Repeated use of the emergency department: qualitative study of the patient's perspective

Moderating Effects of Individual Traits on the Association Between Nature and Patient Wait Experiences

OBJECTIVES

We empirically investigated to what extent plants in the emergency department (ED) waiting areas influence patient wait experiences (i.e., anxiety, perceived service quality, and perception of wait time) depending on individual differences in cognitive thinking styles and one's bonds with the natural world.

BACKGROUND

Positive effects of nature on patient experiences in healthcare environments are well established by empirical research findings. However, evidence is scarce on the impact of nature on patient wait experiences and the roles of patient traits often related to their backgrounds.

METHODS

A within-subjects study was conducted (N = 116) with two virtually built ED waiting rooms: with versus without indoor and outdoor plants.

RESULTS

Findings confirmed that plants lower anxiety and improve perceptions of service quality and wait time. Cognitive thinking style significantly moderated how plants affected patient wait experiences. Although participants with higher connectedness to nature showed more positive responses to the nature condition, connectedness to nature did not significantly affect the association between nature and wait experiences.

CONCLUSIONS

This study contributes to the existing body of knowledge on nature's effects in healthcare environments by examining the roles of individual differences in patients' and visitors' cognitive styles and connectedness to nature. Results highlighted the impact of these differences in patient experiences for effective implications of nature in waiting areas of healthcare facilities.

Experiences of Frequent Users of Emergency Departments in Health Care Setting in French-Speaking Switzerland: A Qualitative Study

AIMS

Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland.

METHODS

Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis.

RESULTS

Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences.

CONCLUSION

The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.

An observational pilot study: Prevalence and cost of high frequency emergency department users at Örebro University Hospital, Sweden

Background

There is little research on high frequency emergency department users (HEDU) in Sweden. We aim to determine the prevalence and costs of HEDU compared to non-HEDU at Örebro University Hospital (ÖUH). Additionally, we will determine the factors and outcomes associated with being a HEDU.

Methods

This was a retrospective, observational cohort study of ED patients presenting to ÖUH, Sweden between 2018–19. Analyses used electronic registry, ambulance, and cost data. The definition for HEDU was ≥4 visits/year. HEDUs were categorized further into Repeat, High and Super HEDU with 4–7, 8–18 and ≥19 visits/year, respectively. We used multivariable logistic regression to determine the adjusted odds ratios for factors and outcomes between HEDU and non-HEDU.

Findings

Of all ÖUH ED patients, 6.1% were HEDU and accounted for 22.4% of ED visits and associated costs. Compared to the mean cost of non-HEDU, the Repeat, High and Super HEDU were more costly by factors of 4, 8 and 27, respectively. The HEDUs were more likely to be male, self-referred, present with abdominal pain, arrive by ambulance, at night and from the Örebro municipal region. Super HEDU were more likely to be of adult age and assigned lower acuity scores. HEDU were more likely to be directed to the surgical zone, less likely to receive radiologic imaging or achieve a 4-hr time target. In contrast to the Repeat and High HEDU, Super HEDU were less likely to be admitted, but more likely to leave without being seen.

Conclusion

ÖUH has a HEDU population with associated factors and outcomes. They account for a substantial proportion of ED costs compared to non-HEDU.

Analyse von Einflussfaktoren auf die Transporthäufigkeit von Frequent Usern mit Angststörung

Einleitung

Frequent User wählen wiederholt den Notruf 112 und sind für eine Vielzahl von Einsätzen verantwortlich. In vielen Fällen ist eine Angststörung ursächlich für das Verhalten. Hierbei spielen vermutlich eine unzureichende Anbindung an eine geeignete Versorgungseinrichtung sowie eine mangelhafte Compliance eine wesentliche Rolle.

Methodik

Als Frequent User mit Angststörung wurden diejenigen Patientinnen definiert, bei denen im Einsatzprotokoll die Kombination aus der (Verdachts‑)Diagnose „psychiatrischer Notfall“ sowie dem psychiatrischen Befund „ängstlich“ dokumentiert wurde und es im betrachteten Zeitraum (01.10.2020 bis 31.05.2021) zu mindestens 2 Einsätzen der Notfallrettung kam (n = 74). Ergänzend erfolgte eine Auswertung aus den Daten aus dem Einsatzleitsystem. Die Einsätze (n = 326) wurden in Bezug auf die Transporthäufigkeit in Abhängigkeit von mNACA-Score, Einsatzort sowie der Notrufmeldung analysiert.

Ergebnisse

In 52,1 % handelte es sich um mNACA-II-Einsätze, in 42,3 % um mNACA-III-Einsätze und in 5,5 % um mNACA-IV-Einsätze. Neben dem mNACA-Score hatte weder der Einsatzort noch die Einsatzzeit noch die Dringlichkeit Einfluss auf die Transporthäufigkeit. Im Ergebnis zur Alarmierung zum „psychiatrischen Notfall“ wurden signifikant mehr Transporte durchgeführt. Das Alter war ebenfalls nicht maßgeblich.

Schlussfolgerung

Neben der Notwendigkeit der Verbesserung der Gesundheitskompetenz von vulnerablen Gruppen muss sich auch der Rettungsdienst in den kommenden Jahren vermehrt auf ein verändertes Einsatzspektrum einstellen. Damit einhergehend müssen Schnittstellen und die Anbindung an alternative Versorgungsformen optimiert werden. Neben einem Case Management sind Strukturen denkbar, die psychosoziale Hilfe unmittelbar an die Notfallrettung anbinden.

Graphic abstract

Mental Health and Addiction Related Emergency Department Visits: A Systematic Review of Qualitative Studies

Mental health and addiction (MHA) related Emergency Department (ED) visits have increased significantly in recent years. Studies identified that a small subgroup of patients constitutes a disproportionally large number of visits. However, there is limited qualitative research exploring the phenomenon from the perspectives of patients who visited ED frequently for MHA reasons, and healthcare providers who provide care to the patients since the overwhelming majority of studies were quantitative based on clinical records. Without input from patients and healthcare providers, policymakers have inadequate information for designing and implementing programs. The purpose of this study was to systematically review the literature of qualitative research on frequent MHA related ED visits. The findings of the review revealed that a lack of community resources and existing community resources not meeting the needs of patients were critical contributing factors for frequent MHA related ED visits.

