Non-urgent visits to emergency departments: a qualitative study in Iran exploring causes, consequences and solutions

Understanding low acuity emergency department presentations in infancy: A cohort study

OBJECTIVE

Low acuity presentations (LAPs) contribute to large numbers of ED presentations and carry numerous consequences. The present study sought to improve the understanding of regional infant LAPs by analysing temporal patterns of presentation, discharge diagnoses and potential predictive factors.

METHODS

This retrospective observational study examined ED presentations among children less than 12 months old (infants) to the Royal Prince Alfred Hospital between 2017 and 2019. Descriptive statistics were used to identify temporal patterns of presentation and common discharge diagnoses among LAPs. Multivariable logistic regression was used to determine the association between early life, demographic and perinatal factors and low acuity presenters.

RESULTS

Of 6881 infant ED presentations, 19.8% were LAPs, occurring disproportionately on weekdays (82.2%) and during hours of 08.00-17.00 (69.9%). Respiratory tract infections and gastrointestinal complaints were most common overall, though non-allergic rash, feeding difficulties, eczema and developmental concerns contributed substantially among LAPs. Socio-economic status (SES) (odds ratio [OR] 1.71), overseas maternal nationality (OR 1.25) and Medicare ineligible maternal financial class (OR 0.49) were associated with low acuity presenters. Low appearance, pulse, grimace, activity and respiration score (OR 3.53), low SES (OR 3.26), complicated delivery (OR 1.64), maternal multiparity (OR 0.50), maternal partner presence (OR 0.40) and obstetric complications (OR 0.37) were associated with repeat, multi-low acuity presenters (multi-LAPs).

CONCLUSION

A substantial minority of infant ED presentations are LAPs. Targeted interventions may benefit from focusing on families with a background of socioeconomic disadvantage, social isolation, cultural and linguistic diversity and perinatal complications, with a view to strengthening engagement with community-based services among these groups.

Inappropriate Use of Emergency Services from the Perspective of Primary Care Underutilization in a Local Romanian Context: A Cross-Sectional Study

Background: The underutilization of primary care services is a possible factor influencing inappropriate emergency service presentations. The objective of this study was to evaluate the proportion and characteristics of patients inappropriately accessing emergency room services from the perspective of primary care underutilization. Methods: This cross-sectional study included patients who visited the emergency room of a County Hospital, initially triaged with green, blue, or white codes, during a 2-week period in May 2017. Two primary care physicians performed a structured analysis to correlate the initial diagnosis in the emergency room with the final diagnosis to establish whether the patient's medical complaints could have been resolved in primary care. Results: A total of 1269 adult patients were included in this study. In total, the medical problems of 71.7% of patients could have been resolved by a primary care physician using clinical skills, extended resources, or other ambulatory care and out-of-hours services. Conclusions: Low awareness of out-of-hours centers and a lack of resources for delivering more complex services in primary care can lead to inappropriate presentations to the emergency services. Future research on this topic needs to be conducted at the national level.

Analysis of Emergency Department Use by Non-Urgent Patients and Their Visit Characteristics at an Academic Center

Objective

We studied the extent and reasons for non-urgent emergency department (ED) visits in a single university hospital, their predictors, and patient outcomes to propose solutions suitable for Middle Eastern healthcare systems.

Design

We conducted a retrospective review of electronic medical records, including all non- and less-urgent ED visits with complete triage records (levels 4 and 5 triage based on the Canadian Triage and Acuity Scale (CTAS) over one year. The data on patient demographics, visit characteristics, and patient disposition were analyzed using SPSS software.

Setting

The study was conducted in the ED at King Abdullah Bin Abdul-Aziz University Hospital (KAAUH), a Saudi university hospital located within the campus of Princess Nourah Bint Abdulrahman University.

Participants

A chart review was carried out for 18,880 patients with CTAS 4 or 5 visiting the KAAUH ED between July 2020 and July 2021. Additionally, a total of "11,857" patients with missing triage acuity or CTAS levels 1, 2, or 3 were excluded from the study.

