Characteristics of low-acuity paediatric emergency department consultations in two tertiary hospitals in Switzerland: a retrospective observational study

How are fast tracks organized in adult and pediatric emergency departments in Switzerland? A cross-sectional survey

BACKGROUND

In response to the challenges faced by emergency departments (ED), including overcrowding and high patient volumes, Fast Track (FT) systems are designed to optimize patient flow, yet their implementation and impact in Switzerland remain understudied. Our study provides a comprehensive description of Fast Track (FT) processes across both pediatric and adult settings in Switzerland and compares challenges.

METHODS

We conducted a cross-sectional online survey of ED leadership in Switzerland from May to September 2023, using the WHO SARA framework to explore FT processes. The survey included 28 pediatric EDs and their corresponding adult EDs, with questions addressing FT availability, staffing, infrastructure, and operational challenges. Results were analyzed descriptively, providing insights into FT organization and highlighting barriers to implementation and expansion.

RESULTS

The survey achieved a response rate of 93% (52/56 EDs). Overall, 68% of surveyed hospitals have implemented a FT system, with a higher prevalence in adult EDs (88%) than in pediatric EDs (59%). The absence of FTs in certain pediatric departments was primarily due to structural and personnel constraints. Most FTs are managed internally by hospitals, employing emergency team members, and occasionally general practitioners, reflecting a tailored approach to staffing based on departmental needs. Despite the strategic organization of FTs, operational challenges persist; 45% of respondents identified staff shortages as a major challenge, particularly in pediatric FTs (63%) compared to adult FTs (32%). Financial barriers, including disparities in external physician compensation, remain significant obstacles to FT expansion. Satisfaction levels among EDs with their FT systems were generally high, with improvements in personnel resource allocation and patient flow frequently reported.

CONCLUSION

While FT systems in Swiss EDs have enhanced patient care and operational efficiency, their expansion and effectiveness are hampered by staffing and financial limitations. Addressing these barriers requires a collaborative effort to reform health system policies and financial frameworks, ensuring the sustainable implementation of FTs to meet the growing demands of emergency care.

Low-acuity emergency department presentation characteristics and their association with Medicare-subsidised general practitioner services across New South Wales: A data linkage study

OBJECTIVES

Identify clinical and demographic characteristics of low-acuity presentations (LAPs) to the ED and analyse correlations between population rates of LAPs to ED and rates of Medicare-subsidised general practitioner (GP) services across statistical areas.

METHODS

Retrospective data linkage study using state-wide ED data and publicly available data on GP services per population by statistical area. We performed multilevel logistic regression to determine predictors of LAP at an individual level after adjusting for remoteness categories and performed correlations between rates of LAP and GP services per population across statistical areas in New South Wales, Australia. The primary outcome was the rate of LAPs to ED, LAPs being defined as patients who self-presented to ED, assigned an Australasian Triage Score of 4 or 5 and subsequently discharged from ED.

RESULTS

There were 2.9 million ED presentations in 2021, of which 39.9% presentations were classified as LAP. LAPs were associated with younger age, routine care, eyes, ear, nose and throat and musculoskeletal presentations. The rate of LAPs was higher in non-metropolitan areas. Additionally, 85% of LAPs were seen and discharged from ED within 4 h. There was an inverse correlation between the rate of Medicare-subsidised GP services and the rate of total ED or LAPs in non-metropolitan areas (ρ = -0.47, ρ = -056 and P = 0.012, P = 0.001, respectively). In metropolitan areas, correlations were either positive for all ED presentations (ρ = +0.41, P = 0.007) or not significant for LAPs (ρ = +0.18, P = 0.57).

CONCLUSIONS

A relationship between LAPs to ED and Medicare-subsidised GP episodes of care exists for non-metropolitan but not metropolitan areas.

Caregiver alignment with triage acuity levels and drivers for discrepancy between caregiver assessment and triage acuity levels: a cross-sectional questionnaire based study

BACKGROUND

Caregiver concern is the main driver to paediatric emergency departments visits. Understanding caregiver worries is crucial to guide patients to the most appropriate healthcare setting. Previous research shows mixed findings on the accordance between caregiver assessment and professional triage.

METHODS

We assessed data from two questionnaire-based studies conducted over 27 months in two tertiary paediatric emergency departments in Switzerland to compare caregiver perception of their child's medical acuity and standard nurse triage. Furthermore, we examined socioeconomic factors associated with caregiver perception.

RESULTS

Our study of 2,126 children seen in the two paediatric emergency departments showed that caregiver assessment aligned well with the acuity assigned by professional triage in 89% (1,901/2,126) of cases. In 142 cases (7%, 142/2,126), caregivers rating their child's severity higher than nurse's triage while in 83 cases (4%, 83/2,126), they rated it lower. In an univariable analysis, we found that family's difficulties paying bills (20% vs. 12%) and low maternal education (19% vs. 10%) were associated with a higher percentage of caregiver rating their child's severity higher than nurse's triage. Fever as the main complaint was associated with caregiver rating their child's severity lower than nurse's triage.

CONCLUSIONS

This questionnaire-based study shows that caregiver's assessment of the severity of the child and nurse triage are concordant in most situations. Our study sheds light on the association between caregiver assessment and professional triage in two paediatric emergency departments in Switzerland, revealing some of the factors leading to discordance. These factors most probably reflect health illiteracy. It is important that healthcare professionals recognize and address factors influencing caregiver assessments to facilitate accurate decision-making and enhanced paediatric emergency care outcomes.

Drivers for low-acuity pediatric emergency department visits in two tertiary hospitals in Switzerland: a cross-sectional, questionnaire-based study

PURPOSE

Low-acuity pediatric emergency department (PED) visits are frequent in high-income countries and have a negative impact on patient care at the individual and health system levels. Knowing what drives low-acuity PED visits is crucial to inform adaptations in health care delivery. We aimed to identify factors associated with low-acuity PED visits in Switzerland, including socioeconomic status, demographic features, and medical resources of families.

METHODS

We conducted a prospective, questionnaire-based study in the PEDs of two Swiss tertiary care hospitals, Bern and Lausanne. We invited all consecutive children and their caregiver attending the PED during data collection times representative of the overall PED consultation structure (e.g. day/night, weekdays/weekends) to complete a questionnaire on demographic features, socioeconomic status, and medical resources. We collected medical and administrative data about the visit and defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed, and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.

RESULTS

We analysed 778 PED visits (September 2019 to July 2020). Most children visiting our PEDs had a designated primary care provider (92%), with only 6% not having seen them during the last year. Fifty-five per cent of caregivers had asked for medical advice before coming to the PED. The proportion of low-acuity visits was 58%. Low-acuity visits were associated with caregiver's difficulties paying bills (aOR 2.6, 95% CI 1.6 - 4.4), having already visited a PED in the last 6 months (aOR 1.7, 95% CI 1.1 - 2.5) but not with parental education status, nor parental country of birth, parental employment status or absence of family network.

CONCLUSION

Economic precariousness is an important driver for low-acuity PED visits in Switzerland, a high-income country with compulsory health coverage where most children have a designated primary care provider and a regular pediatric follow-up. Primary care providers and PEDs should screen families for economic precariousness and offer anticipatory guidance and connect those in financial need to social support.