Improving Emergency Department Patient-Physician Conversation Through an Artificial Intelligence Symptom-Taking Tool: Mixed Methods Pilot Observational Study

BACKGROUND

Establishing rapport and empathy between patients and their health care provider is important but challenging in the context of a busy and crowded emergency department (ED).

OBJECTIVE

We explore the hypotheses that rapport building, documentation, and time efficiency might be improved in the ED by providing patients a digital tool that uses Bayesian reasoning-based techniques to gather relevant symptoms and history for handover to clinicians.

METHODS

A 2-phase pilot evaluation was carried out in the ED of a German tertiary referral and major trauma hospital that treats an average of 120 patients daily. Phase 1 observations guided iterative improvement of the digital tool, which was then further evaluated in phase 2. All patients who were willing and able to provide consent were invited to participate, excluding those with severe injury or illness requiring immediate treatment, with traumatic injury, incapable of completing a health assessment, and aged <18 years. Over an 18-day period with 1699 patients presenting to the ED, 815 (47.96%) were eligible based on triage level. With available recruitment staff, 135 were approached, of whom 81 (60%) were included in the study. In a mixed methods evaluation, patients entered information into the tool, accessed by clinicians through a dashboard. All users completed evaluation Likert-scale questionnaires rating the tool's performance. The feasibility of a larger trial was evaluated through rates of recruitment and questionnaire completion.

RESULTS

Respondents strongly endorsed the tool for facilitating conversation (61/81, 75% of patients, 57/78, 73% of physician ratings, and 10/10, 100% of nurse ratings). Most nurses judged the tool as potentially time saving, whereas most physicians only agreed for a subset of medical specialties (eg, surgery). Patients reported high usability and understood the tool's questions. The tool was recommended by most patients (63/81, 78%), in 53% (41/77) of physician ratings, and in 76% (61/80) of nurse ratings. Questionnaire completion rates were 100% (81/81) by patients and 96% (78/81 enrolled patients) by physicians.

CONCLUSIONS

This pilot confirmed that a larger study in the setting would be feasible. The tool has clear potential to improve patient-health care provider interaction and could also contribute to ED efficiency savings. Future research and development will extend the range of patients for whom the history-taking tool has clinical utility.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024115; https://drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00024115.

A Mixed-Methods Investigation into Patients' Decisions to Attend an Emergency Department for Chronic Pain

OBJECTIVE

This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born.

DESIGN AND METHODS

This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts.

RESULTS

ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort.

CONCLUSION

This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

BACKGROUND

Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits.

METHODS

This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached.

RESULTS

In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit.

CONCLUSIONS

This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.

Predictors of Frequent Emergency Department Utilization for Mental Health Reasons

Overcrowding in emergency departments (ED) jeopardizes quality and access to health care, which represents a major issue for service delivery. This study determined predictors of frequent ED utilization among 320 patients recruited from six hospital ED in Quebec (Canada). Data collection included patient interviews and administrative databanks. A hierarchical linear regression analysis was performed using the Andersen Behavioral Model as a framework, with variables organized into predisposing, enabling, and needs factors. Results showed that needs factors were most strongly associated with ED utilization, particularly schizophrenia and personality disorders. Predisposing and enabling factors each contributed one variable to the model: past hospitalization for Mental Health (MH) reasons, and having regular care from an outpatient psychiatrist over the 12 months prior to interview at the ED, respectively. Increasing integration of MH services in networks may reduce unnecessary ED utilization and overcrowding, while providing better accessibility and care continuity for patients who visit ED for MH reasons.

Experience of emergency department patients after a visit for hyperglycaemia: implications for communication and factors affecting adherence postdischarge

BACKGROUND

While studies have reported factors affecting adherence to diabetic care plans from a chronic disease perspective, no studies have addressed issues with post-discharge adherence facing patients with diabetes after an emergency department (ED) presentation for hyperglycaemia. This study's objectives were to describe patient perspectives on their experience during and after an ED visit for hyperglycaemia and to identify factors that influence postdischarge adherence.

METHODS

We conducted a qualitative description (QD) study of adult patients who had visited a Canadian ED for hyperglycaemia. Consistent with QD, purposive sampling was utilised, seeking diversity across age, gender and diabetes type. Participants took part in semistructured interviews and thematic analysis was used to identify and describe core themes. Frequent team meetings were held to review the analysis and to develop the final list of themes used to recode the data set. Analytic insights were tracked using reflective memos and an audit trail documented all steps and decisions.

RESULTS

22 patients with type 1 and 2 diabetes were interviewed from June to October 2019. Participants identified several factors that impacted their ability to adhere to discharge plans: communication of instructions, psychosocial factors (financial considerations, shame and guilt, stigma and mental health), access to follow-up care and paediatric to adult care transitions.

CONCLUSIONS

This study describes the patient experience with the communication of discharge instructions, as well as factors affecting adherence post-ED discharge for hyperglycaemia. Our findings suggest four strategies that could improve the patient experience, improve adherence to discharge plans and potentially decrease the frequency of recurrent ED visits for hyperglycaemia.

Frequent attenders' experiences of encounters with healthcare personnel: A systematic review of qualitative studies

Rather than measure demographic factors such as socioeconomics, the aim of this study was to examine the lived experience of frequent attenders by synthesizing findings on their encounters with healthcare personnel. The Scopus, CINAHL, PsycARTICLES, and PubMed (Medline) databases were searched in May 2020 in order to screen studies by title and abstract (n = 1794) and full-text (n = 20). Findings from the included studies (n = 6) were then pooled using meta-aggregation, yielding the following results: difficulties in resolving frequent attenders' situations may create "service circles," frustrating patients with their situation; frequent attenders' own expertise regarding their condition should be recognized and valued alongside that of healthcare professionals when performing collaborative care; a lack of empathy and disparagement may make frequent attenders feel misunderstood and unappreciated; frequent attenders should be recognized as individuals by taking their circumstances into account and providing support accordingly. Frequent attenders' experiences demonstrate the importance of shared decision-making, continuity of care, and acknowledging these patients' individual circumstances. Identifying the variety of frequent attenders' service needs by synthesizing their experiences is a practical way of organizing patient-centered healthcare services.

Healthcare Providers' Perceptions of Challenges with Frequent Users of Emergency Department Care in Switzerland: A Qualitative Study

Frequent users of emergency departments (FUED; ≥ 5 ED visits/year) commonly cumulate medical, social, and substance use problems requiring complex and sustained care coordination often unavailable in ED. This study aimed to explore ED healthcare providers' challenges related to FUED care to gain insight into the support and resources required to address FUED complex needs. An online survey was sent to all general adult emergency services within Switzerland (N = 106). Participants were asked to indicate the extent to which they perceived that FUED represented a problem and to describe the main challenges encountered. In total, 208 physicians and nurses from 75 EDs (70.7%) completed the survey. Among the 208 participants, 134 (64%) reported that FUED represented a challenge and 133 described 1 to 5 challenges encountered. A conventional content analysis yielded 4 main categories of perceived challenges. Negative consequences in the ED secondary to FUED's presence (eg, ED overcrowding, staff helplessness, and fatigue) was the most frequently reported challenge, followed by challenges related to FUEDs' characteristics (eg, mental health and social problems) leading to healthcare complexity. The third most frequently encountered challenge was related to the ED inappropriateness and inefficiency to address FUEDs' needs. Finally, challenges related to the lack of FUED healthcare network were the least often mentioned. ED healthcare providers experience a wide range of challenges related to FUED care. These findings suggest that currently EDs nor their staff are equipped to address FUEDs' complex needs.

Health care utilisation changes among Alaska Native adults after participation in an indigenous community programme to address adverse life experiences: a propensity score-matched analysis

The aim of this study was to investigate whether participation in Family Wellness Warriors Initiative (FWWI), an Alaska Native program that addresses adverse life experiences, is associated with changes in health care utilisation. The study method was a propensity score-matched cohort analysis using retrospective electronic health record data from Southcentral Foundation, a tribal health care system, from 2012 to 2017. Ninety p\articipants in FWWI trainings were identified as the intervention cohort and were propensity matched with 90 people who participated in other emotional wellness-related interventions. The primary outcome was the number of total health system visits. Secondary outcomes included emergency department (ED) visits, substance-use visits and visits with somatisation potential. After adjustment for covariates, FWWI participants showed a 36% reduction in total system visits (incidence rate ratio 0.64, 95% CI 0.49-0.84) and a 70% reduction in substance use visits (incidence rate ratio 0.30, 95% CI 0.10-0.93) when compared to the control. FWWI participants showed a 40% reduction in ED visits (incidence rate ratio 0.60, 95%CI 0.35-1.02) when compared to the control that was borderline significant. No significant differences were found for visits with somatisation potential (incidence rate ratio 1.25, 95% CI 0.79-1.99).

Experience of being a frequent user of primary care and emergency department services: a qualitative systematic review and thematic synthesis

BACKGROUND

Frequent users of healthcare services are often categorised as 'heavy-cost patients'. In the recent years, many jurisdictions have attempted to implement different public policies to optimise the use of health services by frequent users. However, throughout this process, little attention has been paid to their experience as patients.

OBJECTIVE

To thematically synthesise qualitative studies that explore the experience of frequent users of primary care and emergency department services.

DESIGN

Qualitative systematic review and thematic synthesis.

SETTING

Primary care and emergency department.

PARTICIPANTS

Frequent users of primary care and emergency department services.

METHODS

A qualitative systematic review was conducted using three online databases (MEDLINE with full text, CINAHL with full text and PsycINFO). This search was combined to an extensive manual search of reference lists and related citations. A thematic synthesis was performed to develop descriptive themes and analytical constructs.

STUDY SELECTION

Twelve studies were included. All included studies met the following inclusion criteria: qualitative design; published in English; discussed frequent users' experiences from their own perspectives and users' experiences occurred in primary care and/or emergency departments.

RESULTS

The predominant aspects of frequent users' experiences were: (1) the experience of being ill and (2) the healthcare experience. The experience of being ill encompassed four central themes: physical limitations, mental suffering, impact on relationships and the role of self-management. The healthcare experience embraced the experience of accessing healthcare and the global experience of receiving care.

CONCLUSION

This synthesis sheds light on potential changes to healthcare delivery in order to improve frequent users' experiences: individualised care plans or case management interventions to support self-management of symptoms and reduce psychological distress; and giving greater importance on the patient-providers relationship as a central facet of healthcare delivery. This synthesis also highlights future research directions that would benefit frequent users.

Effects of a geriatric education program for emergency physicians: a mixed-methods study

Emergency physicians (EPs) often regard care for older adults as complex, while they lack sufficient geriatric skills. This study evaluates the effect of a geriatric education program on EPs' geriatric knowledge, attitude and medical practice when treating older adults. A mixed-methods study was performed on EPs from two Dutch hospitals. Effects were measured by pre-post tests of EPs' (n = 21) knowledge of geriatric syndromes and attitudes toward older adults, and by a retrospective pre-post analysis of 100 records of patients aged 70 years or more. Six EPs were purposively sampled and interviewed after completion of the education program. The program significantly improved EPs' geriatric knowledge. EPs indicated that the program improved their ability and attentiveness to recognize frailty and geriatric syndromes. The program also significantly improved EPs' attention for the older patient's social history and circumstances (P = 0.04) but did not have a significant effect on medical decision making. EPs valued especially the case-based teaching and indicated that the interactive setting helped them to better understand and retain knowledge. Combined quantitative and qualitative data suggest that EPs benefit from geriatric emergency teaching. Future enhancement and evaluation of the geriatric education program is needed to confirm benefits to clinical practice and patient outcomes.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

