The use of the accident and emergency department

Factors reducing inappropriate attendances to emergency departments before and during the COVID-19 pandemic: A multicentre study

INTRODUCTION

Inappropriate attendances (IAs) to emergency departments (ED) create an unnecessary strain on healthcare systems. With decreased ED attendance during the COVID-19 pandemic, this study postulates that there are less IAs compared to before the pandemic and identifies factors associated with IAs.

METHODS

We performed a retrospective review of 29,267 patient presentations to a healthcare cluster in Singapore from 7 April 2020 to 1 June 2020, and 36,370 patients within a corresponding period in 2019. This time frame coincided with local COVID-19 lockdown measures. IAs were defined as patient presentations with no investigations required, with patients eventually discharged from the ED. IAs in the 2020 period during the pandemic were compared with 2019. Multivariable logistic regression was performed to identify factors associated with IAs.

RESULTS

There was a decrease in daily IAs in 2020 compared to 2019 (9.91±3.06 versus 24.96±5.92, P<0.001). IAs were more likely with self-referrals (adjusted odds ratio [aOR] 1.58, 95% confidence interval [CI] 1.50-1.66) and walk-ins (aOR 4.96, 95% CI 4.59-5.36), and those diagnosed with non-specific headache (aOR 2.08, 95% CI 1.85-2.34), or non-specific low back pain (aOR 1.28, 95% CI 1.15-1.42). IAs were less likely in 2020 compared to 2019 (aOR 0.67, 95% CI 0.65-0.71) and older patients (aOR 0.79 each 10 years, 95% CI 0.78-0.80).

CONCLUSION

ED IAs decreased during COVID-19. The pandemic has provided a unique opportunity to examine factors associated with IAs.

Accident and emergency department attendance rates of people experiencing homelessness by GP registration: a retrospective analysis

BACKGROUND

People experiencing homelessness are known to have complex health needs and to be high users of hospital accident and emergency (A&E) departments. It is unclear whether access to a day-time specialist homeless medical practice, as opposed to routine general practice, influences A&E attendance rates.

AIM

This study investigated whether registration with a specialist homeless service would alter A&E attendance rates in a single geographical region in Scotland.

DESIGN & SETTING

A health board area with a specialist service for people experiencing homelessness was selected. Data were obtained from the hospital records of 4408 A&E attendances by people experiencing homelessness at NHS Lothian (based on a broad definition of homelessness and including those in temporary accommodation) between January 2015 and July 2017.

METHOD

The attendances were compared between people registered with a specialist service and those registered with a mainstream GP.

RESULTS

The reasons for attendance and urgency of attendance were broadly similar between the two groups. Repeat attendance was similarly high in both groups. Almost 70% in both groups attended with problems deemed urgent, very urgent, or requiring immediate resuscitation. The patients registered with the specialist homeless service were more likely to be older and male; however, this did not affect the frequency of attendance.

CONCLUSION

People experiencing homelessness attending A&E mainly do so for urgent or very urgent problems. This was not related to the type of day-time primary care service they had access to. Strategies to reduce attendances, such as out-of-hours mobile medical units, should be explored.

Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore

INTRODUCTION

Inappropriate attendances (IAs) at emergency departments (ED) are contributed by patients with mild or moderate medical conditions that can be effectively managed by primary care physicians. IAs strain limited ED resources and have an adverse impact on efficiency. This study aimed to identify factors associated with IA at the ED of a tertiary hospital in Singapore.

METHODS

We conducted a retrospective cohort study of all eligible visits to the aforementioned ED between 1 January 2015 and 31 December 2015. The appropriateness of each attendance was estimated using criteria based on investigations or procedures that were performed on the attendee and the discharge type of that attendance. IAs were then compared against appropriate attendances in these areas: attendee demographics; referral source; time of ED visit; proximity to ED and 24-hour general practitioner clinics; and history of ED visits in 2014. Multivariate analysis was performed on significant variables associated with IAs.

RESULTS

Among 120,606 attendances, 11,631 (9.6%) were IAs. Multivariate analysis showed that gender, ethnicity, referral source, time of ED visit, nationality and history of frequent visits to the ED were factors associated with IAs. Moreover, the odds of IA were found to be higher among attendees who were younger, were self-referred, or had at least one IA in 2014.

CONCLUSION

This study identified subgroups in the population who were more likely to contribute to IAs at the ED. These findings offer relevant insights into future research directions and strategies that might potentially reduce avoidable IAs.

General practitioners providing non-urgent care in emergency department: a natural experiment

OBJECTIVE

To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators.

DESIGN

Propensity score matched cohort study.