Results

The majority (61.4%) of the 30,737 ED visits were less-urgent or non-urgent. The most common reasons for non-urgent visits were routine examination/investigation (40.9%), medication refilling (14.6%), and upper respiratory tract infection/symptoms (9.9%). Most visits (73.4%) were during weekdays and resulted in the prescription of medication (94.2%), laboratory tests (62.8%), sick leaves (4.7%), radiology examinations (3.6%), and a visit to primary healthcare clinics (family medicine) within a week of the emergency visit (3.6%).

Conclusion

Less- and non-urgent ED visits often did not need any further follow-ups or admission and represented a burden better managed by a primary healthcare center. Policymakers should mitigate unnecessary ED visits through public awareness, establish clear regulations for ED visits, improve the quality of care in primary healthcare centers, facilitate booking for outpatient department appointments, and regulate the systems of payment coverage/insurance and referral by other organizations.

Implementation of the Acute Care Clinic Easy Scheduling System at the Brooke Army Medical Center

Introduction

Emergency departments (EDs) have continued to struggle with overcrowding, causing delays in patient care and increasing stress on the medical staff and resources. This was further illustrated during the recent coronavirus disease 2019 pandemic, where we saw large unpredictable surges to the ED as hospitals tried to meet the medical needs of patients while trying to minimize the spread of coronavirus disease. A previous study from the Department of Emergency at the Brooke Army Medical Center (BAMC) found that nearly half of the patients presenting to the ED could have been managed in a primary care setting. We sought to pilot an alternate appointment scheduling system, Acute Care Clinic Easy Scheduling System, to allow patients to see and book available appointments while waiting in the ED waiting room.

Materials and Methods

Our appointment display system was created through collaboration with the BAMC Information Management Division. A Tableau data interface connects to the Composite Health Care System to view available primary appointments across the San Antonio Military Health Care System. These are displayed in real-time on multiple TV screens outside the ED and in the ED waiting room. Patients were provided signage that provides a way to call or use a World Wide Web–based interface to immediately schedule the open appointments within the next 48 hours. Patients voluntarily opted to use this system and may opt to leave the ED if another appointment became available within an acceptable time frame to them.

Results

This section is not applicable to this article.

Conclusions

Expansion of the Acute Care Clinic Easy Scheduling System within the Military Health Care System may (1) help reduce ED crowding, (2) improve access to care through a live-tracking system that patients can review and select from, and (3) reduce the number of unfilled primary care appointments. The system in place in the BAMC ED serves as a template for other MTFs to use.

Reasons for patients with non-urgent conditions attending the emergency department in Kenya: A qualitative study

INTRODUCTION

Scant literature exists on the non-urgent use of emergency departments in Sub-Saharan Africa and its effects on the provision of effective emergency care services. With the surge in the prevalence of non-communicable diseases compounded by an already prevailing significant problem of communicable diseases and injuries in this setting, there has been a rising demand for emergency care services. This has led to ED overcrowding, increased healthcare costs, extended waiting periods and overstretched essential services. The main objective of this study was to determine why patients visit the ED for non-urgent care.

METHODS

A descriptive qualitative study was conducted at a tertiary university hospital ED in Nairobi, Kenya. Purposive sampling was used to select patients triaged as less urgent or non-urgent. In-depth interviews were conducted until thematic saturation was achieved. The interviews were audio recorded, transcribed verbatim and analyzed thematically.

RESULTS

Thematic saturation was reached after interviewing twenty-four patients. The obtained data was discussed under three main themes: (1) reasons why patients visited the ED for non-urgent care, (2) patients understanding of the roles of the ED, and (3) patients' perceptions about the urgency of their medical conditions. Several factors were identified as contributing to the non-urgent use of the ED including positive experiences during past visits, a perception of availability of better services and the closure of other departments after office-hours and on weekends. It was found that non-urgent ED visits occurred despite most patients having an understanding of the role of the ED as an appropriate location for the treatment of patients with life threatening conditions.

CONCLUSION

This study highlights several reasons why patients with non-urgent medical conditions seek care in the ED despite being able to correctly identify its purpose within the national emergency care framework. Regular patient education regarding which conditions warrant ED attendance and alternative sites of care for non-urgent conditions could potentially help reduce ED patient numbers.