Reasons for Emergency Department Use among Patients with Mental Disorders

Disproportionate use of emergency departments (EDs) by patients with mental disorders suggests the need to evaluate factors associated with ED use. Based on the Andersen Behavioral model, this mixed-method study identified the contributions of predisposing, enabling and needs factors in ED use among 328 patients with mental disorders. We hypothesised that ED use for mental health (MH) reasons would be most strongly associated with need factors. The study was conducted in four EDs located in different territories of Quebec (Canada). ED teams assisted with patient recruitment. Participants completed a questionnaire including a qualitative component on reasons for using the ED and assessments of ED and MH services. Data were organised according to the Andersen model, and analysed thematically. ED users were generally single, with low socioeconomic status and inadequate knowledge of MH services (predisposing factors). Most had a regular source of care which facilitated ED referrals (enabling factors); although inadequate access to outpatient care contributed to ED use. Needs factors were the primary motivators in ED use among patients with mental disorders, especially self-rated importance of problems, and MH diagnoses including suicidal ideation/attempts, depression, anxiety, and substance use disorders. Results confirmed our hypothesis that ED visits were more strongly related to needs factors. The mixed methodology reinforced the importance of predisposing and enabling factors in ED use, particularly in more complex cases. Various strategies (e.g. shared care, recruitment of addiction liaison nurses for SUD screening) are suggested for improving access to other resources and reducing non-urgent ED use.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

The Introduction and Development of the H-index for Imaging Utilizers: A Novel Metric for Quantifying Utilization of Emergency Department Imaging

OBJECTIVE

The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging.

METHODS

Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h.

RESULTS

Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%.

CONCLUSIONS

The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources.

An evaluation of the use of management care plans for people who frequently attend the emergency department

OBJECTIVE

To evaluate the use of management plans for people who frequently attend the emergency department (ED).

BACKGROUND

Management plans are used to decrease ED utilisation by people who frequently attend. There is limited evidence regarding the use management plans for this population and the perspectives of staff who use them has previously not been considered.

DESIGN

A descriptive observational design including before and after measures of attendance (November 2010 to September 2014) and survey of staff perceptions (July to November 2014). The setting was a major metropolitan hospital ED in Australia.

METHODS

The date for commencement of each plan was determined. Data were extracted regarding ED attendance 12 months before and after implementation. Staff perspectives were obtained via an online survey.

RESULTS

Fifty-seven patients made 1482 ED attendances. Of these 830 occurred in the 12 months before the management plan was implemented and 652 during the 12 months after. The number of attendances per patient decreased from a median of 11 to 4. Staff considered management plans to be beneficial to care planning practices and individual patient outcomes.

CONCLUSIONS

Management plans were acceptable to staff, and implementation of management plans was associated with a decrease in ED attendance.

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

PURPOSE

Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care.

METHODS

For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods.

RESULTS

Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes.

CONCLUSIONS

Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

Patient's Perspective on Management of Chronic Pain Associated With Frequent Emergency Attendances and Psychiatric Diagnoses

This case presents a patient's perspective of clinical care and management of chronic pain with a psychiatric component, the latter of which was not initially apparent to both patient and services. It aims to understand patient's experience of illness (part A), its effects on patient's family (part B), experience of care from liaison psychiatry (part C), service provision for persons with chronic pain and its often-neglected mental health aspect (part D), and patient's hopes for the future (part E). Early involvement of liaison psychiatry may target the interaction between physical and psychological factors and provide appropriate interventions across the health-care system.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

'They do not care how much you know until they know how much you care': a qualitative meta-synthesis of patient experience in the emergency department

BACKGROUND

Patient experience is positively associated with both clinical effectiveness and patient safety and should be a priority for emergency care providers. While both quantitative and qualitative approaches can be used to evaluate patient experience in the emergency department (ED), the latter is well aligned to develop a detailed understanding of features influencing the lived experience of ED patients. This study aimed to systematically review the literature of qualitative studies to identify determinants of adult patient experience in the ED.

METHODS

A Preferred Reporting Items for Systematic review and Meta-Analysis compliant systematic review was conducted using PubMed, CINAHL, EMBASE, BNI and bibliography searches to identify qualitative studies exploring patient experiences in ED published in English between 1997 and 2018. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Descriptive text and quotations relating to patient experience were extracted from included studies and a meta-synthesis conducted using thematic analysis.

RESULTS

A total of 625 records were screened from which 40 studies underwent full review and 22 were included. Results were coded by two researchers (BG and JML). Meta-synthesis identified 198 discrete units of analysis which were clustered around five analytical themes. These were based on the perceived 'needs' of patients visiting the ED and were defined as communication, emotional, competent care, physical/environmental and waiting needs. Findings were translated into a conceptual model for optimising patient experience in the ED.

CONCLUSION

This meta-synthesis provides a framework for understanding the determinants of patient experience in the ED. The resulting conceptual model and recommendations may have the potential to directly inform practice and improve the patient experience.

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County

BACKGROUND

In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use.

METHODS

A population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services.

RESULTS

Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12-44% for those in the lowest income groups. However, age and gender differences were observed with men 65-79 years (OR 1.75 CI: 1.51-2.03) and women 80+ years (OR 1.50, CI 1.19-1.87) in the lowest income groups having a higher odds of frequent ED use.

CONCLUSION

This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

Testing of the 'Always Events' approach to improve the patient experience in the emergency department

Maintaining quality of care and meeting patient expectations in the face of rising demand within emergency departments (ED) is a significant challenge for clinicians. This study tested the Always Events (AE) approach as a means to identify AE's relevance to patient care in the ED and act on this to address patient concerns. The project team looked to identify aspects of care patients would like to see improved within the minor injuries stream (MIS). Following triage, patients typically have presentations that do not require admission and require a single interaction with a clinician. Interventions seeking to improve patient experience were created and impact was monitored using patient feedback using a quality improvement (QI) framework. AEs were identified via convenience sampling using a short semistructured survey questionnaire. Patients were asked 'What should always happen in the Emergency Department?' Communication and information provision regarding how the department worked were identified as key themes. Two interventions, an educational poster and a video campaign, were designed and implemented. Improvement was assessed via convenience sampling of patient questionnaires using a 5-point Likert scale and free-text responses. Initial patient satisfaction levels regarding information provision stood at 80%, rising to 88% after our poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions was initially 83% in the baseline sample before rising to 86% following poster and video interventions. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period. Implementing the AE approach in the MIS has improved patient experience. Our poster intervention had the greatest benefit regarding patient understanding of the ED and information provision. This project has also indicated that the AE method can be successfully combined with a QI tool and applied in the ED to address patient needs.