SETTING

GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016.

PARTICIPANTS

Non-urgent attendances visits to the A&E department.

MAIN OUTCOMES

Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E clinical indicators (spent 4 hours plus, left without being seen and 7-day reattendance).

RESULTS

A total of 5426 patients seen by GPs in A&E were matched with 10 852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio (RR) 0.28, 95% CI 0.25 to 0.31), referred fewer patients to other specialists (RR 0.31, 95% CI 0.24 to 0.40), ordered fewer radiological investigations (RR 0.38, 95% CI 0.34 to 0.42), ordered fewer blood tests (0.57, 95% CI 0.52 to 0.61) and ordered fewer investigations (0.93, 95% CI 0.90 to 0.96). However, they intervened more, offered more primary care follow-up (RR 1.78, 95% CI 1.67 to 1.89) and referred more patients to outpatient and other A&E clinics (RR 2.29, 95% CI 2.10 to 2.49). Patients seen by GPs in A&E were on average less likely to spend 4 hours plus in A&E (RR 0.37, 95% CI 0.30 to 0.45) compared with standard care in A&E. There was no difference in reattendance after 7 days (RR 0.96, 95% CI 0.84 to 1.09).

CONCLUSION

GPs in A&E tended to manage self-reporting minor cases with fewer resources than standard care in A&E, without increasing reattendance rates.

The quality, safety and governance of telephone triage and advice services - an overview of evidence from systematic reviews

Background

Telephone triage and advice services (TTAS) are increasingly being implemented around the world. These services allow people to speak to a nurse or general practitioner over the telephone and receive assessment and healthcare advice. There is an existing body of research on the topic of TTAS, however the diffuseness of the evidence base makes it difficult to identify key lessons that are consistent across the literature. Systematic reviews represent the highest level of evidence synthesis. We aimed to undertake an overview of such reviews to determine the scope, consistency and generalisability of findings in relation to the governance, safety and quality of TTAS.

Methods

We searched PubMed, MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library for English language systematic reviews focused on key governance, quality and safety findings related to telephone based triage and advice services, published since 1990. The search was undertaken by three researchers who reached consensus on all included systematic reviews. An appraisal of the methodological quality of the systematic reviews was independently undertaken by two researchers using A Measurement Tool to Assess Systematic Reviews.

Results

Ten systematic reviews from a potential 291 results were selected for inclusion. TTAS was examined either alone, or as part of a primary care service model or intervention designed to improve primary care. Evidence of TTAS performance was reported across nine key indicators – access, appropriateness, compliance, patient satisfaction, cost, safety, health service utilisation, physician workload and clinical outcomes. Patient satisfaction with TTAS was generally high and there is some consistency of evidence of the ability of TTAS to reduce clinical workload. Measures of the safety of TTAS tended to show that there is no major difference between TTAS and traditional care.

Conclusions

Taken as a whole, current evidence does not provide definitive answers to questions about the quality of care provided, access and equity of the service, its costs and outcomes. The available evidence also suggests that there are many interactional factors (e.g., relationship with other health service providers) which can impact on measures of performance, and also affect the external validity of the research findings.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2564-x) contains supplementary material, which is available to authorized users.

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.

Reducing inappropriate accident and emergency department attendances: a systematic review of primary care service interventions

BACKGROUND

Inappropriate attendances may account for up to 40% of presentations at accident and emergency (A&E) departments. There is considerable interest from health practitioners and policymakers in interventions to reduce this burden.

AIM

To review the evidence on primary care service interventions to reduce inappropriate A&E attendances.

DESIGN AND SETTING

Systematic review of UK and international primary care interventions.

METHOD

Studies published in English between 1 January 1986 and 23 August 2011 were identified from PubMed, the NHS Economic Evaluation Database, the Cochrane Collaboration, and Health Technology Assessment databases. The outcome measures were A&E attendances, patient satisfaction, clinical outcome, and intervention cost. Two authors reviewed titles and abstracts of retrieved results, with adjudication of disagreements conducted by the third. Studies were quality assessed using the Scottish Intercollegiate Guidelines Network checklist system where applicable.

RESULTS

In total, 9916 manuscripts were identified, of which 34 were reviewed. Telephone triage was the single best-evaluated intervention. This resulted in negligible impact on A&E attendance, but exhibited acceptable patient satisfaction and clinical safety; cost effectiveness was uncertain. The limited available evidence suggests that emergency nurse practitioners in community settings and community health centres may reduce A&E attendance. For all other interventions considered in this review (walk-in centres, minor injuries units, and out-of-hours general practice), the effects on A&E attendance, patient outcomes, and cost were inconclusive.

