Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. 

Among 17 included articles, three intervention categories were identified: case management (n = 12), individualised care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualised care plans examined ED utilisation and found no change in median ED visits post-intervention.

Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient.

The authors conclude that the impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. They go on to say that future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.

This is an open access article and is available to read in free full text at:  http://dx.doi.org/10.1371/journal.pone.0123660

Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM (2015). Reducing frequent visits to the emergency department: A systematic review of interventions. PLoS ONE 10(4): e0123660.

This retrospective analysis reports on an evaluation of the TQC's effect on achieving the National Emergency Access Target and associated safety and quality indicators.

Based on the results of the study, the authors conclude that "TQC resulted in improvement in timeliness of care for emergency patients without compromising safety and quality. Success is attributed to effective engagement of stakeholders with a hospital-wide approach to redesigning the care pathway and establishing a new set of principles that underpin care from the time of ED arrival".

Now available to read in free full text at: http://dx.doi.org/10.1111/1742-6723.12338 

Lowthian, J., Curtis, A., Straney, L., McKimm, A., Keogh, M. and Stripp, A. (2015), Redesigning emergency patient flow with timely quality care at the Alfred. Emergency Medicine Australasia, 27(1), 35–41.

Available to read in free full text at: http://crpit.com/abstracts/CRPITV164Clissold.html

Clissold, A., Filar, J., Mackay, M., Qin, S. and Ward, D. (2015). Simulating hospital patient flow for insight and improvement. In: Proceedings of the 8th Australasian Workshop on Health Informatics and Knowledge Management (HIKM 2015), Sydney, Australia. CRPIT, 164.  Maeder, A. and Warren, J. Eds., ACS. 15-23.

To read the full story in The Press, go to:  http://www.stuff.co.nz/the-press/news/66232375/rebuild-workers-clog-christchurch-hospital-ed

The study was undertaken in four EDs in England and authors conducted "... independent observations of the measure and compared these with senior clinician's perceptions of crowding and safety". They conclude that the "... ICMED can easily be collected in multiple EDs with different information technology systems. The ICMED seems to predict clinician's concerns about crowding and safety well, but future work is required to validate this before it can be advocated for widespread use".

This article is available to read in free full text at:  http://emj.bmj.com/content/32/2/105.full

Boyle, A., et al. (2015). Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding. Emergency Medicine Journal, 32, 105-108.

Separate discrete event simulation (DES) models were developed for the EDs of a 1,000-bed urban medical center and a 560-bed community medical center using patient flow information. These models characterized the effects of reducing patient dwell time on ED care area census (i.e., staffing needs), waiting room census, total length of stay (LOS) and waiting time. Dwell time was defined as the time interval from when a patient entered the main ED care area to when the patient exited the ED by discharge or hospital admission. 

Results: DES results for each site demonstrate how natural patient arrivals and common hospital admission processes generate common temporal patterns of decreased crowding. Improving flow translates to most substantial reductions in waiting timeand waiting room census during evening hours (17:00 to 22:00 hours). Significant effects on ED care area census and staffingdemands are lagged, not occurring until overnight hours (2:00 to 8:00 hours). We reduced patient dwell time in 5% incrementswithin the urban ED (16.2 min) and community ED (13.5 min) from 5% to 15%. For example, a 10% decrease in dwell timeat the urban ED (32.4 min) and community ED (27.0 min) resulted in respective decreases in evening waiting room census by49% (10.8 patients) and 26% (3.5 patients) during evening hours and ED care area census by 16% (3.6 patients) and 11% (2.0 patients) overnight.

Conclusions: DES results suggest that increasing ED efficiency will most significantly decrease delays experienced by evening arrivals and provide opportunities to decrease care area census and reduce staff overnight.

This is an open access article and is available to download and read in free full text at:  http://dx.doi.org/10.5430/jha.v4n1p43

Hamrock, E., et al. (2015). Relieving emergency department crowding: Simulating the effects of improving patient flow over time. Journal of Hospital Administration, 4(1), 43-47.