Emergency Department Utilization by Native American Children

OBJECTIVES

The aims of this study were to determine differences in emergency department (ED) use by Native American (NA) children in rural and urban settings and identify factors associated with frequent ED visits.

METHODS

This cross-sectional, cohort study examined visits to 6 EDs: 2 rural, 2 midsize urban, and 2 large urban EDs from June 2011 to May 2012. Univariate and multiple regression analyses were conducted. Frequent ED visitors had more than 4 visits in the study period.

RESULTS

We studied 8294 NA visits (5275 patients) and 44,503 white visits (33,945 patients). Rural EDs had a higher proportion of NA patients, those below 200% of the income poverty level, and those who traveled more than 10 miles from their residence to attend the ED (all P < 0.05) compared with midsize and urban EDs. Native American patients had a high proportion of mental health diagnoses compared with whites (4.9% vs 1.9%, P < 0.001). Frequent ED visitors had greater odds of NA race, age younger than 1 year, public insurance, female sex, residence within less than 5 miles from the ED, and chronic disease.

CONCLUSIONS

Native American children seem to have greater challenges compared with whites obtaining care in rural areas. Native American children were more likely to be frequent ED visitors, despite having to travel farther from their residence to the ED. Native American children visiting rural and midsize urban EDs had a much higher prevalence of mental health problems than whites. Additional efforts to provide both medical and mental health services to rural NA are urgently needed.

Navigating medically complex patients through system barriers: Patients’ perspectives on care coordination

Introduction

Care coordination can improve healthcare quality and reduce costs. The objective of this study was to provide a qualitative understanding of the most helpful coordination services as experienced by patients receiving these services to reduce emergent hospital use.

Methods

Using case study methodology, we conducted focus group conversations with 51 care coordination patients and semi-structured interviews with 29 care coordinators at nine sites throughout Texas. The study team performed constant comparative analysis, beginning with start codes based on prior research.

Results

On average, focus group participants were 47 years old. The majority of participants reported a high school or General Equivalency Diploma level of education or less (84%), an annual income less than $14,999 (87%), and living with multiple chronic health conditions (60%). The majority (85%) of care coordinators reported backgrounds in nursing or social work. In our analysis, themes of what patients found most helpful fell under a broad social support framework (instrumental, informational, emotional, and advocacy) that care coordinators were uniquely situated to provide.

Discussion

Our paper adds to existing evidence by providing perspectives of patients with complex medical and non-medical needs about which care coordination services are most helpful. In this sample, patients with high needs describe reliance on professional sources, rather than their own social networks, to address several aspects of social support and to help meet non-health-related, as well as health-related needs. This can inform providers’ approaches to treatment as well as program administrators’ decisions about addressing and prioritizing services in care coordination programs.

Patient perspectives on emergency department self-referral after bariatric surgery

BACKGROUND

Reducing avoidable emergency department (ED) visits is an increasingly important target of quality improvement and cost containment efforts in bariatric surgery. Administrative and clinical registry data provide an incomplete picture of the factors contributing to postoperative ED utilization. Patient-centered interviews can help identify intervention opportunities.

OBJECTIVES

We sought to understand the circumstances surrounding patient self-referral to the ED after elective, primary bariatric surgery.

SETTING

A quality improvement collaborative in Michigan.

METHODS

A prospective review of clinically abstracted data and patient interviews was completed across 40 hospitals participating in a statewide quality improvement collaborative. Trained nurses collected data on the circumstances surrounding patients' 30-day postoperative ED visits using a previously validated interview tool. Over a year, 201 of 633 total ED visits met the inclusion criteria, with 78% of those patients being interviewed.

RESULTS

The most common reported chief complaints were abdominal pain and nausea/vomiting. Patients reported high compliance with provider-driven perioperative measures to reduce ED visits. One third of patients stated urgency as the reason for not contacting their surgeon prior to their visit. A majority of patients believed their ED visit was both necessary and unavoidable.

CONCLUSIONS

Most patients experienced non-life-threatening symptoms but believed their concerns required immediate medical attention in an ED. Patients did not seek lower acuity alternatives despite the increasing availability of these lower cost options. Urgent care centers are one practical alternative for patients who need expeditious professional evaluation. Focused, patient-centered education and promotion of appropriate lower acuity options may decrease nonurgent ED utilization among postoperative bariatric patients.

"Hospital was the Only Option": Experiences of Frequent Emergency Department Users in Mental Health

The experiences of individuals with mental illness and addictions who frequently present to hospital emergency departments (EDs) have rarely been explored. This study reports findings from self-reported, quantitative surveys (n = 166) and in-depth, qualitative interviews (n = 20) with frequent ED users with mental health and/or substance use challenges in a large urban centre. Participants presented to hospital for mental health (35 %), alcohol/drug use (21 %), and physical health (39 %) concerns and described their ED visits as unavoidable and appropriate, despite feeling stigmatized by hospital personnel and being discharged without expected treatment. Supporting this population may require alternative service models and attention to staff training in both acute and community settings.

Living with chronic obstructive pulmonary disease: The stories of frequent attenders to the Emergency Department

AIMS AND OBJECTIVES

To explore the experiences of chronic obstructive pulmonary disease (COPD) amongst individuals who have a high frequency of presentations to the Emergency Department and their carers.

