title: Effectiveness and safety of short-stay units in the emergency department: a systematic review.
abstract: OBJECTIVE
  Overcrowding is a serious and ongoing challenge in Canadian hospital emergency departments (EDs) that has been shown to have negative consequences for patient outcomes. The American College of Emergency Physicians recommends observation/short-stay units as a possible solution to alleviate this problem. However, the most recent systematic review assessing short-stay units shows that there is limited synthesized evidence to support this recommendation; it is over a decade old and has important methodologic limitations. The aim of this study was to conduct a more methodologically rigorous systematic review to update the evidence on the effectiveness and safety of short-stay units, compared with usual care, on hospital and patient outcomes.
  
  
  METHODS
  A literature search was conducted using MEDLINE, the Cochrane Library, Embase, ABI/INFOM, and EconLit databases and gray literature sources. Randomized controlled trials of ED short-stay units (stay of 72 hours or less) were compared with usual care (i.e., not provided in a short-stay unit), for adult patients. Risk-of-bias assessments were conducted. Important decision-making (gradable) outcomes were patient outcomes, quality of care, utilization of and access to services, resource use, health system-related outcomes, economic outcomes, and adverse events.
  
  
  RESULTS
  Ten reports of five studies were included, all of which compared short-stay units with inpatient care. Studies had small sample sizes and were collectively at a moderate risk of bias. Most outcomes were only reported by one study and the remaining outcomes were reported by two to four studies. No deaths were reported. Three of the four included studies reporting length of stay found a significant reduction among short-stay unit patients, and one of the two studies reporting readmission rates found a significantly lower rate for short-stay unit patients. All four economic evaluations indicated that short-stay units were a cost-saving intervention compared to inpatient care from both hospital and health care system perspectives. Results were mixed for outcomes related to quality of care and patient satisfaction.
  
  
  CONCLUSIONS
  Insufficient evidence exists to make conclusions regarding the effectiveness and safety of short-stay units, compared with inpatient care.
authors.affiliation: Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Galipeau
authors.affiliation: Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: Kusala
authors.initials: K
authors.lastname: Pussegoda
authors.affiliation: Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: Adrienne
authors.initials: A
authors.lastname: Stevens
authors.affiliation: The Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Jamie C
authors.initials: JC
authors.lastname: Brehaut
authors.affiliation: IWK Health Centre, Halifax, Nova Scotia.
authors.forename: Janet
authors.initials: J
authors.lastname: Curran
authors.affiliation: Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.|The Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Forster
authors.affiliation: The Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Tierney
authors.affiliation: The Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.|The Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: Edmund S H
authors.initials: ES
authors.lastname: Kwok
authors.affiliation: The Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: James R
authors.initials: JR
authors.lastname: Worthington
authors.affiliation: Queen Elizabeth II Health Science Centre, Halifax, Nova Scotia, Canada.
authors.forename: Samuel G
authors.initials: SG
authors.lastname: Campbell
authors.affiliation: Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.|The Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Moher
mesh_terms: D002170:Canada; D003441:Crowding; D004636:Emergency Service, Hospital / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D061214:Patient Safety; D011787:Quality of Health Care; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome