD 68.3 lower (84.76 to 51.84 lower)	⨁◯◯◯ VERY LOW	CRITICAL
Mortality
1	observational studies	serious²	no serious inconsistency	no serious indirectness	very serious³	none	2/608 (0.33%)	0.2%	Peto OR 2.20 (0.23, 21.23)	2 more per 1000 (from 2 fewer to 39 more)	⨁◯◯◯ VERY LOW	CRITICAL
30 day unscheduled readmissions
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	Serious³	none	43/608 (7.1%)	9.4%	RR 0.75 (0.52 to 1.09)	23 fewer per 1000 (from 45 fewer to 8 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Admitted
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	153/1057 (14.5%)	42.4%	RR 0.34 (0.28 to 0.41)	280 fewer per 1000 (from 250 fewer to 305 fewer)	⨁◯◯◯ VERY LOW	IMPORTANT
% achieving NEAT
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	-		OR 1.15 (1.07 to 1.24)	140 more per 1000 (from 70 more to 210 more)	⨁◯◯◯ VERY LOW
% achieving NEAT of those discharged
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	Serious³	none	-		OR 1.17 (1.07 to 1.28)	160 more per 1000 (from 70 more to 250 more)	⨁◯◯◯ VERY LOW
% achieving NEAT of those admitted
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	-		OR 1.1 (0.98 to 1.23)	100 more per 1000 (from 20 fewer to 210 more)	⨁◯◯◯ VERY LOW
% seen within recommended waiting times - Harvey 2008
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	Serious³	none	352/608 (57.9%)	46%	RR 1.26 (1.13 to 1.4)	120 more per 1000 (from 60 more to 184 more))	⨁◯◯◯ VERY LOW	IMPORTANT
Did not wait to be seen patients (Harvey 2008)
1	observational studies	serious¹	no serious inconsistency	Serious²	Very serious³	none	11/608 (1.8%)	2.5%	RR 0.73 (0.34-1.54)	7 fewer per 1000 (from 16 fewer to 13 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Did not wait to be seen patients (Asha 2013)
1	observational studies	serious¹	no serious inconsistency	Serious²	Serious³	none	-		OR 0.72 (0.58 to 0.89)	330 fewer (from 540 fewer to 110 fewer)	⨁◯◯◯ VERY LOW
Did not wait to be seen patients (Shetty 2012)
1	observational studies	serious¹	no serious inconsistency	Serious²	no serious imprecision	none	1137/11845 (9.6%)	10.7%	RR 0.9 (0.83 to 0.97)	11 fewer per 1000 (from 3 fewer to 18 fewer)	⨁◯◯◯ VERY LOW

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 2 increments if other factors suggest additional very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs.

Table 12Clinical evidence profile: Early versus late consultant review in AMU (consultant present versus consultant absent): cohort study evidence

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Early (Consultant present)	Late (Consultant absent)	Relative (95% CI)	Absolute	Quality	Importance
Length of stay - Days (Better indicated by lower values)
1	observational studies	Serious¹	no serious inconsistency	Serious²	no serious imprecision	none	2064	864	-	MD 1.34 lower (2.67 to 0.01 lower)	⨁◯◯◯ VERY LOW	CRITICAL
% discharged on day of admission
1	observational studies	Serious¹	no serious inconsistency	Serious²	Serious³	none	664/2064 (32.2%)	23.0%	RR 1.4 (1.22-1.6)	129 more per 1000 (from 71 more to 193 more)	⨁◯◯◯ VERY LOW	IMPORTANT
% patients discharged within 24 hours and readmitted within 1 week for same clinical problem
1	observational studies	Serious¹	no serious inconsistency	Serious²	very serious³	none	37/2064 (1.8%)	1.5%	RR 1.19 (0.64 to 2.23)	3 more per 1000 (from 5 fewer to 18 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Mortality during admission
1	observational studies	Serious¹	no serious inconsistency	Serious²	Serious³	none	194/2064 (9.4%)	10.1%	RR 0.93 (0.73 to 1.19)	7 fewer per 1000 (from 27 fewer to 19 more)	⨁◯◯◯ VERY LOW	CRITICAL

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: The evidence is indirect as the exact time of consultant review was not reported.
3: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs.