CONCLUSION

Studies showed a negligible effect on A&E attendance for all interventions; data on patient outcomes and cost-effectiveness are limited. There is an urgent need to examine all aspects of primary care service interventions that aim to reduce inappropriate A&E attendance.

Who uses emergency departments inappropriately and when - a national cross-sectional study using a monitoring data system

BACKGROUND

Increasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide. A potentially avoidable pressure is inappropriate attendances (IA); typically low urgency, self-referred patients better managed by other services. This study examines demographics and temporal trends associated with IA to help inform measures to address them.

METHODS

Using a national ED dataset, a cross-sectional examination of ED attendances in England from April 2011 to March 2012 (n = 15,056,095) was conducted. IA were defined as patients who were self-referred; were not attending a follow-up; received no investigation and either no treatment or 'guidance/advice only'; and were discharged with either no follow-up or follow-up with primary care. Small, nationally representative areas were used to assign each attendance to a residential measure of deprivation. Multivariate analysis was used to predict relationships between IA, demographics (age, gender, deprivation) and temporal factors (day, month, hour, bank holiday, Christmas period).

RESULTS

Overall, 11.7% of attendances were categorized as inappropriate. IA peaked in early childhood (adjusted odds ratio (AOR) = 1.53 for both one and two year olds), and was elevated throughout late-teens and young adulthood, with odds reducing steadily from age 27 (reference category, age 40). Both IA and appropriate attendances (AA) were most frequent in the most deprived populations. However, relative to AA, those living in the least deprived areas had the highest odds of IA (AOR = 0.89 in most deprived quintile). Odds of IA were also higher for males (AOR = 0.95 in females). Both AA and IA were highest on Mondays, whilst weekends, bank holidays and the period between 8 am and 4 pm saw more IA relative to AA.

CONCLUSIONS

Prevention of IA would be best targeted at parents of young children and at older youths/young adults, and during weekends and bank holidays. Service provision focusing on access to primary care and EDs serving the most deprived communities would have the most benefit. Improvements in coverage and data quality of the national ED dataset, and the addition of an appropriateness field, would make this dataset an effective monitoring tool to evaluate interventions addressing this issue.

[Effect of the incorporation of a general practitioner on emergency department effectiveness]

BACKGROUND AND OBJECTIVES

To know the effect that the presence of a general practitioner (GP) has on emergency department's effectiveness, efficiency and health care.

PATIENTS AND METHOD

Prospective interventional study carried out in the emergency medicine unit fast track area (FTA), which is ideally opened from 8 am to 12 am, and staffed by 2 residents.

INTERVENTION

8 resident hours (from 4 pm to 12 am) were substituted by 8 GP hours. The study period was August 2002 (GP presence), and the control period, October 2002. From each period, 10 days and 100 patients were randomly selected. From each day, FTA census (P), percentage of revisits and patients leaving without being seen, elapsed time to FTA actual closing (OT), percentage of patients moved to the observation area, and percentage of admissions were recorded. From each patient, epidemiological and clinical characteristics, waiting time to be seen (WT), number of tests performed, elapsed time to treatment (TT), and length of stay (LOS) were collected along with the number of patients finally discharged without hospital specialist consultation and those discharged with no test ordered. To assess perceived care quality, a telephone survey was performed. Three effectiveness indexes were defined and determined: P/WT (E1), P/OT (E2), and perceived care quality/perceived WT (E3). Finally, fixed and variables costs (C) from both periods were calculated, and cost-effectiveness analysis for each effectiveness index and period performed.

RESULTS

Periods showed no differences regarding daily census and patient characteristics. In the study period (GP presence), all time variables significantly improved: 20% reduction in WT, 25% in TT, 36% in LOS, and 17.5% in OT. A decrease in the number of tests ordered (41% less), in the percentage of patients moved to the observation area (78% less), and in the revisit rate (75% less) was also noted. Finally, E1 improved in 77% and E2 in 51%. Cost-effectiveness analysis clearly supported the study period, showing a decrease in C/E1 (55% less), in C/E2 (33% less), and in C/E3 (6% less). From the telephone survey, no differences between periods were detected except a perceived WT in the study period lower than that in the control period.

CONCLUSIONS

The presence of a GP in a FTA leads to an improvement in the effectiveness and quality of care received by attended patients. In addition of these important features, this presence is also efficient. Therefore, it is an intervention that could be taken into account by administrators to better manage emergency departments.

Emergency medicine in the Netherlands, the necessity for changing the system: results from two questionnaires

OBJECTIVE

To obtain information about patient, staff and organization characteristics of Emergency Departments in the Netherlands, and evaluate the changes between 1996 and 1999.

METHODS

The heads of the Emergency Departments of all hospitals in the Netherlands were sent a questionnaire concerning patient, staff, and organization characteristics, as well as questions about intended future developments. The results were compared with data obtained from a comparable questionnaire in 1996.

RESULTS

In the Netherlands, 113 hospitals (113/126) have an Emergency Department; 105/113 returned the questionnaire (93%). Ninety-two percent of the hospitals reported an increase in annual Emergency Department census and in the number of self-referred patients. The number of Emergency Departments staffed by only surgical residents decreased (52% in 1996 versus 41% in 1999), whereas the number of hospitals employing emergency physicians increased (24% in 1996 versus 45% in 1999). In 92% of the hospitals, nurses who work in the Emergency Department receive specific training. For emergency physicians, a specific training programme is not available, and in fact 30% of the physicians did not have any specific emergency medicine training. Therefore, none of the emergency physicians were fully trained in emergency medicine. According to 88% of all responders, there is a future for emergency medicine as an independent speciality in the Netherlands, and 35% of all hospitals intend to initiate a training programme for emergency physicians in the future.

CONCLUSION

Almost all hospitals in the Netherlands reported an increase in the number of patients visiting the Emergency Department, especially in the number of self-referred patients. A majority of the Emergency Departments are now staffed by emergency physicians instead of surgical residents. Developing specific training programmes for emergency physicians should be a priority for the Netherlands in the future.

How to minimize inappropriate utilization of Accident and Emergency Departments: improve the validity of classifying the general practice cases amongst the A&E attendees

Studies have found that one-third to two-thirds of all patients attending Accident and Emergency (A and E) Departments could be managed appropriately by general practitioners (GPs). There is also evidence that referral to GPs can be acceptable to patients. The question of primary concern is screening non-urgent cases with high degrees of sensitivity (S), specificity (SP), and positive predictive value (PPV). This paper reports the findings of the validity (S, SP and PPV) of nurses and patients in triaging A and E visitors. A cross sectional study was conducted over a 1 year period and subjects were randomly selected from four A and E Departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. S, SP and PPVs were computed for both non-weighted and weighted conditions. The gold standard for defining the true urgency status of each selected patient was based on a review of the patient's record 3-21 days (or longer if necessary) following the A and E visit. The record review in each A and E was blinded and done independently by a panel of two (and if disagreement existed, three) senior emergency physicians who did not practice in the same hospital. The greatest weights would be for incorrect decisions with greatest impact on patients' well being. The most accurate unweighted nurses' triage classification had an average sensitivity of 87.8%, specificity of 83.9%, and a PPV of 70.1%. When weighted, the average sensitivity reduced to 75%, specificity to 65.7%, and PPV to 54%. The most accurate unweighted patients' self-triage classification yielded a sensitivity of 62.5%, specificity of 69.2%, and a PPV of 58.1%, and correspondingly reduced to 43.3, 49.2 and 38.6% if weights were applied. Validity of the derived patients' self-classifications was too inaccurate for practical use. Hong Kong's current use of a five-point urgency scale by nurses would be further refined for identifying non-urgent visitors. If a mechanism was put in place for additional screening on visitors with a borderline semi-urgent or non-urgent status, the nurses could safely reassign non-urgent patients to GP care. If implemented, a significant impact on hospital costs could be realized.

Care-giving and care-seeking behaviours of parents who take their children to an emergency department for non-urgent care

OBJECTIVE

This study explored the care-giving and care-seeking behaviours of parents who took their children to the emergency department (ED) of a large urban hospital in Western Canada for non-urgent care.

METHOD

Data were collected from a convenience sample of 114 parents during a two-week period in January 1992, using a self-administered 53-item questionnaire. The data were analyzed using nonparametric statistics (Chi-square) and thematic content analysis.

RESULTS

Eighty-two percent of parents were unsure of or overestimated the seriousness of their child's illness or injury. Prior to attending the ED, 40% of parents administered comfort measures and 45% gave medications. Only 17% of parents used at-home reading materials, while 31% sought lay advice. Fifty-eight percent of parents did not try to contact their family physician or the ED by telephone before coming to the ED. Forty-eight percent of parents who phoned their family physician were unable to obtain advice, and those who did were almost always referred to the ED. Eighty-eight percent of those who phoned the ED were instructed to bring the child to the ED.

INTERPRETATION

The results suggest the need for more acceptable, accessible community primary care services.

