Self-referring patients at the emergency department: appropriateness of ED use and motives for self-referral

Patient self-referral patterns in a developing country: characteristics, prevalence, and predictors

BACKGROUND

Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors.

METHODS

This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients' mode of referral (self-referral or institutional referral) was considered the outcome variable.

RESULTS

Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p < 0.001). Among patients attending the study sites through institutional referral, approximately 10% were referred from community clinics, 6% from union sub-centers, 25% from upazila health complexes, 22% from district hospitals, 22% from other tertiary care hospitals, and 42% from private clinics. Patients visiting the outpatient department (adjusted odds ratio [aOR] 3.3, 95% confidence interval [CI] 2.28-4.82, p < 0.001), residing in urban areas (aOR 1.29, 95% CI 1.04-1.64, p = 0.007), belonging to middle- and high-income families (aOR 1.34, 95% CI 1.03-1.62, p = 0.014, and aOR 1.98, 95% CI 1.54-2.46, p = 0.005, respectively), and living within 20 km of healthcare facilities (aOR 3.15, 95% CI 2.24-4.44, p-value < 0.001) exhibited a higher tendency for self-referral to tertiary care facilities.

CONCLUSIONS

A considerable number of patients in Bangladesh, particularly those from affluent urban areas and proximity to healthcare facilities, tend to self-refer to tertiary care centers. Inadequacy of facilities in primary care centers significantly influences patients to opt for self-referral.

[Redirection of patients from the emergency department to ambulatory care: a feasibility study]

BACKGROUND

§ 120 para. 3b SGB V mandates the Federal Joint Committee to define guidelines for the initial assessment of self-referred walk-in patients as well as for the redirection of patients who can be treated by office-based physicians. A corresponding streaming and redirection process was tested in a feasibility study at the RoMed Clinic Rosenheim.

MATERIALS AND METHODS

For the duration of the study, triage nurses of the emergency department (ED) first assessed self-referred walk-in patients with the Manchester Triage System (MTS). Patients in categories green and blue who did not obviously need the ED's resources were additionally assessed by health professionals of the Association of Statutory Health Insurance Physicians of Bavaria using the software Structured Initial Medical Assessment in Germany (SmED). Patients with a recommendation for non-hospital medical treatment were streamed to the out-of-hours practice on campus or were redirected to a physician office after video consultation with an office-based physician. Patient pathways were documented and a qualitative survey using semistructured guided interviews of all stakeholder groups was carried out.

RESULTS

1,091 self-referred walk-in patients were included. Direct streaming to the ED occurred in 525 cases,13 refused to participate. Based on SmED, 24 additional patients were referred to the ED, 514 patients were streamed to the out-of-hours practice, 23 received a video consultation and five left the ED. After video consultation, eight patients were redirected to a physician's office, 10 were discharged, and five referred to the ED of which one did not want an office-based physician. No returnees from practices to the ED were identified. Generally, the redirection process was evaluated positively in the interviews (n=18). In particular, potential for technical improvement was identified.

CONCLUSION

Overall, the results indicate the feasibility of the redirection process and high acceptance levels. Using SmED in addition to MTS appeared useful before redirection but not necessary for streaming on campus. Redirection to physician offices can help reduce strain on the ED when the out-of-hours practice is not operating. In addition to arranging acute care appointments, video consultations offer an additional potential to treat patients. In a follow-up study, a broader range of patients should be included and appropriateness of redirection decisions should be evaluated.

A snapshot in time: a 1-month review of all referrals to paediatric liaison psychiatry services in Dublin following emergency department presentation

INTRODUCTION

An emerging picture has seen increasing numbers of young people with mental health crisis attend paediatric emergency departments in Ireland. Following paediatric review, many are referred to in-house paediatric liaison psychiatry (PLP) services. This pilot study describes referral patterns and practice over a 1-month period across three Dublin centres.

METHODS

Case notes of all referrals to PLP were reviewed to extract relevant clinical and administrative data. For those admitted, costs associated with length of stay were estimated. Clinical profile, management and intra-hospital pathway differences were explored.

RESULTS

Fifty-nine young people under 16 years presented to one of the three EDs with an acute MH presentation. The sample consisted of 39 females (66%) with a mean age of 13.7 years. The majority (n = 34, 58%) presented out of hours. A substantial portion of youths presenting (n = 37, 63%) were admitted, and had a mean duration of stay of 4.51 days. There were differences between hospitals in terms of frequency of presentation with self-harm, admission rates and length of stay.

DISCUSSION

Different PLP service configuration, staffing and funding streams may explain some of the differences observed across centres, although the findings should be interpreted with caution given the limited sample size. Standardisation of service provision and management is needed for PLP services. Additional community CAMHS resourcing is needed to support the development of alternative pathways for youth in need of urgent MH review.