BACKGROUND

Patients with COPD are amongst the most frequent attenders in the Emergency Department despite the chronic nature of their condition. Good self-management has previously been identified as a key to maintaining health and reducing COPD exacerbations. There has been limited investigation of those with COPD who frequently attend the Emergency Department.

DESIGN

Descriptive qualitative phase of a mixed methods study.

METHODS

Individuals who had attended an Emergency Department within a single health district at least three times in the previous year for COPD were invited to participate in semistructured face-to-face interviews. A total of 19 individuals consented to participate, of whom 12 were male. Half of the interviews included both those with COPD and carers. Data were audio-recorded and transcribed, before being analysed using thematic analysis.

RESULTS

Five main themes emerged from the data, namely (i) a sense of grief, loss and guilt, yet hope for the future; (ii) the impact on carers; (iii) the end point of self-management; (iv) the healthcare experience; and (v) the primary care experience.

CONCLUSION

The experience of individuals with COPD who frequently present to the Emergency Department and their carers highlights the complexity of living with this disease. Providing effective intervention to manage exacerbation requires an understanding of the issues that are faced by patients and their carers. Clear systems and skills for sharing information are essential to decrease avoidable use of the Emergency Department.

Better safe than sorry? Frequent attendance in a hospital emergency department: an exploratory study

Introduction

Pain accounts for the majority of attendances to the Emergency Department (ED), with insufficient alleviation of symptoms resulting in repeated attendance. People who frequently attend the ED are typically considered to be psychologically and socially vulnerable in addition to experiencing health difficulties. This service development study was commissioned to identify the defining characteristics and unmet needs of frequent attenders (FAs) in a UK acute district general hospital ED, with a view to developing strategies to meet the needs of this group.

Methods

A mixed-methods multi-pronged exploratory approach was used, involving staff interviews, focus groups, business data and case note analysis.

Results

Findings reflect an absence of a coherent approach to meeting the needs of FAs in the ED, especially those experiencing pain. FAs to this ED tend to be vulnerable, complex and report significant worry and anxiety. Elevated anxiety on the part of the patient may be contributing to a 'better safe than sorry' culture within the ED and is reported to bear some influence on the clinical decision-making process.

Discussion

It is recommended that a systemic approach is taken to improve the quality and accessibility of individualised care plans, provision of patient education, psychological care and implementation of policies and procedures. Change on an organisational level is likely to improve working culture, staff satisfaction and staff relationships with this vulnerable group of patients. A structured care pathway and supportive changes are likely to lead to economic benefits. Further research should build on findings to implement and test the efficacy of these interventions.

Patient Perspectives on Accessing Acute Illness Care

Introduction

Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs.

Methods

We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews.

Results

The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses.

Conclusion

Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs’ capabilities, and enhancing EDs’ resources to care for older patients.

Frequent emergency department presentations among people who inject drugs: A record linkage study

BACKGROUND

People who inject drugs (PWID) have been described as frequent users of health services such as emergency departments (EDs), however few studies have described demographic factors, patterns of substance use and previous health service use associated with frequent use of EDs in this population.

METHODS

Using a combination of self-reported data from a cohort of PWID and administrative ED data obtained through record linkage, we identified longitudinal factors associated with the use of ED services. Bivariate and multivariate analyses were conducted using negative binomial regression to identify exposures associated with both cumulative ED presentations, and logistic regression to identify exposures of frequent ED presentations (defined as three or more annual presentations).

RESULTS

Among 612 PWID, over half (58%) presented to EDs at least once and over a third (36%) presented frequently between January 2008 and June 2013. Frequent and cumulative ED presentations were associated with reporting the main drug of choice as cannabis (AOR:1.42, 95%CI:1.07-1.89 and AIRR:2.96, 95%CI:1.44-6.07 respectively) or methamphetamine (AOR:1.62, 95%CI:1.17-2.2 and AIRR:2.42, 95%CI:1.08-5.46 respectively) compared to heroin, and past month use of mental health (AOR:1.42, 95%CI:1.08-1.85 and AIRR:3.32, 95%CI:1.69-6.53 respectively) and outpatient services (AOR:1.47, 95%CI: 1.00-2.16 and AIRR:0.95, 95%CI 1.52-10.28 respectively).

CONCLUSION

PWID who are frequent users of EDs are likely to have complex health and substance use-related needs. EDs should actively refer people who present with cannabis and methamphetamine dependence to harm reduction services. Harm reduction services should ensure people referred from EDs are screened for co-occurring mental health conditions and receive adequate support.

Value-Based Approaches for Emergency Care in a New Era

Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients' longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care. When integrated with primary and subspecialty care, emergency care might meet the needs of patients, providers, and payers more efficiently than yet realized. This article uses the Merit-Based Incentive Payment System from the Medicare Access and CHIP Reauthorization Act as a framework to outline a strategy for improving the value of emergency care, including integrating quality and resource use measures across health care delivery settings and populations, encouraging care coordination from the ED, and implementing robust health information exchange systems.

Perceived Case Management Needs and Service Preferences of Frequent Emergency Department Users: Lessons Learned in a Large Urban Centre

Objectives

This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention.

Methods

We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care.

Results

Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers.

Conclusion

Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.

A Decision support system (DSS) for municipal nurses encountering health deterioration among older people

Background

This study is part of a larger project called ViSam and includes testing of a decision support system developed and adapted for older people on the basis of M (R) ETTS (Rapid Emergency Triage and Treatment System). The system is designed to allow municipal nurses to determine the optimal level of care for older people whose health has deteriorated. This new system will allow more structured assessment, the patient should receive optimal care and improved data transmission to the next caregiver.

Methods

This study has an explanatory approach, commencing with quantitative data collection phase followed by qualitative data arising from focus group discussions over the RNs professional experience using the Decision Support system. Focus group discussions were performed to complement the quantitative data to get a more holistic view of the decision support system.

Results

Using elements of the decision support system (vital parameters for saturation, pain and affected general health) together with the nurses' decision showed that 94 % of the older persons referred to hospital were ultimately hospitalized. Nurses felt that they worked more systematically, communicated more effectively with others and felt more professional when using the decision support system.