Appendix G. Excluded clinical studies

Table 13Studies excluded from the clinical review

Study	Exclusion reason
ADAMS 2005³	Incorrect setting and population (in-hospital cardiac arrests occurring hospital-wide).
ADIGUEZL 2015⁴	Incorrect comparison (pulmonary specialist versus intensivist).
AGA 2012⁵	Incorrect setting (surgical care).
AGRAWAL 2009⁶	Incorrect setting (general surgery).
AHMED 2010⁷	Incorrect setting (outpatient clinic).
ALI 2010⁸	Before and after study. Time to consultant review not measured. Insufficient data provided to make a comparison.
ANDERSON 1988¹⁰	Time to consultant review not measured. No outcomes of interest.
ANDERSON 2013⁹	Time to consultant review not measured. Observational study set in USA.
ANGUS 2000¹¹	Does not fit protocol. Observational study set in USA.
ANON 2005¹	Incorrect intervention. Summary paper only.
AUDIT 1996¹³	Contains no relevant outcome data.
BARNES 2011¹⁴	Incorrect setting (head and neck surgery).
BEIRI 2006¹⁵	Incorrect setting (orthopaedic and trauma surgery).
BELL 2013¹⁶	No data reported.
BEWICK 2009¹⁷	Incorrect comparison (generalist versus specialist).
BRAY 2013¹⁹	Does not fit with current practice
BLUNT 2000¹⁸	Incorrect comparison (intensivist versus non-specialist).
BRODIE 2012²⁰	Review paper checked for references.
BROWN 1989²¹	Incorrect comparison (consultant versus critical care specialist).
CADTH 2014²²	Review paper checked for references
CALDER 1998²³	Incorrect setting (surgical care).
CAPP 2012²⁴	No outcomes of interest.
CARBERRY 2006²⁵	Narrative paper.
CARIGA 2011²⁶	Incorrect setting (neurology clinic).
CARROLL 2004²⁷	Incorrect setting (neurology).
CASALINO 2014²⁸	Incorrect comparison (specialist advice versus no specialist advice).
CHA 2009²⁹	Incorrect intervention.
CHEN 2015A ³⁰	Incorrect intervention with no extractable outcomes
CHRISTMAS 2005³¹	Incorrect setting (trauma service).
CLARKE 2005³³	Diagnosis of role players.
COHEE 2014³⁴	Incorrect setting (inpatient internal medical wards).
COHEN 1993³⁵	Time to consultant review not measured. Observational study published < 2005.
COOKE 1996³⁶	Narrative/letter to editor.
COOKE 1998³⁷	Review paper checked for references.
CAPP 2012²⁴	No outcomes of interest
CUTLER 2003³⁸	Qualitative review.
DALE 1995³⁹	Time to consultant review not measured. Observational study published < 2005.
DAOUST 2014⁴⁰	Incorrect intervention.
DAY 2005⁴²	Narrative.
DENMANJOHNSON 1997⁴³	Time to consultant review not measured. Observational study published < 2005 and n<200.
DHRAMPAL 2010⁴⁴	Conference abstract
EDKINS 2014⁴⁵	Review paper checked for references.
EDWARDS 2011⁴⁶	Incorrect intervention (registered nurse in triage team)
ELGAYLANI 1997⁴⁷	Incorrect setting (chest pain clinic).
ELMSTAHL 1999⁴⁸	Observational study published < 2005.
EVANS 2011⁴⁹	Time to consultant review not measured.
FISHER 1994⁵¹	No outcomes of interest. Incorrect setting: otolaryngology unit.
FITZPATRICK 2006B⁵²	Incorrect population (trauma patients).
FOSTER 2006⁵³	Incorrect setting (oncology referrals).
GAMBIER 2012⁵⁴	Incorrect setting – internal medicine department. Timing of consultant review not measured.
GARLAND 2012⁵⁵	Incorrect comparison (consultant present versus consultant on call)
GARNER 2006⁵⁶	Incorrect setting (surgery).
GASKELL 1995⁵⁷	Incorrect setting (general surgical ward).
GERSHENGORN 2011⁵⁸	Incorrect comparison (nurses/physicians assistant’s versus junior doctors).
GIBBS 2001⁵⁹	No outcomes of interest.
GILLIGAN 2008⁶⁰	Incorrect setting (hospital-wide).
GLASSER 2009⁶¹	Incorrect setting (military medical centre).
GOMEZ 1996⁶²	Unclear which health professionals delivered intervention.
GOMEZ-SOTO 2008⁶³	Incorrect setting (internal medicine and family medicine).
GULLI 2014⁶⁴	No outcomes of interest.
HALFDANARSON 2006⁶⁵	Narrative.
HARRISON 2007⁶⁶	Narrative.
HELLAWELL 2005⁶⁸	Time to consultant review not linked to outcomes.
HELLING 2010A⁶⁹	Incorrect setting (trauma centres).
HOFFMAN 2003⁷¹	No outcomes of interest.
HOFFMAN 2005⁷²	Incorrect comparison (consultants present in both interventions).
HOFFMAN 2006⁷⁰	Incorrect comparison (consultants present in both interventions).
HOLZMAN 1994⁷³	Incorrect setting (surgery)
HOPKINS 2014⁷⁴	Time to consultant review not measured.