An integrative review of adult patient-reported reasons for non-urgent use of the emergency department

OBJECTIVE

To conduct an integrative review of the scientific literature to explore adult patient-reported reasons for using the emergency department (ED) non-urgently.

METHOD

A literature search of CINAHL, Cochrane, Embase, PsycINFO, and MEDLINE was conducted with filters for humans, published January 1, 1990-September 1, 2021, and English language. Methodological quality was assessed using Critical Appraisal Skills Programme Qualitative Checklist for qualitative and National Institutes Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for quantitative studies. Data was abstracted on study and sample characteristics, and themes/reasons for ED use. Cited reasons were coded using thematic analysis.

RESULTS

Ninety-three studies met inclusion criteria. Seven themes were found: need to be risk averse with respect to the health issue; knowledge and awareness of alternative sources of care; dissatisfaction with primary care provider; satisfaction with ED; ED accessibility and convenience resulting in low access burden; referred to the ED by others; and relationships between patients and health care providers.

DISCUSSION

This integrative review examined patient-reported reasons for attending the ED on a non-urgent basis. The results suggest that ED patients are heterogenous and many factors influence their decision-making. Considering the complexity with which patients live, treating them as a single entity may be problematic. Limiting excessive non-urgent visits likely requires a multi-pronged approach.

CONCLUSION

For many ED patients, they have a very clear problem which needed to be addressed. Future studies should explore psychosocial factors driving decision-making (e.g., health literacy, health-related personal beliefs, stress and coping ability).

Minor traumatic injuries in the emergency department pre- and post-implementation of an emergency care access point

OBJECTIVE

In the Netherlands, out-of-hours General Practice Cooperatives (GPCs) increasingly collaborate with Emergency Departments (EDs) to form an Emergency Care Access Point (ECAP). ECAPs aim to decrease the number of low-urgent ED attendances, of which many compromise minor traumatic injuries. In this study, we evaluated the impact of ECAP implementation on the incidence of minor traumatic injuries in the ED.

METHODS

We evaluated a total of 2772 ED patients who presented with a minor traumatic injury (categorized into traumatic wounds and isolated extremity injuries) 1 year before and 1 year after ECAP implementation. We compared patient characteristics, throughput, diagnosis, treatment and follow-up before and after ECAP implementation.

RESULTS

ECAP implementation was associated with a reduction in ED volume for minor traumatic injuries: -12.4% for isolated extremity injuries (1249 vs. 1094) and -74.6% for traumatic wounds (342 vs. 87). Multivariable logistic regression analysis controlling for patient characteristics showed that ECAP implementation was associated with higher rates of substantial injuries in the ED (OR 1.20, 95% CI = 1.01-1.43), and more patients requiring outpatient follow-up.

CONCLUSION

Implementation of an ECAP was associated with a reduction of ED utilization by patients with minor traumatic injuries, traumatic wounds in particular. This healthcare intervention may therefore help to reduce ED utilization for low-urgent complaints.

The characterization of a hospitalized population at the pediatric emergency service of Mother and Child Hospital, Marrakech, Morocco

Introduction

the pediatric emergency department is the first contact between the population and the hospital. Consequently, its dysfunction influences the quality of the general health care system. However, any successful policy must first be based on convincing results hence the need to better explore this service, diagnose the various dysfunctions, and survey disease trends to identify the needs of the local population. In this perspective, we propose to describe the epidemiological profile of children hospitalized at the emergency service of the Mother-Child hospital, University Hospital Centre Marrakech, and establish the prevalence table for childhood pathologies.

Methods

a retrospective study was carried out in pediatric emergency services for 1658 hospitalized patients between March 2015 and December 2018. The collected data concerns mainly the socio-demographic, clinical profile, evolution status, mode of admission, and medical history.

Results

the characterization of the studied population by sex and age showed a predominance of male with a sex ratio of 1.36, infants with 625 patients. Concerning the final diagnosis, the most frequent pathologies affected the respiratory system in 28% of cases, then the digestive system (11.3%), while infectious pathologies represented 10.7% of admissions. The death rate in the emergency department was 7.4%. Multivariate analysis of the data showed a statistically significant relationship between the final diagnosis (16 diseases by a system according to The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)) and age, season, and weight. Thus, for the association between the digestive system diseases and weight (aOR=1.052, 95% CI= 1.019-1.086, p=0.02). While for the skin and subcutaneous tissue diseases and the autumn season (aOR=11.37, 95% CI= 1.272-101.777, p=0.03) and age has a negative significance for most diseases.

Conclusion

the epidemiological profile study will allow knowledge of patient´s pathologies typology for a well-supported and better definition of needs.

