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| A systematic review of dedicated models of care for emergency urological patients |
Ned Kinneara,*( ),Matheesha Herathb,Dylan Barnettb,Derek Hennesseyc,Christopher Dobbinsa,Tarik Sammoura,b,James Moorea,b
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a Discipline of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
b Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
c Department of Urology, Mercy University Hospital, Cork, Ireland |
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Abstract Objective: To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients (EUPs).
Methods: A search of Cochrane, Embase, Medline and grey literature from January 1, 2000 to March 26, 2019 was performed using methods pre-published on PROSPERO. Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines. Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs, which reported at least one secondary outcome. Studies were excluded if they examined pathways dedicated only to single presentations, such as torsion, or outpatient solutions, such as rapid access clinics. The primary outcome was the spectrum of models. Secondary outcomes were time-to-theatre, length of stay, complications and cost.
Results: Seven studies were identified, totalling 487 patients. Six studies were conference abstracts, while one study was of full-text length but published in grey literature. Four distinct models were described. These included consultant urologists allocated solely to the care of EUPs (“Acute Urological Unit”) or dedicated registrars or operating theatres (“Hybrid structures”). In some services, EUPs bypassed emergency department assessment and were referred directly to urology (“Urological Assessment Unit”) or were managed by other dedicated means. Allocating services to EUPs was associated with reduced time-to-theatre, length of stay and hospital cost, and improved supervision of junior medical staff.
Conclusion: Multiple dedicated models of care exist for EUPs. Low-level evidence suggests these may improve outcomes for patients, staff and hospitals. Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.
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Received: 24 August 2019
Available online: 26 June 2020
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Corresponding Authors:
Ned Kinnear
E-mail: ned.kinnear@gmail.com
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Preferred reporting items for systematic reviews and meta-analyses flow diagram.
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| Year | First author | Country | EUP cohort | Design | Care structure | Enrolment (month) | Patients (n) | Demo-graphics | TTT (h) | LOS (day) | Cost | Other result | Throughput (n/week) | | Trad. | Interv. | Trad. | Interv. | Trad. | Interv. | | 2012 2015 | Russell [23] Russell [30] | UK | Admitted | Prosp. | -Registrar-delivered ward service | -Consultant-delivered ward service | 12 | 12 | - | - | - | - | Δ 4.6 to 2.1 | £502 000 saving p.a. | - | - | | 2015 | Nican [24] | Ireland | ED | Prosp. | -ED reviews all surgical patients | -SAU reviews all surgical patients | - | 4 | - | 101 | NA | - | 2 † | - | - | 6 | | 2015 | Tharakan [25] | UK | Admitted | Retro. | -Urology registrar on-site until 8 p.m. | -Urology registrar on-site until 10 p.m. | 1 | 1 | - | 77 | - | - | - | - | ‡ | 6 | | 2016 | Raza [26] | UK | Surgery | Retro. | -Registrar has all-day elective duties | -Registrar is rostered all-day solely to EUPs | 1 | 1 | 50 | 73 | - | Δ 7 to 3 | Same § | - | || | 14 | | 2017 | Golda [27] | Canada | ED | Retro. | -Consultant & theatre rostered all day to elective duties | -A consultant rostered solely to EUPs, & 3 half-day EUP theatre lists/week | - | - | - | - | - | - | - | ¶ | †† | - | | 2017 | Narra [28] | Australia | Surgery | Prosp. | -No dedicated EUP theatre lists | -2 half-day EUP theatre lists/week | - | 8 | - | 70 | NA | - | - | - | ‡‡ | 2 | | 2018 | Hegazy [29] | Ireland | Urolithiasis | Prosp. | -No EUP pathways & limited emergency theatre capacity | -Specified EUP pathways & increased emergency theatre capacity | 2 ∫ | 2 ∫ | 58 ∫ | 58 ∫ | - | Δ 56 to 13 | Δ 5.2 to 2.8 | - | - | 7 |
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Eligible studies.
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| Year & first author | Selection | Comparability | Outcome | Total quality scores | | Representative-ness of the exposed cohort | Selection of the non-exposed cohort | Ascertainment of exposure | Demonstration that outcome of interest was not present at start of study | Comparability of cohorts on the basis of the design or analysis | Assessment of outcome | Was follow-up long enough for outcomes to occur? | Adequacy of follow up of cohorts | | 2012 Russell, et al [23] | * | * | - | NA | - | - | NA | NA | 2 | | 2015 Russell, et al [30] | * | * | - | NA | - | - | NA | NA | - | | 2015 Tharakan, et al [25] | * | - | * | NA | - | * | NA | NA | 3 | | 2016 Raza, et al [26] | * | * | * | NA | - | * | NA | NA | 4 | | 2017 Golda, et al [27] | - | - | - | NA | - | - | NA | NA | 0 | | 2018 Hegazy, et al [29] | * | * | - | NA | - | - | NA | NA | 2 |
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Assessing risk of bias amongst comparative cohort studies. Newcastle-Ottawa Quality Assessment Scale.
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| Year & first author | Study objective | Study population | Intervention (s) | Outcome measure | Statistical analysis | Results and conclusions | Competing interests | Total score | | Cr 1 | Cr 2 | Cr 3 | Cr 4 | Cr 5 | Cr 6 | Cr 7 | Cr 8 | Cr 9 | Cr 10 | Cr 11 | Cr 12 | Cr 13 | Cr 14 | Cr 15 | Cr 16 | Cr 17 | Cr 18 | | 2015 Nic an Riogh, et al [24] | * | * | - | * | * | * | * | NA | * | * | NA | - | NA | - | - | - | - | - | 8 | | 2017 Narra, et al [28] | * | - | - | * | * | - | * | NA | - | * | NA | - | NA | - | - | - | - | - | 6 |
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Assessing risk of bias amongst non-comparative cases series. Modified Delphi criteria checklist.
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