HORWITZ 2007⁷⁵	Time to consultant review not measured. Observational study set in USA.
IMPERATO 2012⁷⁶	Before and after study set in USA.
JEUNE 2013⁷⁸	Time to consultant review not linked to outcomes.
JIMENEZ 2003⁷⁹	Not a comparative study
JOHANSSON 2001⁸⁰	Does not match protocol
JOHNSTONE 2015 ⁸¹	Incorrect population
JUNG 2016 ⁸²	Incorrect intervention
KAPUR 1999⁸³	Time to consultant review not measured.
KAWAR 2011⁸⁴	Incorrect intervention.
KENDRICK 2006⁸⁵	No outcomes of interest.
KENNELLY 2014⁸⁶	No outcomes of interest
KENT 2011⁸⁷	Incorrect intervention.
KERR 2010⁸⁸	No outcomes of interest.
KHADJOOI 2009⁸⁹	Not a comparative study.
KIRTON 2007⁹⁰	No outcomes of interest.
KMIETOWICZ 2007⁹¹	News article checked for references.
LAINE 1993⁹²	Time to consultant review not measured.
LAL 2000⁹³	Time to consultant review not measured.
LAMMERS 2003⁹⁴	Time to consultant review not measured.
LANGHORNE 1995⁹⁵	Meta-analysis comparing stroke units to normal wards. Time to consultant review not measured.
LAUPLAND 2010⁹⁶	Time to consultant review not measured.
LAURENS 2011⁹⁷	Incorrect setting (hospital-wide intervention).
LEVY 2013⁹⁸	Narrative paper.
LEWIS 1988⁹⁹	Timing of consultant review not reported.
LILLY 2014¹⁰⁰	Incorrect intervention (telemedicine).
LONDERO 2014¹⁰¹	Time to consultant review not linked to outcomes.
LONGSWORTH 1990¹⁰²	Time to consultant review not linked to outcomes.
MAGIN 2013¹⁰³	Incorrect setting (secondary referral clinic).
MAHMOOD 2009¹⁰⁴	Time to consultant review not linked to outcomes.
MANAWADU 2014A¹⁰⁵	Incorrect population (in-hospital stroke).
MARRIOTT 2003¹⁰⁶	Time to consultant review not measured.
MARTIN 1997¹⁰⁸	No outcomes of interest.
MCMANUS 2002¹⁰⁹	Review paper checked for references.
MEYER 2005¹¹¹	Incorrect intervention.
MEYNAAR 2009¹¹²	Incorrect intervention (intensivists versus junior doctors).
MIRZA 2013¹¹³	Incorrect setting (ENT clinic).
MORRIS 2009¹¹⁴	Time to consultant review not measured.
MULLEN 2009¹¹⁵	Conference abstract
MUNRO 2006¹¹⁶	Poor quality data source (survey)
MURPHY 1996¹¹⁷	Unclear intervention.
MURRELL 2011¹¹⁸	Observational study set in USA.
NCEPOD 2007¹⁰⁷	Time to consultant review not linked to outcomes.
NEWBY 1998¹¹⁹	Incorrect setting (chest pain clinic).
O’CONNOR 1996A¹²⁰	Incorrect population (trauma patients).
O’KEEFFE 2012¹²¹	Incorrect populations (‘did not wait’ patients).
PATEL 2014¹²²	Time to consultant review not measured.
POURMAND 2013¹²³	Incorrect comparison (junior doctors with input from consultant versus junior doctors alone).
RAFMAN 2013¹²⁴	Observational study set in Singapore
REDMOND 1993¹²⁵	Short article, insufficient information.
ROTHEN 2007¹²⁶	Time to consultant review not measured.
ROTHWELL 2007¹²⁷	Incorrect intervention (referral to outpatient clinic).
SAKR 2015¹²⁸	Timing of consultant review not measured.
SALAZAR 2001¹²⁹	Observational study published < 2005
SCHULTZ 2013¹³⁰	Time to consultant review not linked to outcomes.
SECOR 1983¹³¹	Does not match protocol
SHOWKATHALI 2013¹³³	Incorrect setting (cardiothoracic centre). Time to consultant review not measured.
SILBER 2009¹³⁴	Time to consultant review not measured. Observational study set in USA.
SOONG 2013¹³⁵	Incorrect intervention.
SPIGOS 1996¹³⁶	Observational study set in USA and published <2005.
STEVENS 2001¹³⁷	Time to consultant review not measured.
SVIRSKY 2013¹³⁸	Incorrect intervention (early triage by junior doctors).
TING 1991¹³⁹	Observational study set in USA and published <2005.
TRAUB 2015¹⁴⁰	Observational study set in USA.
TRAVERS 2006¹⁴¹	Non-randomised study set in Singapore.
VAGHASIYA 2014¹⁴²	No outcomes of interest.
VOLPP 2007¹⁴³	Observational study set in USA.
VOLPP 2009¹⁴⁴	Observational study set in USA.
VOLPP 2013¹⁴⁵	Observational study set in USA.
VOSK 1998¹⁴⁶	No outcomes of interest.
WALLS 2009¹⁴⁷	No outcomes of interest.
WANKLYN 1997¹⁴⁸	Incorrect comparison (SHOs and registrars).
WARD 2009¹⁴⁹	Does not link consultant working patterns to clinical outcomes.
WARD 2013¹⁵⁰	Does not match protocol
WILCOX 2013¹⁵²	Incorrect comparison (high versus low intensity staffing).
WILCOX 2014¹⁵³	Timing of consultant review not measured.
WOODS 2008¹⁵⁴	No outcomes of interest.