Public perceptions of urgency of severe cases of COVID-19 and inflammatory gastrointestinal disease

Background

There is evidence that perceived urgency of medical complaints is associated with emergency care utilization. Patients’ perception of urgency can differ from physicians’ assessment. This study explored public perceptions of urgency of severe cases of COVID-19 and inflammatory gastrointestinal disease and analyzed variations in perceptions of urgency by characteristics of the afflicted person in the vignettes and sociodemographic characteristics of respondents.

Methods

Vignettes with severe symptoms of either inflammatory gastrointestinal disease or COVID-19 with comparable urgency of treatment were used in a telephone survey in Germany (N = 1,207). Besides disease, the vignettes varied in terms of sex, age (child, middle-aged person, old person) and daytime (Tuesday morning, Tuesday evening). Respondents were asked to rate the urgency of the reported symptoms with four items. A sum scale was computed. Variations in perceptions of urgency according to vignette characteristics and sociodemographic characteristics of the respondents (sex, age, educational level, migration background, children (yes/no) and personal affliction) were analyzed using a linear regression model.

Results

In terms of vignette characteristics, multivariate analysis showed a lower estimated urgency for males, as well as for the middle-aged and aged persons, compared to the child vignettes, and for COVID-19, compared to inflammatory gastrointestinal disease. Regarding the characteristics of the respondents, estimated urgency increased with age and was lower among respondents, who were previously affected by the symptoms themselves.

Conclusion

Although urgency in the vignettes was comparable, variations in estimated urgency by age and sex of the afflicted person and the described disease as well as age and personal affliction of the respondents were identified. This could result in an inadequate health care service utilization. Therefore, variations in public perceptions of urgency should be considered in the planning of public campaigns on adequate health care services utilization.

Characteristics of Patients Who Visited Emergency Department: A Nationwide Population-Based Study in South Korea (2016-2018)

The utilization of the emergency department (ED) has been continuously increasing and has become a burden for ED resources. The aim of this study was to describe the characteristics, outcomes, common diagnoses, and disease classifications of patients who were referred to the ED. This nationwide epidemiologic study examined the data from adult patients (>18 years) who visited EDs from 1 January 2016 to 31 December 2018. Most EDs in Korea provide data from ED patients to the National Emergency Medical Center (NEMC). The disposition of ED patients was classified as discharge, admission, death, and re-transfer. From 2016 to 2018, the proportion of referred patients out of the total ED visits increased from 7.3% to 7.8%. The referred patients were older (61.1 vs. 50.5 years), had worse vital signs, longer ED lengths of stay (409.1 vs. 153.3 min), and higher admission (62.3 vs. 16.9%) and re-transfer rates (4.4 vs. 1.9%) than the direct-visit patients. Among the referred patients in the 3 years, 62.3% were hospitalized, and the most common disease classification was “disease of the digestive system” (19.8%). The most common diagnosis was pneumonia (6.0%), followed by urinary tract infection, gastrointestinal bleeding, and hepatobiliary infection. The number of patients referred to EDs is increasing, and more than 60% of referred patients are hospitalized. Detailed characteristics of these patients will be helpful for improving ED management and the distribution of medical resources.

En quoi les patients adressés dans les services d’urgences après avis médical sont-ils différents des patients venant d’eux-mêmes ?

Introduction : Peu d’études évaluent les caractéristiques des patients adressées aux urgences après un avis médical et celles des patients s’y rendant de leur propre initiative. L’objectif de cette étude était de comparer ces deux populations définies par leur mode d’adressage.

Matériel et méthodes : Étude transversale rétrospective réalisée dans les services d’urgence en Occitanie de 2016 à 2018. Les analyses ont porté sur les données du résumé de passage aux urgences. Deux groupes de patients ont été créés : les adressés après avis médical et les non-adressés venant directement.

Résultats : Sur 1 812 795 passages, 80 % sont venus aux urgences de leur propre initiative. Parmi les 20 % adressés, 75 % ont été régulés par le Samu et 25 % adressés par un médecin de ville. Les patients adressés étaient plus âgés que les patients non adressés (âge moyen de 57 ± 26 versus 36 ± 24 ans). Les patients adressés étaient dirigés dans 71 % des cas vers les établissements publics et arrivaient avec un transport sanitaire dans 76 % des cas. La durée médiane de passage aux urgences était plus importante dans le groupe des patients adressés (4 h 23 min contre 2 h 25 min pour les non-adressés). Les patients adressés étaient plus graves (3 % de CCMU4-5 versus 0,4 % dans le groupe non adressé) et plus hospitalisés (38 versus 12 % dans le groupe non adressé). Les motifs de consultations, en revanche, étaient assez similaires entre les deux groupes.

Conclusion : Les patients adressés aux urgences étaient très différents de ceux venant d’eux-mêmes.

Effects of access to radiology in out-of-hours primary care on patient satisfaction and length of stay

BACKGROUND

Direct access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear.

OBJECTIVES

To provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology.

METHODS

A multi-methods observational study in April 2014-October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS.