Care-giving and care-seeking behaviours of parents who take their children to an emergency department for non-urgent care

OBJECTIVE

This study explored the care-giving and care-seeking behaviours of parents who took their children to the emergency department (ED) of a large urban hospital in Western Canada for non-urgent care.

METHOD

Data were collected from a convenience sample of 114 parents during a two-week period in January 1992, using a self-administered 53-item questionnaire. The data were analyzed using nonparametric statistics (Chi-square) and thematic content analysis.

RESULTS

Eighty-two percent of parents were unsure of or overestimated the seriousness of their child's illness or injury. Prior to attending the ED, 40% of parents administered comfort measures and 45% gave medications. Only 17% of parents used at-home reading materials, while 31% sought lay advice. Fifty-eight percent of parents did not try to contact their family physician or the ED by telephone before coming to the ED. Forty-eight percent of parents who phoned their family physician were unable to obtain advice, and those who did were almost always referred to the ED. Eighty-eight percent of those who phoned the ED were instructed to bring the child to the ED.

INTERPRETATION

The results suggest the need for more acceptable, accessible community primary care services.

Using conjoint analysis to assess patients' preferences when visiting emergency departments in Hong Kong

OBJECTIVES

To explore factors related to emergency department (ED) attendances in Hong Kong, the authors piloted the application of conjoint analysis in eliciting patient preferences regarding ED visits.

METHODS

The study recruited 390 semi-urgent or non-urgent patients from a targeted convenience sample of three large EDs. Respondents were asked to rank eight scenarios structured to explore the relative importance of three key attributes-self-perceived illness severity, waiting time, and consultation fee-that may result in an ED visit.

RESULTS

Seventy-eight percent of the respondents would consider visiting a parallel clinic instead of the ED for semi-urgent and non-urgent conditions. The relative importance attached to illness severity, waiting time, and consultation fee were 47.8%, 33.6%, and 18.7%, respectively.

CONCLUSIONS

This study demonstrated that Hong Kong patients are receptive to the concept of parallel clinics, and illustrated that conjoint analysis is a rigorous survey technique for eliciting the views of patients on health care services in the ED setting.

Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong

Accident and Emergency Departments (A&E) have been a popular source of primary care, and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners (GPs). Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E, some recent studies have revealed contrary evidence. In this study 2410 patients were randomly selected from four A&E at different times. The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. Two emergency physicians reviewed each case independently, and if their independent ratings were in agreement, this became the gold standard. Patients classified as GP cases were given a telephone interview, and a sample was selected and matched with cases from general out patient clinics (GOPC) in the public sector by morbidity. Reasons for not attending a private GP included closure of clinic, deterioration of symptoms, GPs' inability to diagnose properly, and patients' wish to continue medical treatment in the same hospital. Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability, closure of the GOPC, patients' wish to continue treatment at the same hospital, GOPC too far away, no improvement shown after visits to GOPC doctors, and GOPC doctors' inability to make proper diagnoses. The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities.

Measuring the inappropriate utilization of accident and emergency services?

Accident and Emergency (A&E) departments are increasingly popular venues for primary care, causing a serious threat to healthcare quality. This paper reports the development of a comprehensive research method for identifying primary care patients attending A&E. Patients were randomly selected from the four A&E departments across different time periods and different regions in Hong Kong. The definition of GP cases was based on a retrospective record review conducted by a panel of emergency physicians using the standard laid down by the Hong Kong College of Family Physicians. The patients sampled were similar in sex and age distribution to A&E attendees for the whole territory. The level of GP cases was found to be 57 per cent, with a significantly higher proportion of patients in the younger age group. The high level of use reflects the lack of a well co-ordinated development of primary care services and interfacing with secondary care.

Increasing patient numbers: the implications for New Zealand emergency departments

Within the New Zealand (NZ) health care system, a number of changes have affected the way health care is accessed and delivered. Emergency Departments (EDs) are noticing increased attendance of patients with minor or non-urgent conditions. This increase in patient volume, together with on-going fiscal constraints and restructuring, has placed an added strain on the functioning of EDs. New Zealand nurses need to question the role currently given to EDs and identify the issues surrounding the increased use of these departments for primary health care. Is this move feasible in the NZ environment, and what are the implications for emergency nurses?

Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective

Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient's perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.