To listen to an item on Radio NZ Checkpoint, go to: http://www.radionz.co.nz/national/programmes/checkpoint/audio/20154576/capital-dhb-achieves-key-government-target-after-a-battle

Respondents generally saw themselves as ‘sensible’ users of National Health Services, and it was felt that a lack of understanding, was the most powerful barrier to appropriate use of non-urgent and emergency services, with four generic barriers to appropriate use: 

• Convenience (using services that are the easiest option)
• Service unaware (not knowing what else is available and not understanding the system)
• Worried user (anxious and risk averse about the health of another, e.g. child, old person) and
• Emotionally attached (a strong attachment to A&E as most reliable option).

The author discusses the implications of these findings for development of a marketing communications campaign.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1179/1753807614Y.0000000048 or contact your DHB library, or organisational or local library for assistance.

Craker, S.M. (2014). Influences on choices to inform a persuasive communications campaign to reduce non-urgent Accident and Emergency attendance. Journal of Communication in Healthcare, 7(3), 181-196.

This analysis uses de-identified person-level data to examine the influence of some of the most commonly proposed causes of pressure in A&E, including:

• rising demand 
• levels of crowding inside A&E departments
• availability of inpatient beds
• changing case-mix in A&E as the population ages and long-term conditions become more prevalent
• satisfaction with access to GP practices
• the influence of temperature.

The report is available to download and read in full text at: http://www.qualitywatch.org.uk/focus-on/ae-attendances

Blunt, I. (2014). Focus on: A&E attendances. Why are patients waiting longer? London: Health Foundation and Nuffield Trust.

The study found that capacity alert call days reversed rising occupancy trends, with 6 out of 7 flow parameters reporting significant improvement over the 48 h following the call. The authors conclude that escalation processes that alert and engage the whole hospital in tackling overcrowding can successfully deliver sustained improvements in occupancy, patient throughput and access block.

To read the full abstract and for information on how to access the full text, go to: http://www.publish.csiro.au/paper/AH13103.htm or contact your local, DHB or organisational library for assistance.

Khanna, S., Boyle, J., & Zeitz, K. (2014). Using capacity alert calls to reduce overcrowding in a major public hospital. Australian Health Review, 38(3), 318-324.

To read the full abstract, and for access to a free full text version of the article, go to: http://www.intjem.com/content/7/1/16/abstract

O'Connor, E., et al. (2014). Evaluating the effect of emergency department crowding on triage destination. International Journal of Emergency Medicine, 7, 16, doi:10.1186/1865-1380-7-16.

Describes the characteristics, reasons for leaving and outcomes of patients who did not wait (DNW) to be seen by a health practitioner in a regional Australian emergency department (ED). Nearly 15 000 patients presented on the study days, with 648 (4.3%) DNWs. Almost six percent of patients who DNW were Australasian Triage Scale (ATS) category 3, 84.3% were ATS category 4 and 9.9% were ATS category 5. Most DNW patients presented on Sundays and between 4pm and midnight. Just over half of the patients who DNW sought additional medical treatment, with 4.9% requiring subsequent hospital admission. Frustration with perceived waiting times was the most common reason for leaving without being seen.

To read the full abstract and for information on how to access the full text, go to: http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12223/abstract or contact your DHB library, or your local or organisational library for assistance.

Blake, D. F., et al. (2014). ‘Did not waits’: A regional Australian emergency department experience. Emergency Medicine Australasia, 26 (2), 145-152.

This study evaluated the effect of adding a stream for complex, ambulatory patients in an Australian emergency department (ED). In 2011, a new stream was added to the pre-existing acute care (high complexity patients) and fast track (low complexity patients) streams. Space in acute care was set aside for the purpose of assessing patients who would previously have been assigned to acute care and who were capable of sitting in a chair with limited nursing care. The stream was separately resourced with staff redeployed from acute care. Early involvement of an emergency physician was a core characteristic of the process. Two 13 week periods before and after the intervention were compared. Results of the trial were that presentations increased by 8.2%. Forty-three per cent of patients were triaged to the new stream. The median ED length of stay fell from 327 minutes to 267 minutes, the average daily occupancy of the department fell from 38.1 patients to 34.9 patients and the proportion of patients who did not wait to be seen fell from 12% to 5.6%.

To read the full abstract, go to: http://www.emeraldinsight.com/journals.htm?issn=0952-6862&volume=27&issue=4&articleid=17108147&show=abstract or contact your local, DHB or organisational library for assistance.

Byungjoon B. J. Kim, Delbridge, Theodore R., & Kendrick, Dawn B. (2014). Improving process quality for pediatric Emergency Department. International Journal of Health Care Quality Assurance, 27 (4).

Process changes were made in various departments, and organisation-wide method changes involved standardising the discharge process, using status boards for visual control, and improving accuracy and timeliness of data entry.

The authors conclude that  YNHH improved discharges by 11:00 A.M, achieved a decrease in the average length of stay, and associated improved financial outcomes, by embracing five key components of demand capacity management: real-time communication, inter/intradepartmental and interdisciplinary collaboration, staff empowerment, standardisation of best practices, and institutional memory.

To read the full abstract, and for information on how to access the full text, go to: http://www.ingentaconnect.com/content/jcaho/jcjqs/2013/00000039/00000010/art00002 or contact your DHB library, or organisational or local library for assistance.

Jweinat, J., et al. (2013). The Safe Patient Flow Initiative: A collaborative quality improvement journey at Yale-New Haven Hospital. Joint Commission Journal on Quality and Patient Safety, 39(10), 447-459.

A new fast-track cardiac diagnostic tool trialled at Christchurch Hospital is already cutting down the number of unnecessary hospital admissions involving people presenting with chest pain.

The Accelerated Diagnostic Pathway (ADP), developed by Dr Martin Than and a cross-speciality team at Christchurch Hospital, was designed to speed up the diagnostic process without compromising patient safety. It was put to the test in a two-year randomised control trial funded by the Health Research Council of New Zealand (HRC).

"The results showed that we could double the number of patients that were discharged early from 10 per cent to about 20 per cent. Effectively one in five patients could be discharged within two hours," says Dr Than.

A paper on the study will be released online on 7 October 2013 in the Journal of the American Medical Association (JAMA).

The usual process for ruling out a heart attack is quite time consuming, and only about 10 to 20 per cent of patients with chest pain will actually have a heart attack as the cause of their pain. The assessment process typically involves a blood test for cardiac troponin when the patient comes in, then a later follow-up troponin test about six hours later. This later test means that patients usually have to be admitted or put in observation wards.

"Potentially there is not only a huge burden on the system, there is a lot of worry for the patient and their family for something that’s not as serious as feared."

Building on their earlier accelerated pathways studies at Christchurch Hospital, Dr Than and his colleagues made use of modern troponin assays in the trial, which involved 544 patients.

Those patients in the experimental group underwent serial troponin tests and an ECG, as well as undergoing risk assessment using the Thrombolysis In Myocardial Infarction score (TIMI). The TIMI score was designed to predict the risk of people coming into hospital with a cardiac problem, and the risk of them coming to harm over the next 30 days.

Dr Than's group hypothesised that if your TIMI score was zero and you had two negative troponin tests and an ECG in the first two hours then you were at less than 1 per cent risk of having a heart attack. You could therefore go home and be followed up as an outpatient, or proceed more quickly to the next inpatient investigations – also saving time.

Doctors in the emergency department were not forced to follow the pathway and there were a further 15 per cent of people that doctors admitted for investigation even though they were categorised as low risk by the diagnostic pathway. None of these patients turned out to have heart disease.

"Potentially we could have seen 35 per cent of patients discharged early, but as the pathway becomes more accepted over time those are gains that will also hopefully be picked up."

The study team was confident in the data and implemented the pathway immediately at Christchurch Public Hospital in mid-2012.

"We’ve been auditing it and it’s been a very successful pathway. We're not aware of any adverse events and we are turning people around quickly."

The pathway has been implemented at Nambour Hospital on Australia’s Sunshine Coast in Queensland without any adverse events, and the Director General of Health in Queensland wants to adopt it for the whole state. It has also been implemented at a hospital in Hong Kong.