RESULTS

In total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39).

CONCLUSION

Access to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.

Self-referred walk-in patients in the emergency department - who and why? Consultation determinants in a multicenter study of respiratory patients in Berlin, Germany

BACKGROUND

Emergency department (ED) consultations are on the rise, and frequently consultations by non-urgent patients have been held accountable. Self-referred walk-in (SRW) consulters supposedly represent a predominantly less urgent patient population. The EMACROSS study aimed to explore consultation determinants and motives in SRW patients with respiratory symptoms.

METHODS

Multicenter survey of adult ED patients with respiratory complaints in eight emergency departments in central Berlin, Germany. Secondary hospital records data including diagnoses was additionally assessed. Characteristics of SRW and non-SRW patients were compared. Determinants of SRW consultation were evaluated by binary logistic regression. Consultation motives were analyzed descriptively. As a supplemental approach, network analysis (lasso-regularized mixed graphical model) was performed to explore connections between consultation determinants, consultation features and motives.

RESULTS

Between June 2017 and November 2018, n = 472 participants were included, the median age was 55 years (range 18-96), 53.2% of patients were male and n = 185 cases (39.2%) were SRW consulters. The SRW group showed lower proportions of potentially severe (pneumonia and respiratory failure, p < 0.001, χ2 test) and chronic pulmonary conditions. Determinants of SRW consultation identified by logistic regression were younger age (p < 0.001), tertiary education (p = 0.032), being a first-generation migrant (p = 0.002) or tourist (p = 0.008), having no regular primary care provider (p = 0.036) and no chronic pulmonary illness (p = 0.017). The area under the curve (AUC) for the model was 0.79. Personal distress and access problems in ambulatory care were stated most frequently as consultation motives in the SRW group; network analysis showed the scarcity of associations between demographic and medical SRW determinants and motives triggering the actual decision to consult.

CONCLUSIONS

As to "who" consults, this study identified demographic and medical predictors of SRW utilization. The said markers seem only remotely connected to "why" people decide for SRW visits. To alleviate ED crowding by addressing frequent SRW consultation motives, interventions focused on the ability for symptom self-assessment and at better-accessible alternative care seem sensible.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

Understanding people who self-referred in an emergency department with primary care problems during office hours: a qualitative interview study at a Daytime General Practice Cooperative in two hospitals in The Hague, The Netherlands

OBJECTIVE

To provide insight into the motives for hospital self-referral during office hours and the barriers deterring general practitioner (GP) consultation with a primary care request.

SETTING

People who self-referred at a Daytime General Practice Cooperative (GPC) in two hospitals in The Hague, The Netherlands.

PARTICIPANTS

A total of 44 people who self-referred were interviewed in two hospitals. The average age of interviewees was 35 years (range 19 months to 83 years), a parent of a young patient was interviewed, but the age of patients is shown here. There were more male patients (66%) than female patients (34%). Patients were recruited using a sampling method after triage. Triage was the responsibility of an emergency department (ED) nurse in one hospital and of a GP in the other. Those excluded from participation included (a) children under the age of 18 years and not accompanied by a parent or legal guardian, (b) foreign patients not resident in the Netherlands, (c) patients unable to communicate in Dutch or English and (d) patients directly referred to the ED after triage by the GP (in one hospital).

RESULTS

People who self-referred generally reported several motives for going to the hospital directly. Information and awareness factors played an important role, often related to a lack of information regarding where to go with a medical complaint. Furthermore, many people who self-referred mentioned hospital facilities, convenience and perceived medical necessity as motivational factors. Barriers deterring a visit to the own GP were mainly logistical, including not being registered with a GP, the GP was too far away, poor GP telephone accessibility or a waiting list for an appointment.

CONCLUSION

Information and awareness factors contribute to misperceptions among people who self-referred concerning the complaint, the GP and the hospital. As a range of motivational factors are involved, there is no straightforward solution. However, better dissemination of information might alleviate misconceptions and contribute to providing the right care to the right patient in the right setting.

Patterns of paediatric emergency admissions and predictors of prolonged hospital stay at the children emergency room, University of Calabar Teaching Hospital, Calabar, Nigeria

BACKGROUND

There is a high prevalence of paediatric emergency cases in less developed countries. However, prolonged hospital stay at emergency units may further overstretch the facilities.

OBJECTIVE

To assess the patterns of presentations, services offered and predictors of a prolonged stay at the Children Emergency Room of a tertiary hospital in Southern Nigeria.

METHODS

This prospective cross-sectional, study was conducted at the University of Calabar Teaching Hospital, Nigeria from 1st January-31st December 2014. Socio-demographic and clinical characteristics of consecutively recruited children (n=633) were recorded in a proforma. Binary logistic regression was conducted to determine predictors of prolonged stay (>72 hours).