Provision for clinic patients in the ED produces more nonemergency visits

This study sought to evaluate how the addition of a general practitioner (GP) surgery influences the utilization of an emergency department (ED). An intervention trial with historical control was conducted in a Swedish university hospital ED. A GP surgery was established in the ED by the addition of GP physicians without the addition of other personnel (nurses, secretaries, aids). The number of persons evaluated and managed by the GP physicians and ED physicians were quantified preintervention (April 1992 to October 1993) and postintervention (April 1994 to October 1995). Further information was obtained by questionnaires distributed to all physicians and patients during three sample study weeks: 1 week before intervention and 6 and 18 months after the intervention. Patient volume, percentages of inappropriate visits, and types of services were recorded. The addition of GP physicians increased the number of visits to the ED by 27% (4,694 per month to 5,952 per month). The percentage of patients managed in the ED who had nonurgent complaints (primary health care needs) increased with the intervention from 22% (95% confidence interval [CI] 19%, 25%) to 33% (95% CI 30%, 37%). The increased demand on the ED of patients with nonurgent complaints increased the average waiting time for patients with urgent or emergent complaints from 35 minutes to 40 minutes (14%). The introduction of GPs to an ED increased the number and proportion of patients presenting to the ED with nonurgent complaints.

Nonurgent emergency department visits: the effect of having a regular doctor

OBJECTIVES

The authors assess the association between having a regular doctor and presentation for nonurgent versus urgent emergency department visits while controlling for potential confounders such as sociodemographics, health status, and comorbidity.

METHODS

A cross-sectional study was conducted in emergency departments of five urban teaching hospitals in the northeast. Adult patients presenting with chest pain, abdominal pain, or asthma (n = 1696; 88% of eligible) were studied. Patients completed a survey on presentation, reporting sociodemographics, health status, comorbid diseases, and relationship with a regular doctor. Urgency on presentation was assessed by chart review using explicit criteria.

RESULTS

Of the 1,696 study participants, 852 (50%) presented with nonurgent complaints. In logistic regression analyses, absence of a relationship with a regular physician was an independent correlate of presentation for a nonurgent emergency department visit (odds ratio 1.6; 95% confidence interval 1.2, 2.2) when controlling for age, gender, marital status, health status, and comorbid diseases. Race, lack of insurance, and education were not associated with nonurgent use.

CONCLUSIONS

Absence of a relationship with a regular doctor was correlated with use of the emergency department for selected nonurgent conditions when controlling for important potential confounders. Our study suggests that maintaining a relationship with a regular physician may reduce nonurgent use of the emergency department regardless of insurance status or health status.

First stop A & E: a New Zealand perspective

This article will review the literature studies on the various aspects of inappropriate attenders at Accident and Emergency (A & E) departments. Included in the review is a discussion questioning whether A & E attendance is indeed inappropriate from the perspective of both the patient and the health care professionals. Primary health care providers in the community are discussed, concluding with recommendations to improve the health care needs of the patients and the community.

Use of an accident and emergency department by hospital staff

OBJECTIVE

To assess the number of attendances by hospital staff at an accident and emergency (A&E) department, and reasons for their attendance.

METHODS

A&E attendances by hospital staff were studied for a 12 month period. Comparison was made with attendances by non-hospital staff in full or part time employment. Differences between the observed and expected numbers of attendances were analysed using chi 2 analysis.

RESULTS

560 staff attendances were recorded out of 78,103 total attendances. There was an observed excess number of attendances by nursing staff for work related incidents when compared to the control group (P = 0.01). However, there were fewer attendances by nursing staff for non-work related incidents (P = 0.01). Staff other than doctors and nurses attended the A&E department more frequently than the control group for non-work related incidents (P = 0.01), but their attendance for incidents occurring at work were the same as the control group (P = NS).

CONCLUSIONS

The increased use of A&E resources by staff other than doctors and nurses may be inappropriate and further research into their reasons for attendance is warranted.

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost

OBJECTIVE

To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost.

DESIGN

A randomised controlled trial.

SETTING

A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis.

PATIENTS

All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion.

MAIN OUTCOME MEASURES

Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences.

RESULTS

4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively.

CONCLUSION

General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff.

Emergency department uses of physician assistants and nurse practitioners: a national survey

A study was undertaken to determine the extent to which physician assistants (PAs) and/or nurse practitioners (NPs) are a source of health care delivery in emergency departments (EDs) in the United States. The National Hospital Ambulatory Medical Survey (NHAMCS) uses a multistage probability sample that examines patient visits within EDs. The sample included 437 hospitals with EDs. Visits were mostly from self-referred patients to EDs within nonfederal, short-stay hospitals, or general hospitals. Analysis of NHAMCS data found that a PA and/or NP was seen for 3.5 million ED visits in 1992. Remarkably little difference in gender, reason for visit, diagnosis, and medication prescribed was found between PA/NP visits and visits to all providers. This was the first study that systematically identified the extent of PA/NP-delivered ED services in the United States and compared it with physician services. Overall, PAs and NPs were found to be significant sources of health care service for hospital EDs. They are involved in care for almost 4% of all ED visits nationally and manage a wider range of conditions than has been previously reported. When types of visits are analyzed, including reasons for ED care, diagnosis, and treatment, it appears that visits associated with care by ED-based PA/NPs are similar to all ED visits, including those attended by emergency medicine physicians. More studies are needed to better understand the role of PAs and/or NPs in various ED settings. Recruitment and use of PAs and NPs may be a cost-effective strategy for improved delivery of emergency services.