Appendix H. Excluded economic studies

No studies were excluded.

Bookshelf ID: NBK564900

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.) Chapter 19, Early versus late consultant review.
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Emergency and acute medical care in over 16s: service delivery and organisation.

Chapter 19Early versus late consultant review

19. Early versus late consultant review

19.1. Introduction

19.2. Review questions

Is early consultant triage in the ED (Rapid Assessment and Treatment (RAT) model) more clinically and cost effective than later consultant review?

Is early consultant review in the AMU, ICU, HDU, CCU or Stroke Unit more clinically and cost effective than later consultant review?

19.3. Clinical evidence

19.3.1. Other outcomes that could not be analysed in Revman

19.3.2. Clinical investigations

19.3.3. Unplanned readmissions

19.3.4. Admissions

19.4. Economic evidence

Published literature

New cost-effectiveness analysis

19.5. Evidence statements

Clinical

Emergency departments

Acute medical units

Economic

19.6. Recommendations and link to evidence

References

Appendices

Appendix A. Review protocols

Table 9Review protocol: Early versus late consultant review

Appendix B. Clinical article selection

Figure 1Clinical article selection

Appendix C. Forest plots

Emergency Department – RCT evidence

Figure 2Early (SWAT) versus late (standard care): Proportion of patients who met NEAT

Figure 3Early (SWAT) versus late (standard care): Proportion of admitted patients who met NEAT

Figure 4Early (SWAT) versus late (standard care): Proportion of discharged patients who met NEAT

Figure 5Early (SWAT) versus late (standard care): Admissions

Figure 6Early (SWAT) versus late (standard care): Discharged

Emergency Department – Observational evidence

Figure 7Mortality

Figure 8ED length of stay (minutes)

Figure 930 day unscheduled re-admissions

Figure 10Admissions

Figure 11Patients achieving NEAT

Figure 12Discharged patients achieving NEAT

Figure 13Admitted patients achieving NEAT

Figure 14Patients seen within the recommended time

Figure 15Patients who did not wait to be seen

Figure 16Patients who did not wait to be seen

Figure 17Patients who did not wait to be seen

AMU – observational evidence

Figure 18Early versus late (Consultant present versus consultant absent) in AMU: length of stay (days)

Figure 19Early versus late (Consultant present versus consultant absent) in AMU: percent discharged on day of admission

Figure 20Early versus late (Consultant present versus consultant absent) in AMU: percent of patients discharged within 24 hours and readmitted within 1 week for same clinical problem

Figure 21Early versus late (Consultant present versus consultant absent) in AMU :mortality during admission

Appendix D. Clinical evidence tables

Appendix E. Economic evidence tables

Appendix F. GRADE tables

Table 10Clinical evidence profile: Early versus late consultant review in ED (SWAT versus standard care control): RCT evidence

Table 11Clinical evidence profile: Early versus late consultant review in ED: observational evidence

Table 12Clinical evidence profile: Early versus late consultant review in AMU (consultant present versus consultant absent): cohort study evidence

Appendix G. Excluded clinical studies

Table 13Studies excluded from the clinical review

Appendix H. Excluded economic studies

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