RESULT

The median age of participants was 2 (1 - 4.6) years. Three-fifths of children were admitted at off-hours and the commonest symptom was fever (73.9%). About 16.4% (95%CI:13.6% - 19.4%, n= 103/633) of the children had prolonged stay while those with sepsis had the longest mean stay (65.5±72.1 hours). Children admitted on account of Sickle cell disease (OR:11.2, 95%CI:1.3-95.1, P-value = 0.03), Malaria (OR:10.7, 95%CI:1.4-82.5, P-value = 0.02) or sepsis (OR:10.5, 95%CI:1.3 - 82.7, P-value = 0.03) had higher odds of prolonged hospital stay. There was no significant difference in hospital stay among children admitted by the consultant as compared to other health personnel (P-value = 0.08).

CONCLUSION

Prevention and proper management of Sickle cell disease and malaria reduces paediatric hospital stay in our environment. Paediatric emergency medicine should be re-organized to cater for high volume of off-hour admissions.

Prevalence and determinants of self referrals to a District-Regional Hospital in KwaZulu Natal, South Africa: a cross sectional study

Introduction

Self-referrals to inappropriate levels of care result in an increased patient waiting time, overburdening of higher levels of care, reduced primary healthcare utilisation rate and increasing healthcare costs. Furthermore, self-referral places an additional encumbrance on various levels of care as allocation of resources and infrastructure cannot be accurately planned, based on the facility catchment population. The aim of this study was to determine the prevalence and determinants of patient self-referral at the out-patient department of Stanger Hospital, KwaZulu-Natal between January and June 2017.

Methods

A cross-sectional study was conducted at the out-patient department in Stanger Hospital, using interviewer administered questionnaires to collect information from 385 patients, through convenience sampling, between January and June 2017. Multivariable regression analysis was used to test for factors associated with self-referral.

Results

of the 385 patients interviewed 36% (n = 138) were self-referrals. Most of the self-referrals were male (51.5%) and of the African race (57.2%). Five institutional factors namely: care received from healthcare workers (91.3%); waiting times (88.4%); help offered (87%); treatment and attitude of healthcare workers (63%) and availability of medication (55.8%) were considered as the main drivers of self-referral. Multivariable regression analysis established a significant positive association between patient self-referral and age (40 years and below), attitude of healthcare workers, quality of care received form healthcare workers, waiting times and the availability of diagnostic tests.

Conclusion

This study indicates that most patients attending Stanger Hospital do comply with the prescribed referral pathway, however a significant proportion still bypass the referral system.

Understanding healthcare self-referral in Nigeria from the service users' perspective: a qualitative study of Niger state

BACKGROUND

The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60-90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users' decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users.

METHODS

Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis.

RESULTS

Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen's model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users' expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms.

CONCLUSIONS

The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.

Determining factors for the increase in self-referrals to the Emergency Department of a rural hospital in Huelva (Spain)

OBJECTIVE

To analyse the increase of self-referral patients at the Emergency Department of Riotinto District Hospital (in Huelva, Spain) during a short period. The study focused on patients' profiles to identify key factors that explained the increase of self-referrals.

MATERIAL AND METHODS

Retrospective descriptive study using patient's data from a hospital emergency department between 2003-2015, excluding the period 2012-14 due to the lack of records. Socio-demographic variables, type of referral, access to health services, hospital route, transfer time and organisational changes were analysed, among other factors. Descriptive statistics, chi-square test, and binary logistic regression analysis were used.

RESULTS

Self-referral patients to the hospital emergency department revealed a growing trend. Logistic regression model showed that the variables that best predict its occurrence were the health system changes from 2008 and the time it takes to get to the Extra-hospital Emergency Services, where those changes act as modifiers of the effect. From 2008, the likelihood of self-referral in towns with an Extra-hospital Emergency Service over 2 minutes away by car was of 76.43%. When including the triage level, the logistic regression model showed that 83.1% of patients referred themselves.

CONCLUSIONS

Changes in the health system and in the time for patients to get to the reference hospital from their origin, affect the likelihood of self-referral to the emergency department. Once the patient's severity level was included, this variable, along with the time to get to the emergency department, modified the probability of self-referral to the emergency department. We found an increase in hospital services together with a reduction of resources in the primary care emergency system. This may have led to inefficiencies in the public health system, together with an increase in self-referrals and greater problems to service users.

Diagnosis and mortality of emergency department patients in the North Denmark region

Background

Emergency departments handle a large proportion of acute patients. In 2007, it was recommended centralizing the Danish healthcare system and establishing emergency departments as the main common entrance for emergency patients. Since this reorganization, few studies describing the emergency patient population in this new setting have been carried out and none describing diagnoses and mortality. Hence, we aimed to investigate diagnoses and 1- and 30-day mortality of patients in the emergency departments in the North Denmark Region during 2014–2016.

