Effectiveness and safety of emergency department-based streaming interventions for low-acuity utilizers - systematic review and meta-analysis

Emergency department (ED) crowding is a global challenge, presumably aggravated by low-acuity utilization. Various patient streaming interventions have been implemented in EDs to reduce potentially unnecessary utilization and improve care coordination and patient throughput. This systematic review examined the effectiveness and safety of ED-based streaming for low-acuity patients. A search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was conducted up to December 2, 2025. Screening and data extraction were performed in duplicate. RCTs, non-randomized controlled trials, interrupted time series, and before-after studies on general practitioner (GP) streaming, ED streaming, and urgent care (UC) streaming for low-acuity utilizers were eligible. We assessed outcomes related to care effectiveness, patient safety, and cost-effectiveness. Random-effects meta-analyses were performed. Risk of bias was assessed by the Effective Public Health Practice Project tool. We included 137 publications reporting on 119 research projects. Meta-analyses showed higher proportions of cases managed in alternative tracks for GP streaming (0.32; CI 0.17;0.51) compared to ED streaming (0.25; CI 0.15;0.37). Both GP and ED streaming demonstrated reductions in length of stay, particularly for low-acuity patients (GP: SMD − 0.85; CI -1.37;-0.33; ED: SMD − 0.39; CI -0.56;-0.22). Safety outcomes, including leaving without being seen and unplanned ED reattendances, generally improved or were unchanged. The impact on ED utilization and cost-effectiveness remained inconclusive due to inconsistent evidence. There was high variability across outcomes, likely due to diverse context factors and multifaceted interventions. This review provides a comprehensive synthesis of various ED-based streaming interventions for low-acuity patients, with effect estimation by meta-analyses. Results suggest that GP and ED streaming improve care without compromising safety, with indications of a greater potential for alternative care with GP streaming. The predominance of observational studies with potential biases and unexplained heterogeneity, however, results in very low overall certainty of the evidence. PROSPERO CRD42022355935.