Chest pain of suspected cardiac origin is one of the most common presenting complaints in hospitals in the western world and represents up to 25 per cent of admissions. In the United States it leads to about 8 million visits per year at a cost of $20 billion annually.

"That sort of volume of patients puts a lot of strain on a health system because one of the biggest challenges in the modern era is the issue of available beds and overcrowding in the emergency department," says Dr Than.

They found that the average percentage of patients waiting less than 4 hours fell from 98% to 95% almost immediately following the operational standard change, and conclude that, consequently, outcomes are likely to suffer.

To view the full abstract and for information on how to access the full text, go to:
http://emj.bmj.com/content/30/3/e22.abstract or contact your DHB library, or organisational or local library for assistance.

Woodcock, T., et al. (2013). The impact of changing the 4 h emergency access standard on patient waiting times in emergency departments in England. Emergency Medicine Journal, 30:e22.

To read the full article, go to: http://www.nursingreview.co.nz/issue/december-2012/ed-s-reluctant-frequent-fliers/#.VCyQ1vmSwXw

The authors note that emergency department length of stay was greater for emergency department to ward patients, and of the emergency department to ward patients who died. At an emergency department length of stay of 4 hours there were fewer ICU patients remaining in the emergency department, compared with ward patients . The authors suggest that future studies reporting on emergency department length of stay should differentiate for patients admitted from the emergency department to the ward,  intensive care or stepdown (high dependency) unit.

To view the full abstract and for information on how to access the full text, go to:
http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12021/abstract or contact your DHB library, or organisational or local library for assistance.

Flabouris, A., et al. (2013), Association between emergency department length of stay and outcome of patients admitted either to a ward, intensive care or high dependency unit. Emergency Medicine Australasia, 25(1), 46–54. 

They conclude from the results of the study that the target did not appear to have a negative effect on the quality or safety of emergency department care and had little effect on the use of testing.

To view the full abstract and for information on how to access the full text, go to:
http://www.annemergmed.com/article/S0196-0644(12)01404-7/abstract or contact your DHB library, or organisational or local library for assistance.

Weber, E.J., et al. (2012). Implications of England's four-hour target for quality of care and resource use in the emergency department. Annals of Emergency Medicine, 60(6), 699-706.

This is an open access article and is available to read in full text at: https://www.mja.com.au/journal/2012/197/9/appropriateness-healthdirect-referrals-emergency-department-compared-self

Ng, J., et al. (2012). Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals. Medical Journal of Australia. 197(9), 498-502.

The authors review and evaluate an emergency department health care system in India that adopts a system dynamic model, redesigning the process using value stream mapping to eliminate non-value-added activities to achieve just-in-time services.

To read the full abstract, and for information on how to access the full text, go to: http://www.emeraldinsight.com/journals.htm?articleid=17046851&show=abstract or contact your local, DHB or organisational library for assistance.

Chadha, R., et al. (2012). Lean and queuing integration for the transformation of health care processes: A lean health care model. Clinical Governance: An International Journal, 17(3), 191 - 199.

Only four studies met the criteria for the review. The quality of one study was appraised as moderately high; others were rated as weak.

The authors note that although the results are consistent, and low acuity patients seem to benefit the most from a rapid assessment zone, there is only limited evidence to support its implementation.

To read the full abstract, and for information on how to access the full text, go to: http://emj.bmj.com/content/29/5/372.short or contact your local, DHB or organisational library for assistance.

Bullard, M.J., et al. (2012). The role of a rapid assessment zone/pod on reducing overcrowding in emergency departments: A systematic review. Emergency Medicine Journal, 29:372-378.

To view the full abstract and for information on how to access the full text, go to:
http://emj.bmj.com/content/early/2012/01/04/emermed-2011-200532.abstract  or contact your DHB library, or organisational or local library for assistance.

Higginson, I. (2012). Emergency department crowding. Emergency Medicine Journal,  4 January, doi:10.1136/emermed-2011-200532

The target is that 95 percent of patients will be admitted, discharged, or transferred from an ED within six hours.