Attitudes of Dublin accident and emergency department doctors and nurses towards the services offered by local general practitioners

Good communication at the accident and emergency (A&E)-general practice interface is important. Such communication will be affected by the attitudes of A&E staff towards local general practitioners (GPs). The objectives of this study were to establish and compare, using a questionnaire, the attitudes of Dublin A&E doctors and nurses towards the services offered by local GPs. A questionnaire was sent to all nurses and non-consultant doctors working in four of the six Dublin A&E departments. Completed questionnaires were received from 57 (61%) nurses and 35 (81%) doctors. Only two activities (being accessible to patients during normal surgery hours and providing family planning services) were rated by more than one-fifth of doctors and nurses as being performed 'well'. Six activities (being accessible to patients outside surgery hours, providing long-term care for the chronically ill and debilitated, providing appropriate care for 'difficult' patients, advising patients about the appropriate use of services and performing first aid) were rated by more than 40% of both doctors and nurses as being performed 'badly'. For all activities the nurses consistently rated the performance of the 'average GP' more critically than the doctors. These results must be interpreted cautiously. The implications of these findings and how best they can be addressed are discussed.

Primary care in the accident and emergency department: I. Prospective identification of patients

OBJECTIVE

To compare patient characteristics and consultation activities for attenders at accident and emergency departments assessed by nurse triage as presenting with "primary care" or "accident and emergency" type problems.

DESIGN

One year prospective study.

SETTING

A busy, inner city accident and emergency department in south London.

SUBJECTS

Of the 5658 patients treated for new problems during a stratified random sample of 204 three hour sessions between 10 am and 9 pm during June 1989 to May 1990, all "primary care" (2065 patients) and a 10% random sample of "accident and emergency" (291 patients) were included in the analysis.

MAIN OUTCOME MEASURES

Patient's age, sex, duration of presenting problem, diagnosis, laboratory and radiographic investigations, treatments, and referrals.

RESULTS

40.9% of attenders with new problems were classified by triage as presenting with "primary care" problems (95% confidence interval 39.6% to 42.2%). Primary care attenders were more likely than accident and emergency patients to be young adults, to have symptoms with a duration of longer than 24 hours, and to present problems not related to injury (all P < 0.001). Accident and emergency patients were considerably more likely to be referred to on call teams and to be admitted. Even so, 9.7% of primary care patients were referred to on call teams and a further 8.9% were referred to the fracture clinic or advised to return to the accident and emergency department for follow up.

CONCLUSION

Accident and emergency triage can be developed to identify patients with problems that are more likely to be of a primary care type, and these patients are less likely to receive an investigation, minor surgical procedure, or referral. Many patients in this category, however, receive interventions likely to support their decision to attend accident and emergency rather than general practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.

Student nurses' perceptions of accident and emergency nursing: do they match the reality?

This study explores student nurses' perceptions of, and attitudes to, working in an Accident and Emergency (A & E) department prior to allocation there. An assessment of the students' actual experience within the department was then taken. This allowed the students' perceptions to be compared with the reality of the work. The sample consisted of all students training for part 10 of the register who were allocated to the unit over a 4-week period (n = 22). Data was collected by two self completion questionnaires, one given pre-allocation the second post-allocation, a 100% response rate was achieved for each. The results of the study indicate that students' perceptions of the A & E department do not match the reality of the work involved. These perceptions may cause increased anxiety and apprehension for students before they start in the department and this may hinder clinical learning. The results suggest that appropriate preparation prior to the period of clinical experience may help alleviate these difficulties.

Primary medical care outside normal working hours: review of published work

Fundamental changes in the delivery of primary medical care outside normal surgery hours are under consideration in Great Britain. Published research into the provision and utilisation of out of hours services shows long term trends towards decreasing personal commitment among general practitioners and rising demand from patients for primary and hospital accident and emergency department care. Wide variations exist regionally, locally, and between practices. Previous studies, however, have been limited in scope and provide an inadequate basis for assessing the potential impact of change. The overall demand for care across all sources of provision cannot be measured: there is a lack of data on costs, and evaluative studies comparing alternative patterns of service delivery have rarely been undertaken. A period of experimentation and evaluation of a range of options should precede the wider adoption of any particular models.