Conclusions

The results of this study showed that, with the help of a decision support system, the correct patients are sent to the Emergency Department from municipal home care. Unnecessary referrals of older patients that might lead to poorer health, decreased well-being and confusion can thus be avoided. Using the decision support system means that healthcare co-workers (nurses, ambulance/emergency department/district doctor/SOS alarm) begin to communicate more optimally. There is increased understanding leading to the risk of misinterpretation being reduced and the relationship between healthcare co-workers is improved. However, the decision support system requires more extensive testing in order to enhance the evidence base relating to the vital parameters among older people and the use of the decision support system.

Personal Characteristics and Experience of Primary Care Predicting Frequent Use of Emergency Department: A Prospective Cohort Study

OBJECTIVE

A small number of patients frequently using the emergency department (ED) account for a disproportionate amount of the total ED workload and are considered using this service inappropriately. The aim of this study was to identify prospectively personal characteristics and experience of organizational and relational dimensions of primary care that predict frequent use of ED.

METHODS

This study was conducted among parallel cohorts of the general population and primary care patients (N = 1,769). The measures were at baseline (T1), 12 (T2) and 24 months (T3): self-administered questionnaire on current health, health behaviours and primary care experience in the previous year. Use of medical services was confirmed using administrative databases. Mixed effect logistic regression modeling identified characteristics predicting frequent ED utilization.

RESULTS

A higher likelihood of frequent ED utilization was predicted by lower socioeconomic status, higher disease burden, lower perceived organizational accessibility, higher number of reported healthcare coordination problems and not having a complete annual check-up, above and beyond adjustment for all independent variables.

CONCLUSIONS

Personal characteristics such as low socioeconomic status and high disease burden as well as experience of organizational dimensions of primary care such as low accessibility, high healthcare coordination problems and low comprehensiveness of care are prospectively associated with frequent ED utilization. Interventions developed to prevent inappropriate ED visits, such as case management for example, should tailor low socioeconomic status and patients with high disease burden and should aim to improve experience of primary care regarding accessibility, coordination and comprehensiveness.

Frequent Emergency Department Utilizers Among Children with Cancer

BACKGROUND

Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED visits, but no studies specifically address children with cancer.

METHODS

A retrospective study of Pediatric Health Information System analyzing ED visits for children with cancer, including ED visits within 365 days from the first inpatient encounter with a discharge diagnosis code for malignancy. We defined frequent ED utilizers as those with four or more visits in the year (top 10th percentile). Patient characteristics and ED services (medications, laboratory, or imaging) for discharged children were assessed. Factors associated with being a frequent ED utilizer were examined with multivariable regression.

RESULTS

Frequent utilizers accounted for 58% of ED visits. Frequent utilizers differed from infrequent utilizers in terms of type of cancer; 39.3% of frequent utilizers had acute lymphoblastic leukemia (ALL) and 16.0% had central nervous system (CNS) tumors compared with infrequent utilizers (21.9% had ALL and 24.8% CNS tumors, P-value < 0.001). Frequent utilization was associated with age 5-9 years (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2-1.6) or 1-4 years (OR = 2.1, 95% CI 1.8-2.4) or <1 year (OR = 2.2, 95% CI 1.9-2.6) compared to 15-19 years and Hispanic ethnicity (OR 1.3, 95% CI 1.1-1.5) compared to white, non-Hispanics, and urban residence (OR = 1.5, 95% CI 1.3-1.7). Few children with cancer received no medication, laboratory, or imaging during their ED visit (frequent 11.0% vs. infrequent 12.5%, P = 0.01).

CONCLUSIONS

The ED is integral to the care provided to children with cancer. The subset of frequent utilizers should be the focus of future research and quality improvement efforts.

Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study

OBJECTIVES

First, to test a model of the drivers of frequent emergency department utilization conceptualized as falling within predisposing, enabling, and need dimensions. Second, to extend the model to include social networks and service quality as predictors of frequent utilization. Third, to illustrate the variation in thresholds that define frequent utilization in terms of the number of emergency department encounters by the predictors within the model.

DATA SOURCE

Primary data collection over an eight week period within a level-1 trauma urban hospital's emergency department.

STUDY DESIGN

Representative randomized sample of 1,443 adult patients triaged ESI levels 4-5. Physicians and research staff interviewed patients as they received services. Relationships with the outcome variable, utilization, were tested using logistic regression to establish odds-ratios.

PRINCIPAL FINDINGS

70.6 percent of patients have two or more, 48.3 percent have three or more, 25.3 percent have four or more, and 14.9 percent have five or more emergency department visits within 12 months. Factors associated with frequent utilization include gender, race, poor mental health, mental health drugs, prescription drug abuse, social networks, employment, perceptions of service quality, seriousness of condition, persistence of condition, and previous hospital admittance.

CONCLUSIONS

Interventions targeting associated factors will change global emergency department encounters, although the mutability varies. Policy interventions to address predisposing factors such as substance abuse or access to mental health treatment as well as interventions that speak to enabling factors such as promoting the resiliency of social networks may result in decreased frequency of emergency department utilization.

Patients' experiences of psychiatric care in emergency departments: A secondary analysis

The number of psychiatric emergencies presenting to EDs in the United States continues to rise. Evidence suggests that psychiatric ED care encounters can have less than optimal outcomes, and result in stress for providers. The primary aim of this study is to describe the perceptions of ED visits by persons experiencing emotional distress, identifying themes among these that may guide nursing interventions that minimize stress and optimize outcomes in the treatment of psychiatric emergency. This secondary analysis used a qualitative, phenomenological method to analyze a de-identified data set originally collected in a study of experiences of psychiatric emergency in a community based crisis management setting. Findings consist of three major themes: "Emergency rooms are cold and clinical", "They talk to you like you're a crazy person", and "You get put away against your will". An overarching theme through all three is the influence of RN communication, both positive and negative, on patient perceptions of their ED encounters. While nurse-patient communication is basic to all areas of practice, it may be a low priority in the urgent and chaotic context of the ED. However, our findings suggest that increased attention to timely, empathic and validating communication and openness to the patient's reality may decrease severity of symptoms, optimize outcomes, and decrease provider stress.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore

OBJECTIVES

This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.

