The Impact of Pandemic-Driven Care Redesign on Hospital Efficiency

Figures & data

Figure 1 Flow diagram of systematic review.

Table 1 Summary of Empirical Research on Hospital Care Redesign and Transformation

No	Year, country	Authors, year, link	Intervention Objectives	Study Design	Unit Of Analysis (Project Sample Size), Study Sample Size	Intervention components
1	2022, Russia	Kulikova and Moskvina (2022)^Citation37	To determine the optimal organizational structure of the ambulance service in Russian regions	Before-and-after study	Ambulance units aggregated by regions	A Unified Dispatch Service was organized in one group of regions, while a complete merger of ambulance units into a single legal entity occurred in another group.
2	2021, Spain	Bernabeu-Wittel et al (2021)^Citation38	To improve survival, offering humanistic palliative care to residents in their home environment, and reducing hospital referrals	Before-and-after study	Hospital (Nursing home); Before medicalisation program (MP) (n=149) and During MP (n=123)	An informatics infrastructure, medical equipment, and human resources, universal testing, separation of ‘clean’ and ‘contaminated’ areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach were provided.
3	2023, Australia	Laurie et al (2023)^Citation39	To develop, implement, and evaluate a digital model of maternal and neonatal care	Prospective before-and-after study	A quaternary center; pre-implementation (n=598) and post-implementation (n=337)	Six culturally and linguistically tailored educational videos, home delivery of equipment and prescriptions, and a smartphone app-to-clinician portal for glycaemic review and management were introduced. ‘The novel model of care included: (1) initial midwife phone call informing patient of the diagnosis of GDM at 24–28 weeks gestation and on the same day; (2) delivery via email of the link to a GDM education video and registration for use of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) M♡THer app; (3) a Bluetooth capable blood glucose meter was couriered to the patient’s home address (at the hospital’s expense) along with National Diabetes Support Scheme (NDSS) registration forms, with planned delivery within 48 h of initial phone contact; (4) a face-to-face dual appointment with the CDE midwife and dietitian was scheduled for day seven and day 14 post-diagnosis (attendance rate was 95%), and (5)if required, a face-to-face insulin education appointment was arranged.’
4	2023, Germany	Leupold et al (2023)^Citation40	The redesign of hypertension management using ICT to improve hypertension control	Interventional study with control group	47 practices and 525 patients (intervention 265; control 260)	Transmission of blood pressure (BP) measurements to a central webspace, etc. ‘PIA is a complex intervention comprising two elements: the PIA-ICT (PIA app and PIA-PrMC) and the PIA education (eLearning/on-site training for practice teams and patients). The following features characterize the electronic PIA intervention: 1.PIA communication: Highly secure communication between patients (PIA app) and practices (PIA-PrMC): a.PIA app for patients: transmission of BP measurements, graphic display of BP over time with individual target range, medication plan, ordering of prescription refills, video education and links to BP related information; b.PIA-PrMC with delegation model: recall and step-wise medication adjustments, predefined and guideline-oriented algorithms for medication regimens, graphic display of BP over time with individual target range, electronic transmission of medication plan to PIA app, predefined process with colour scheme for delegation to PrAs, option to export data from the PIA-PrMC to the EHR for documentation. 2.PIA medication plan transfer: electronic transmission from the EHR to the PIA-PrMC and the PIA app; 3.PIA medication safety: the GP signs each medication plan electronically (required by German law as PrAs have no prescribing privileges); 4.PIA eLearning for GPs and PrAs: videos present evidence-based information on hypertension management including medication classes, how to use the PIA-PrMC and the PIA app, how to obtain valid BP measurements in the practice and at home, and the study details. PrAs complete a short, written exam to qualify as a PIA-PrA.’
5	2022, US	Lindsay and Lytle (2022)^Citation41	To redesign standardized flowsheet documentation workflow	Before-and-after study	Nurses (n=5360)	Standards for usability modifications targeting efficiency, reducing redundancy, and improving workflow navigation were implemented.
6	2022, US	Larsen et al (2022)^Citation42	To optimize workflow of a hospital’s lab operations	Before-and-after study	Hospital; Pre intervention (n = 52); post intervention (n=20)	(1) An existing but underused project submission form was enhanced. (2) An internal project scorecard to standardize the evaluation of requests was designed and implemented. (3) The responsibility of submission evaluation across lab members was distributed.
7	2022, US	Parodi, Feeley, and Sanchez (2022)^Citation43	To assess the impact on readmission rates for CMS core measures (CCM) patients and patients receiving care under the Bundled Payment for Care Improvement (BPCI) Advanced Model	Interventional study with control group	Intervention (n=1416 patients), control (n=1203 patients)	A pharmacist-led transitions of care clinic was implemented.
8	2020, China	Song et al (2020)^Citation44	To evaluate the effect of the optimization of the intravenous infusion workflow in isolation wards for patients with COVID-19	Before-and-after study	30 patients	(1) A special, hygienic medical-order-processing and drug-dispensing area near the isolation area was set up. (2) A medical-order processing to the hygienic area outside of the isolation area was relocated, where nurses do not need to wear a full set of PPE. (3) An intravenous admixture was relocated to the hygienic area outside of the isolation area. Nurses in this area do not need to wear PPE.
9	2022, US	Rock et al (2022)^Citation45	To reduce unnecessary Clostridioides difficile testing	Before-and-after study	9 academic and 6 community hospitals	Computerized clinical decision support (CCDS) systems (hard stop or soft stop) was implemented in the EHR.
10	2021, US	Horn, Doucette and Sweeney (2021)^Citation46	To improve the nursing documentation efficiencies and satisfaction of a pediatric admission history workflow	Before-and-after study	Non-profit, free-standing pediatric organization that has outpatient and acute care locations (3347 pediatric admission history forms from 90 days before and 4337 pediatric admission history forms from 90 days after the study intervention; survey with 50 pre-intervention responses and 47 post-intervention responses)	A pediatric essential clinical dataset (ECD) tool was implemented.
11	2020, China	Chen et al (2022)^Citation47	To shorten door-to-needle time (DNT) at a hospital via multidisciplinary and workflow optimisation in the prehospital, in-hospital, and feedback stages	Interventional study with control group	An 898-bed tertiary hospital; n=128 and n=135 patients receiving treatment in the pre-intervention and post-intervention, respectively	‘(1) Engaging the Hospital chief in the study to facilitate improving DNT. (2) Hospital notification via the establishment of a secure web communication platform (ie, WeChat, a Chinese messaging and social app) - hospital providers acquire patient history from family members while at the same time informing patients and their families regarding thrombolysis treatment benefits and risks. (3) Ensuring suspected stroke patients are prioritized for evaluation by an emergency room nurse and physician. (4) Monthly training to stroke and emergency nurses to promptly recognize stroke symptoms and signs, as well as education regarding the therapeutic window for acute stroke patients, by neurologists. (5) Monthly training to emergency room physicians to recognize symptoms and signs of stroke by neurologists. (6) Notifying relevant stroke teams, including emergency healthcare, via a prenotification service before performing head CT scans. (7) Prioritizing CT scan and transfer to radiology. (8) Prioritizing relevant laboratory examination results, especially International Normalized Ratio (INR) for patients prescribed anticoagulants. (9) Facilitating interpretation of head CT by stroke team physicians without requiring formal radiology reports (radiology reports can be given priority in certain circumstances). (10) Training physicians to effectively communicate propositions for thrombolysis with promptly signed informed consent from patients or their families undergoing thrombolysis (family members were allowed to enter the emergency department during the COVID-19 pandemic to sign consent forms). (11) Training nurses to prepare IV rtPA quickly and effectively. (12) Encouraging neurologists to provide immediate feedback if DNT is delayed. (13) Inviting the Hospital chief, along with the staff of neurology, radiology, and emergency departments, to attend monthly stroke meetings to analyze the etiology of DNT-delayed cases. (14) Rewarding associated staff of emergency, neurology, and radiology departments financially if DNT was less than or equal to 60 min. (15) Connecting with the regional Health Bureau and media department of the hospital to raise awareness and public education of acute stroke. (16) Reinforcing standard procedures for acute stroke management after the post-intervention period to achieve a sustainable patient outcome.’

