Abstract
Background: Worldwide health care providers are facing an epidemic of ageing patients, contributing to an increased demand for hospital beds to treat those with increasingly complex and chronic conditions. This results in an increased demand for services. Wards are often divided by speciality with highly trained staff who are knowledgeable of the conditions they are treating, trained to detect minute changes and initiate treatment before deterioration. If emergency departments are full or crowded and need to admit patients to wards, which are also full, patients may be directly admitted or other patients moved, and be treated on a ward where they were not intended to be placed, with staff who may be unfamiliar with their condition. These patients are known as outliers. Outliers are treated under the intended medical team, however, in a different area of the hospital often with staff unfamiliar with their care requirements. In contrast inliers are patients placed on the intended ward with intended health care teams to provide treatment.
Objectives/research question: The purpose of this integrative literature review was to explore the literature in relation to the practice of outlying and to assess if outlying a patient from their intended home ward and specialists influenced patient outcomes and resulted in detrimental patient outcomes. Therefore, this led to the development of the research question: what is the impact on the health outcomes of inpatients who are treated as outliers throughout their hospital stay, compared with those treated on their intended admission space as inliers?
Methods: An integrative literature review was selected as the most appropriate research approach to address the research question. The benefit of selecting this process is the organised pattern to thoroughly assess the available evidence resulting in an analytic summary of any findings, across numerous types of research studies. This contrasts with a systematic literature review which was not appropriate due to the variation of research methodologies. Joanna Briggs Institute (JBI) tools were used to critically assess research for inclusion, before progressing onto data extraction and synthesis for thematic analysis using Braun and Clarke's (2006) approach. This process led to the development of three themes relating to the process of outlying which has been presented in a narrative format.
Findings: A total of 12 studies were included in the review and three themes arose from the thematic analysis. These were: potential failure of care, specialisation and the impact on outliers, and risk to patients and health care providers.
Conclusion: Recommendations included; ensuring the patient is fit to outlie, completing medical reviews of outliers prior to inlier patients, ensuring proper communication channels and documentation to be confirmed prior to outlying to ensure the outlying team can communicate with the admitting specialists, and be contacted if advice on management or review is needed throughout the outlying period. The development of pre-agreed wards to accept outliers is also recommended as this could increase the knowledge and confidence of staff when treating outliers not commonly seen in their department. Due to current future ageing predictions and the research gap in relation to outlying, future research is essential to consider the impact outlying will have on this elderly population with potential for multiple comorbidities complicating treatment.