METHODS

This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.

RESULTS

In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.

CONCLUSIONS

ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.

Non-urgent accident and emergency department use as a socially shared custom: a qualitative study

Objective

We explored attitudes of non-urgent accident and emergency department (AED) patients in the middle-income healthcare setting Saint Vincent and the Grenadines (SVG) in the Caribbean to understand how and why they decide to seek emergency care and resist using primary care facilities.

Methods

In 2013, we conducted 12 semistructured interviews with a purposive sample of non-urgent AED users from a variety of social backgrounds. Verbatim transcripts were analysed with a grounded theory approach.

Results

In this study, we found, first, that participants automatically chose to visit the AED and described this as a locally shared custom. Second, the healthcare system in SVG reinforced this habitual use of the AED, for example, by health professionals routinely referring non-urgent cases to the AED. Third, there was also some deliberate use; patients took convenience and the systemic encouragement into account to determine that the AED was the most appropriate choice for healthcare.

Conclusions

We conclude that the attitudes and habits of the Vincentian non-urgent patient are major determinants of their AED use and are intricately linked to local, socially shared practices of AED use. Findings show that health services research should reconsider rational choice behaviour models and further explore customs of health-seeking.

Social deprivation and adult blunt chest trauma: A retrospective study

INTRODUCTION

The relationship between socioeconomic status and various components of health is well established. Research has also highlighted that social deprivation can affect patterns of injury and outcome after trauma. The interaction between outcomes following blunt chest trauma and socioeconomic status has received limited attention in trauma research. The aim of this study was to investigate the relationship between socioeconomic factors, mechanisms of injury and outcomes following blunt chest trauma using deprivation measures calculated on the basis of domicile postcodes.

METHODS

A retrospective study design was used in order to examine the medical notes of all blunt chest wall trauma patients who presented to the ED of a large regional trauma centre in South West Wales in 2012 and 2013. Baseline characteristics were presented as median and interquartile range or numbers and percentages. Differences between the baseline characteristics were analysed using Mann-Whitney U test and Fisher's exact test. Odds ratios and 95% confidence intervals were presented from the univariable analysis. Multivariable logistic regression analysis was used to identify significant predictors for the development of complications.

RESULTS

Patients in the 'more deprived' group were more likely to be the victims of assault (p < 0.001) and were more likely to have an unplanned re-attendance at the Emergency Department than the patients in the 'less deprived' group (p < 0.001). On multivariable analysis, social deprivation was not a risk factor for the development of complications, but it was a significant risk factor for prolonged length of stay (p < 0.05).

CONCLUSIONS

This is the first study in which social deprivation has been investigated as a risk factor for complications following isolated blunt chest wall trauma. Residing in a 'more deprived' area in South West Wales is not associated with the development of complications following isolated blunt chest wall trauma.

Survival of patients with alcohol use disorders discharged from an emergency department: a population-based cohort study

OBJECTIVES

The aim was to study the cause-specific mortality of users of the emergency department (ED) who received a diagnosis of alcohol use disorder (AUD) in comparison with mortality of other users of the department.

DESIGN

A population-based prospective cohort study.

PARTICIPANTS

All patients aged 18 years and above who were subsequently discharged home from the ED during the years 2002-2008. A total of 107,237 patients were followed by record linkage to a nationwide cause-of-death registry: 1210 patients with AUD as the main discharge diagnosis and 106,027 patients in the comparison group. HR and 95% CIs were calculated.

SETTING

ED at Landspitali-the National University Hospital of Iceland, Reykjavik, Iceland. The hospital offers tertiary care and is the number one trauma centre and community hospital for the greater Reykjavik area. According to the population registry, 78% of the inhabitants of the area attended the ED during the study period.

RESULTS

72 patients died in the AUD group and 4807 in the comparison group. The adjusted HR for all causes of death was 1.91 (95% CI 1.51 to 2.42). The HR for AUDs was 47.68 (95% CI 11.56 to 196.59) while for alcohol liver disease the HR was 19.06 (95% CI 6.07 to 59.87). The HR was also elevated for diseases of the circulatory system: HR 2.52 (95% CI 1.73 to 3.68); accidental poisoning: HR=13.64, (95% CI 3.98 to 46.73); suicide: HR=2.72 (95% CI 1.08 to 6.83); and event of undetermined intent: HR=10.89 (95% CI 4.53 to 26.16).

CONCLUSIONS

AUD as the discharge diagnosis at the ED, among patients who were not admitted to a hospital ward but discharged home, predicts increased mortality. As the results conclusively show the vulnerability of these patients, one can question whether their needs are adequately met at the ED.

Operation of emergency operating centers during mass casualty incidents in taiwan: a disaster management perspective

OBJECTIVE

On April 27, 2011, a train derailed and crashed in Taiwan, causing a mass casualty incident (MCI) that was similar to a previous event and with similar consequences. In both disasters, the emergency operating centers (EOCs) could not effectively integrate associated agencies to deal with the incident. The coordination and utilization of resources were inefficient, which caused difficulty in command structure operation and casualty evacuation.

METHODS

This study was designed to create a survey questionnaire with problem items using disaster management phases mandated by Taiwan's Emergency Medical Care Law (EMCL), use statistical methods (t test) to analyze the results and issues the EOCs encountered during the operation, and propose solutions for those problems.

RESULTS

Findings showed that EOCs lacked authority to intervene or coordinate with associated agencies. Also, placing emphasis on the recovery phase should improve future prevention and response mechanisms.

CONCLUSIONS

To improve the response to MCIs, the EMCL needs to be amended to give EOCs the lead during disasters; use feedback from the recovery phase to improve future disaster management and operation coordination; and establish an information-sharing platform across agencies to address all aspects of relief work.(Disaster Med Public Health Preparedness. 2014;0:1-6).