Methods

Population-based historic cohort study in the North Denmark Region (580,000 inhabitants) of patients with contact to emergency departments during 2014–2016. The study included patients who were referred by general practitioners (daytime and out-of-hours), by emergency medical services or who were self-referred.

Primary diagnoses (ICD-10) were retrieved from the regional Patient Administrative System. For non-specific diagnoses (ICD-10 chapter ‘Symptoms and signs’ and ‘Other factors’), we searched the same hospital stay for a specific diagnosis and used this, if one was given. We performed descriptive analysis reporting distribution and frequency of diagnoses. Moreover, 1- and 30-day mortality rate estimates were performed using the Kaplan-Meier estimator.

Results

We included 290,590 patient contacts corresponding to 166 ED visits per 1000 inhabitants per year. The three most frequent ICD-10 chapters used were ‘Injuries and poisoning’ (38.3% n = 111,274), ‘Symptoms and signs’ (16.1% n = 46,852) and ‘Other factors’ (14.52% n = 42,195). Mortality at day 30 (95% confidence intervals) for these chapters were 0.86% (0.81–0.92), 3.95% (3.78–4.13) and 2.84% (2.69–3.00), respectively.

The highest 30-day mortality were within chapters ‘Neoplasms’ (14.22% (12.07–16.72)), ‘Endocrine diseases’ (8.95% (8.21–9.75)) and ‘Respiratory diseases’ (8.44% (8.02–8.88)).

Conclusions

Patients in contact with the emergency department receive a wide range of diagnoses within all chapters of ICD-10, and one third of the diagnoses given are non-specific. Within the non-specific chapters, we found a 30-day mortality, surpassing several of the more organ specific ICD-10 chapters.

Trial registration

Observational study - no trial registration was performed.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3361-x) contains supplementary material, which is available to authorized users.

Effects of access to radiology in out-of-hours primary care in the Netherlands: a prospective observational study

BACKGROUND

In the Netherlands, out-of-hours primary care is provided in general-practitioner-cooperatives (GPCs). These are increasingly located on site with emergency departments (ED), forming Emergency-Care-Access-Points (ECAP). A more efficient and economical organization of out-of-hours primary emergency care could be realized by increased collaboration at an ECAP. In this study, we compared the effects of different models with respect to access to (hospital) radiology by the GPC. We investigated patient and care characteristics, indication for diagnostics and outcomes at GPCs with and without access to radiology.

METHODS

A prospective observational record review study of patients referred for conventional radiology for trauma by one of five GPCs in the period April 2014-October 2015, covering three organizational models.

RESULTS

The mean age was 31 years and 56% was female. Extremities were predominately involved (91%). There was a medical indication for radiology in 85% and the assessed risk by requesting GPs on abnormalities was high in 66%. There was a significant difference in outcomes between models. Radiological abnormalities (fractures/luxations) were present in 51% without direct access and in 35% with partial and unlimited access. Overall, 61% of the included patients were referred to the ED; 100% in the models without access and 38% in the models with (partial) access.

CONCLUSIONS

GPC access to radiology is beneficial for patients and professionals. The diagnostics were adequately used. With access to radiology, unnecessary referrals and specialist care are prevented. This may lead to a decrease in ED attendance and overcrowding.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study

OBJECTIVES

Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes.

DESIGN

A retrospective study.

PARTICIPANTS

Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month).

PRIMARY OUTCOMES

Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders.

RESULTS

In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1).

CONCLUSION

In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.

Why patients self-refer to the Emergency Department: A qualitative interview study

RATIONALE, AIMS, AND OBJECTIVES

There have been multiple studies investigating reasons for patients to self-refer to the Emergency Department (ED). The majority made use of questionnaires and excluded patients with urgent conditions. The goal of this qualitative study is to explore what motives patients have to self-refer to an ED, also including patients in urgent triage categories.

METHODS

In a large teaching hospital in the Netherlands, a qualitative interview study focusing on reasons for self-referring to the ED was performed. Self-referred patients were included until no new reasons for attending the ED were found. Exclusion criteria were as follows: not mentally able to be interviewed or not speaking Dutch. Patients who were in need of urgent care were treated first, before being asked to participate. Interviews followed a predefined topic guide. Practicing cyclic analysis, the interview topic guide was modified during the inclusion period. Interviews were recorded on an audio recorder, transcribed verbatim, and anonymized. Two investigators independently coded the information and combined the codes into meaningful clusters. Subsequently, these were categorized into themes to build a framework of reasons for self-referral to the ED. Characteristic quotes were used to illustrate the acquired theoretical framework.

RESULTS

Thirty self-referred patients were interviewed. Most of the participants were male (63%), with a mean age of 46 years. Two main themes emerged from the interviews that are pertinent to the patients' decisions to attend the ED: (1) health concerns and (2) practical issues.