Excess cost of emergency department visits for nonurgent care

After examining data for patients with selected conditions and statistically adjusting for patient, diagnosis, and treatment characteristics, this Data Watch finds that charges for emergency department visits were two to three times more than charges for visits in other settings. Large differences persist when conditions are examined individually and when total episode charges are examined. Based on our findings, a rough estimate of nationwide excess charges is $5-$7 billion for 1993.

A rural emergency department

The appropriate use of emergency departments is of growing concern. By knowing which patients are more likely to make inappropriate visits to these departments, efforts can be directed to encourage more suitable care. Our study was done in a rural county hospital in eastern New Mexico. Data were collected from all emergency department visits over a 4-week period. Patient and physician questionnaires were administered to assess aspects of emergency department use, including appropriateness based on published criteria, physicians' opinion of appropriateness, groups who made inappropriate visits, and the perception of the need for and the urgency of a visit. We found that 32% of visits were inappropriate based on published criteria and 24% were considered inappropriate by physician opinion. Two groups with a high rate of inappropriate visits were Hispanics and Medicaid recipients. Patients and physicians have differing opinions of the urgency of a visit and of how soon medical treatment is required. To decrease the frequency of inappropriate use of emergency departments, educational efforts should be focused on the subgroups with high rates of such use.

An audit of the E.N.T. casualty service at the Royal Victoria Eye and Ear Hospital

The only specialised Accident and Emergency unit for ENT in Ireland is at The Royal Victoria Eye and Ear Hospital, Dublin. This provides a service for the entire Republic, operating on a 9 am to 5 pm, Monday to Friday, basis. The aim of the present study was to define the role of this specialised unit. A prospective study of the service over a one month period was conducted. During this time 779 patients were seen of which 350 (45%) were new patients and 429 (55%) were return patients. Fifty two per cent were self referred, 35% were referred by their General Practitioners, 8% by other hospitals and 5% from other sources. The most common diagnosis was otitis externa (21% of new patients and 63% of returns), followed by ear wax (15% of new patients), and epistaxis (9% of new patients). Five per cent of patients required removal of foreign bodies from their ear, nose or oesophagus, and 3% received treatment for trauma to these regions. Of note during this period six new cases of head and neck cancer were detected. From these figures it is the authors' opinion that many of the problems seen could have been dealt with by General Practitioners or as non-emergency referrals to the out-patient department. This indicates the need for further training for primary care physicians and expansion of the present outpatients services. The specialised casualty service should continue to exist to provide a genuine emergency service and valuable training in the speciality.

The open access ENT casualty service

The ENT specialist's experience of emergencies is usually influenced by a process of prior selection in the GP surgery or in a general Casualty Department. A survey of 1,000 consecutive patients presenting to a 24 hour open access ENT Casualty service is presented. For a variety of reasons, over half of these patients had never sought their G.P.'s advice for their ENT complaint but preferred the hospital service. The value of even a brief exposure to ENT casualty work for GP trainees is demonstrated.

Use of the accident and emergency department by patients with diabetes

As part of a District-based audit of diabetes care all attendances (of diabetic and non-diabetic patients) at a local Accident and Emergency department were monitored over a 3-month period. A total of 9505 attendances took place of which 62 (0.7%) were by people with diabetes. This was no different from the expected number of attendances (61.5) based on the rates seen in non-diabetic individuals. Of these 62 attendances, 20 (by 15 individuals) were directly related to diabetes (hypoglycaemia 17, hyperglycaemia 1, for supplies of insulin or equipment 2). When these diabetes-specific attendances were removed from the total, the number of attendances (42) was significantly (p = 0.004) less than that expected. Diabetic males aged 0-19 years attended significantly more often than non-diabetic individuals of the same age but this excess was solely attributable to diabetes.

Unscheduled return visits by patients to the accident and emergency department

To determine why patients reattend an A&E department we surveyed 235 patients who returned unscheduled in a one-month period. Sixty-two per cent returned because of persistent symptoms. Sixty-three per cent presented within a week of their initial visit. Only 32% had attempted to see their GP. Thirty-five per cent of all patients claimed that A&E staff had advised them to return if they had problems. Half of the patients did not require treatment and 61% were discharged home. Twenty-one patients had pathology that had been missed on their first visit. Better patient education may minimize misuse of the service allowing better care for those who need it.