57 Interventions to relieve ED crowding by older adults CHAPTER 3 an intervention within a single institution. Study findings may be difficult to compare because of differences in the organizational structure (e.g., access or systems for referral and follow-up of patients), work routines, bed-capacity and the geographical location of studied ED sites. Also, it is possible that interventions’ measured effects in reducing ED revisits were underestimated in single-institution studies if older adults shifted their visits to other ED sites. Fourth, overall risk of bias was high in most of the included studies. In several studies the reliability of outcome effects may be negatively affected by patient’s self-reported ED revisits. Therefore, individual study findings need to be interpreted with caution. Fifth, we performed an additional search in three specific journals to broaden our search for relevant publications on the abstract phenomenon of crowding. However, using this journal-specific search strategy may have introduced bias in the selection of studies. Finally, we did not include studies published outside of the peer-reviewed scientific literature. Publication bias may have affected our results. Conclusion Given the global aging population and its impact on the growing problem of ED crowding, there is an urgent need to focus future research on intervention studies aimed at improving the organization and efficiency of care for older adults in the ED. The rapid assessment of older patients and streaming of care based on time-efficiency goals, and an ED-based consultant geriatrician seem to be promising strategies for alleviating ED crowding by this specific patient group. Ultimately, this must lead to better quality of care and better health outcomes for older patients in the ED. However, the poor methodological quality, the differences in intervention types and used outcome effects, and the validity of used outcome measures hinder the demonstration of robust evidence to support these interventions. Our hope is that this systematic review will act as a stimulus for conducting more high-quality experimental research on reducing ED crowding by older adults, using uniform and valid effect measures to ensure generalisability in the evaluation of the true effectiveness of interventions.
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