CONCLUSIONS

This study found that there are 2 clearly distinctive reasons for self-referral to the ED: health concerns or practical motives. Self-referral because of practical motives is probably most suitable for strategies that aim to reduce inappropriate ED visits.

Patient and care characteristics of self-referrals treated by the general practitioner cooperative at emergency-care-access-points in the Netherlands

Background

In the Netherlands, out-of-hours primary care is provided in general practitioner-cooperatives (GPCs). These are increasingly located on site and in collaboration with emergency departments of hospitals (ED). At such sites, also called emergency-care-access-points (ECAP), the GPC is generally responsible for the triage and treatment of self-referrals who used to attend the ED. To evaluate the effects and safety of this novel organisation, we studied the characteristics and the quality of care given by GPCs to self-referrals at ECAPs.

Methods

Retrospective analysis (August 2011–January 2012) of 783 records of self-referred patients at three Dutch GPCs in an ECAP. This was supplemented with a retrospective analysis of patient records during a follow-up period of three-months to asses safety.

Results

Patient-characteristics: 59% was male, 46% aged between 16–45 years and 59% trauma-related. Most cases (95%) were triaged low-urgent. None received the highest urgency-category. Quality: The triage outcome was correct in 79%, underestimated in 12% and overestimated in 9%. After GP consultation 20% were referred to the ED, mostly for radio-diagnostics. Of the referrals to secondary care, 98% were according to common medical practice. Thirty percent had a follow-up contact, mostly with their own general practitioner, seldom with the ED. Complications, all non-severe, were registered in 3.2%; 0.4% were possibly preventable.

Conclusions

Self-referred patients at an ECAP are mostly trauma related, low-urgent and male patients. The majority could be treated by the GPC without subsequent referral to the ED. Care given at the GPC is reasonably efficient and safe. Triage and treatment of self-referrals by the GPC at ECAPs might offer opportunities for other countries facing problems with inappropriate emergency department visits.

Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center

PURPOSE

Referrals to the Emergency Department can be distressing to patients with advanced cancer and may be a non-optimizing health care service. We aimed to describe the appropriateness and potential avoidability of Emergency Department referrals in a tertiary cancer care center where only physician referrals are allowed.

METHODS

We prospectively reviewed the electronic medical charts of patients consecutively checked into the Emergency Department in August 2015. The appropriateness of referrals was assessed using a nationally validated classification (Classification Clinique des Malades aux Urgences) and local criteria. Potentially avoidable referrals were assessed using international classifications (Institute for Healthcare Improvement State Action on Avoidable Rehospitalizations diagnostic tool according to Kosecoff's criteria) and local criteria.

RESULTS

We included 500 referrals related to 423 patients. The mean age was 59 years, and 74% of cancers were progressive. The referrals were appropriate in 61% of cases. They were deemed potentially avoidable "with a high likelihood" in 33.4% (CI95% [29.3-37.5]) of cases, potentially avoidable "with a moderate likelihood" in 14.4% (CI95% [11.3-17.5]) of cases, and "non-avoidable" in 52% (CI95% [47.6-56.4]) of cases. Opportunities to avoid referrals after an index stay involved this hospital stay or discharge process in 66 cases (28%), the follow-up period in 59 cases (25%), or both in 66 cases (28%).

CONCLUSIONS

Potentially avoidable ED referrals are common in patients with cancer. These potentially avoidable ED referrals underline the importance of several domains of care coordination.

Motives for self-referral to the emergency department: a systematic review of the literature

BACKGROUND

In several western countries patients' use of Emergency Departments (EDs) is increasing. A substantial number of patients is self-referred, but does not need emergency care. In order to have more influence on unnecessary self-referral, it is essential to know why patients visit the ED without referral. The goal of this systematic review therefore is to explore what motivates self-referred patients in those countries to visit the ED.

METHODS

Recommendations from the PRISMA were used to search and analyze the literature. The following databases; PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. The reference lists of the included articles were screened for additional relevant articles. All studies that reported on the motives of self-referred patients to visit an ED were selected. The reasons for self-referral were categorized into seven main themes: health concerns, expected investigations; convenience of the ED; lesser accessibility of primary care; no confidence in general practitioner/primary care; advice from others and financial considerations. A random-effects meta-analysis was performed.

RESULTS

Thirty publications were identified from the literature studied. The most reported themes for self-referral were 'health concerns' and 'expected investigations': 36% (95% Confidence Interval 23-50%) and 35% (95% CI 20-51%) respectively. Financial considerations most often played a role in the United States with a reported percentage of 33% versus 4% in other countries (p < 0.001).

CONCLUSIONS

Worldwide, the most important reasons to self-refer to an ED are health concerns and expected investigations. Financial considerations mainly play a role in the United States.

Site of Treatment for Non-Urgent Conditions by Medicare Beneficiaries: Is There a Role for Urgent Care Centers?