Notes: Intervention types include (1) changes in process sequences or changes in the organization of processes, (2) changes in physical structure, facilities or equipment, (3) revision of professional roles / skill mix changes, (4) change in the setting / site of service delivery, (5) personnel organization, (6) changes incapacity planning, (7) case management, (8) communication and case discussion with off-site health professionals or cooperation with external services, (9) introduction of multidisciplinary teams, (10) introduction of quality-monitoring mechanisms, (11) changes in medical record systems, (12) integration of services or continuity of care programs. All other categories represent combinations of these interventions. Study types included: (1) before-and-after study and (2) interventional study with a control group. An interventional study tests (or tries out) an intervention – a potential drug, medical device, activity, or procedure – in people. It is also commonly referred to as a clinical trial.⁴⁸ A distinguishing characteristic of an intervention study is that the intervention (the preventative or therapeutic measure) being tested is allocated by the investigator to a group of two or more study subjects (individuals, households, communities). Subjects are followed prospectively to compare the intervention vs. the control. (standard treatment, no treatment or placebo).⁴⁹ A before-and-after study measures differences within a single group before and after an intervention. Unlike a randomized controlled trial, this type of study cannot provide definitive evidence that the intervention caused the differences seen in the study.⁵⁰ Originated back in the 1960s, a term “clinical decision support system” (CDSS) is currently defined as a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.⁵¹ A CDSS consists of three elements: (a) data from patients and from their respective environments; (b) algorithm for generating reports out of the data; and (c) reports. A report is a suggestion of further diagnostic examinations, a therapeutic plan to the operators (ie, physicians or nurses) as a suggestion to be considered for their actual diagnostic or therapeutic decision. In addition, a CDSS can incorporate a reiteration process, consisting in further monitoring of the patient, for example, once the therapy has been started to register the patients response to treatment. A new application of algorithms enables further reporting.⁵²

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