The joint Auckland DHB and University of Auckland project is funded by the Health Research Council. It is investigating the effect of the target on clinical markers of quality of care and the process of policy implementation. The project also aims to develop a dynamic system model, which may be used to predict the effects of interventions to improve the flow of patients through New Zealand's acute care hospitals.

The project began in 2010 and will run until 2013, but will use data from as early as 2006.

Co-Principal Investigator Dr Peter Jones, Auckland DHB Emergency Medicine Specialist and Director of Emergency Medicine Research, says this approach provides a vital baseline for the research.

'Although the target was introduced in 2009, some DHBs didn't start interventions to achieve it until much later, so the point of intervention varies between hospitals and between DHBs.'

Four case study hospitals have been chosen to represent a spread of geographic location, population ethnicity, case load and hospital performance at the time the target was first introduced. A series of clinically relevant quality indicators will be looked at in each of the case study sites.

Dr Jones says there'll also be plenty of opportunity for clinical and professional health sector groups to have a say on the effects of the target's introduction.

Last year he visited every ED in the country to interview the ED clinical directors and service managers about the resources used to help meet the target.

'The data is currently being analysed to compare DHB responses in terms of people, infrastructure and processes, how the target affects change in the wider hospital and the community, and the cost to DHBs of responding to the target.'

There are both differences and similarities in the hospitals' responses to the target that are shaped by historical and cultural context."

The study's other Principal Investigator, Linda Chalmers from the University of Auckland's School of Population Health, says another part of the project will explore the perspectives, experiences and actions of front line clinical and management staff, both in the ED and in the wider hospital.

In early 2011, semi-structured interviews were conducted at the four case study hospitals with clinical and management staff both in the ED and the wider hospital.

'We also collected reports and other documents staff considered relevant to the implementation of the target. These are being analysed to provide insights into the strategic response to the target, such as changes in clinical and operational practice and management.

'There are both differences and similarities in the hospitals' responses to the target that are shaped by historical and cultural context,' says Ms Chalmers. A second round of interviews and document collection is currently underway.

Dr Jones says the introduction of similar targets overseas produced some perverse outcomes, especially when financial incentives were involved. These included delaying ambulances outside the ED so the clock didn't start on a patient's waiting time.

He says the performance of EDs reflect whole of health system performance – not just in the hospital but in the community as well.

'If you've got no rest home beds and hospital beds are filled by people who should be in a rest home, it means new patients can't be admitted to the hospital, which means ED gets overcrowded. That's a reflection of a whole of system failure, not an ED failure.'

Find out more.

The authors discuss the multiple causes of crowding and present an up-to-date literature review of the interventions that reduce the adverse consequences of crowding. They consider interventions at the level of an individual hospital and a policy level.

Boyle, A., et al. (2012). Emergency department crowding: Time for interventions and policy evaluations. Emergency Medicine International, Article ID 838610, doi:10.1155/2012/838610

This is an open access article and is available to read and download at: http://www.hindawi.com/journals/emi/2012/838610/

Harris, B., Bei, J., & Kulstad, E. B. (2012). Crowding does not adversely affect time to percutaneous coronary intervention for acute myocardial infarction in a community Emergency Department. Annals of Emegency Medicine, 59 (1), 13-17.

To read the full abstract, and for information on how to access the full text, go to: http://www.annemergmed.com/article/S0196-0644%2811%2901245-5/abstract or contact your local or organisational library for assistance

The overall nurse-physician agreement on categorization was moderate and the levels of agreement within all subgroups were variable and low. 

The authors conclude that the lack of physician-nurse agreement and the inability to predict hospitalisation have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues.

Durand, A., et al. (2011). Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France. BMC Emergency Medicine, 11 (19), doi:10.1186/1471-227X-11-19.

