• Micaela La Regina, Francesca Guarneri, Elisa Romano, Francesco Orlandini, Roberto Nardi, Antonino Mazzone, Andrea Fontanella, Mauro Campanini, Dario Manfellotto, Tommaso Bellandi, Gualberto Gussoni, Riccardo Tartaglia, and Alessandro Squizzato.
• SS Risk Management, ASL5 Liguria, La Spezia, Italy. micaela.laregina@asl5.liguria.it.
• J Gen Intern Med. 2019 Jul 1; 34 (7): 1314-1321.

BackgroundIn countries with public health system, hospital bed reductions and increasing social and medical frailty have led to the phenomenon of "outliers" or "outlying hospital in-patients." They are often medical patients who, because of unavailability of beds in their clinically appropriate ward, are admitted wherever unoccupied beds are. The present work is aimed to systematically review literature about quality and safety of care for patients admitted to clinically inappropriate wards.MethodsWe performed a systematic review of studies investigating outliers, published in peer-reviewed journals with no time restrictions. Search and screening were conducted by two independent researchers (MLR and ER). Studies were considered potentially eligible for this systematic review if aimed to assess the quality and/or the safety of care for patients admitted to clinically inappropriate units. Our search was supplemented by a hand search of references of included studies. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings.ResultsWe collected 17 eligible papers and grouped them into six thematic categories. Despite their methodological limits, the included studies show increased trends in mortality and readmissions among outliers. Quality of care and patient safety are compromised as patients and health professionals declare and risk analysis displays. Reported solutions are often multicomponent, stress early discharge but have not been investigated in the control group.ConclusionsPublished literature cannot definitely conclude on the quality and safety of care for patients admitted to clinically inappropriate wards. As they may represent a serious threat for quality and safety, and moreover often neglected and under valued, well-designed and powered prospective studies are urgently needed.

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