To read the full abstract, and for information on how to access the full text, go to: http://www.biomedcentral.com/1471-227X/11/19

Forero, R., et al. (2011). Access block and emergency department overcrowding. Critical Care, 15:216 doi:10.1186/cc9998

This article is available to read in full text at: http://ccforum.com/content/15/2/216

The authors assess those factors resulting in increased demand for emergency department services in Ontario. They assess how utilization rates vary according to the severity of patient presentation in the emergency department. They are specifically interested in the impact that access to primary care physicians has on the demand for emergency department services. Additionally, they investigate these trends using a series of novel regression models for count outcomes which have yet to be employed in the domain of emergency medical research.

Using a theoretically appropriate hurdle negative binomial regression model this study illustrates that access to a primary care physician is an important predictor of both the odds and rate of emergency department utilization in Ontario. The authors suggest that restructuring primary care services, with aims of increasing access to undersupplied populations may result in decreased emergency department utilization rates by approximately 43% for low severity triage level cases.

Moineddin, R., et al. (2011). Modeling Factors Influencing the Demand for Emergency Department Services in Ontario: A comparison of methods. BMC Emergency Medicine, 11:13.

This is an open access article and is available to read in full text at: http://www.biomedcentral.com/1471-227X/11/13

In an “Early View” paper published in Emergency Medicine Australasia, the journal of the Australasian College for Emergency Medicine, they report a study of New Zealand’s emergency departments at two points in 2010 to determine ED occupancy.

The researchers also obtained data on target achievement during corresponding time periods from the NZ Ministry of Health.

The data collected in May and August of all 27 hospitals in New Zealand were the same as in previous surveys conducted in Australia.

This paper is the first to publish research on the extent of ED overcrowding and hospital access block in NZ. The study found that access block was seen more in tertiary than secondary hospitals (64% compared with 23%), and that no hospitals with access block were able to meet the Shorter Stays in ED target of 95% discharged or admitted within six hours.

Overcrowding was seen in 57.1% of tertiary hospitals and in 39% of secondary hospitals. Patients experiencing admission delays of eight hours or more numbered 25 in May and 59 in August. This represented 45.5% and 79.7% of patients waiting for admission, respectively.

The researchers concluded that hospital access block was seen more often in larger hospitals and significantly associated with failure to meet the Shorter Stays in ED health target, whereas ED overcrowding was seen in both small and large hospitals, but not associated with failure to meet the target.

The time spent by patients in EDs has been under the spotlight in Australia and New Zealand for several years. New Zealand introduced the Shorter Stays in ED target in July 2009. District Health Boards are encouraged to ensure that 95% of patients presenting to the ED are either discharged from the ED or admitted to hospital within six hours of arrival.

Recently, Australia introduced a National Access Target of 95% leaving ED within four hours. The impetus for the Shorter Stays in ED target in New Zealand was the desire by ED clinicians to reduce ED overcrowding and hospital access block in NZ hospitals in the hope of improving both outcomes for patients and health service efficiency. This was based on overseas experience and anecdotal evidence from NZ.

ED overcrowding and hospital access block have well-documented associations with adverse outcomes for patients, including an increase in mortality both for patients discharged from ED and those admitted to hospital from ED (according to recent Canadian and Australian studies), and as such, these indicators reflect when the acute care system is failing.

Media release, Australasian College for Emergency Medicine, I July 2011

The objective of this study, reported in BMJ Quality & Safety, was to determine whether a prolonged ED stay is associated with an increased risk for the occurrence of AEs for older patients admitted to hospital.

Ackroyd-Stolarz, S., et al. (2011). The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ Quality & Safety, 20, 564-569.

To view the full abstract, and for information, on how to access the full text, go to: http://qualitysafety.bmj.com/content/20/7/564.abstract  or contact your localor organisational library for assistance.

To read the full abstract, and for access to a free full text version of the article, go to: http://www.biomedcentral.com/1471-227X/11/7

Arendts, G. (2011). ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home. BMC Emergency Medicine, 11 (7), doi:10.1186/1471-227X-11-7, Published online 8 June 2011.

Holden, R.J. (2011). Lean thinking in emergency departments: A critical review. Annals of Emergency Medicine, 57(3), 265-278.

To access the full text of this review, go to: http://www.annemergmed.com/article/S0196-0644%2810%2901322-3/fulltext