BACKGROUND

There is limited information on where and how often Medicare beneficiaries seek care for non-urgent conditions when a physician office visit is not available. Emergency departments are often an alternative site of care, and urgent care centers have now also emerged to fill this need. The purpose of the study was to characterize the site of care for Medicare beneficiaries with non-urgent conditions; the relationship between physician office, urgent care center, and emergency department utilization; and specifically the role of urgent care centers.

METHODS

The study is a retrospective, cross-sectional study of fee-for-service Medicare beneficiaries for fiscal year 2012. The main outcome was rate and geographic variation of urgent care center, emergency department, or physician office utilization.

RESULTS

Care for non-urgent conditions most commonly occurred in physician offices (65.0 per 100 beneficiaries). In contrast, urgent care centers (6.0 per 100 beneficiaries) were a more common site of care than emergency departments (1.0 per 100 beneficiaries). Overall, 83% of non-urgent visits were physician offices, 14% urgent care centers, and 3% emergency departments. There was regional variation in urgent care center, emergency department, and physician office utilization for non-urgent conditions. Areas of higher emergency department utilization correspond to areas of lower urgent care center and physician office utilization, whereas areas of higher urgent care center utilization had lower emergency department utilization.

CONCLUSIONS

Urgent care centers are an important site of care for Medicare beneficiaries for non-urgent conditions. There is regional variation in the use of urgent care centers, emergency departments, and physician offices, with areas of low urgent care center utilization having higher emergency department utilization. The utilization of urgent care centers for treatment for non-urgent conditions may decrease emergency department utilization.

Effects of a general practitioner cooperative co-located with an emergency department on patient throughput

BACKGROUND

In 2013 a General Practitioner Cooperative (GPC) was introduced at the Emergency Department (ED) of our hospital. One of the aims of this co-located GPC was to improve throughput of the remaining patients at the ED. To determine the change in patient flow, we assessed the number of self-referrals, redirection of self-referrals to the GPC and back to the ED, as well as ward and ICU admission rates and length of stay of the remaining ED population.

METHODS

We conducted a four months' pre-post comparison before and after the implementation of a co-located GPC with an urban ED in the Netherlands.

RESULTS

More than half of our ED patients were self-referrals. At triage, 54.5% of these self-referrals were redirected to the GPC. After assessment at the GPC, 8.5% of them were referred back to the ED. The number of patients treated at the ED declined with 20.3% after the introduction of the GPC. In the remaining ED population, there was a significant increase of highly urgent patients (P<0.001), regular admissions (P<0.001), and ICU admissions (P<0.001). Despite the decline of the number of patients at the ED, the total length of stay of patients treated at the ED increased from 14 682 hours in the two months' control period to 14 962 hours in the two months' intervention period, a total increase of 270 hours in two months (P<0.001).

CONCLUSION

Introduction of a GPC led to efficient redirection of self-referrals but failed to improve throughput of the remaining patients at the ED.

Self-referrals in the emergency department: reasons why patients attend the emergency department without consulting a general practitioner first-a questionnaire study

Background

To influence self-referral, it is crucial to know a patient’s motives to directly visit the emergency department (ED). The goal of this study is to examine motives for self-referral to the ED and compare these motives in relation to appropriateness.

Methods

All self-referred patients visiting the ED of a Dutch hospital over four separate months in a 1-year period were included. Patients were handed questionnaires that included questions on their reasons to visit the ED directly and where they would seek medical help next time. Additionally, the motives of patients that either appropriately or inappropriately visited the ED were compared. In a previous study on the same patient cohort, the appropriateness of the ED visits was determined using predefined criteria.

Results

A total of 3196 self-referred patients were included, and 48.9 % completed the questionnaires. The majority of patients (28.0 %) attended the ED without a referral because they thought they would get help faster; the next reason was the easier access to radiologic and laboratory investigations (answered by 23.8 %); and the third was the symptoms were considered too severe to visit a general practitioner (GP) (answered by 22.7 %). The majority (78.5 %) would attend the ED the next time they are faced with similar symptoms. Appropriate visits were significantly more seen in females, elderly, and patients in higher triage categories. Patients who expect investigations are necessary, think their symptoms are too severe to visit a GP, or would return to the ED next time were more often appropriately visiting the ED.

Conclusions

The choice of patients to self-refer to an ED is often an explicate decision. Patients are looking for specialist help and want fast and easy access to radiologic and laboratory investigations. Even though the primary care network is well developed in the Netherlands, the reasons for self-referral are similar to the reasons found in previous literature based in other countries. Patients who visit the ED because of health concerns visit the ED more often appropriately than patients visiting for practical reasons.

Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data

OBJECTIVE

To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner (GP) led urgent care centres (UCCs) in northwest London, England.

METHODS

We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables-age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; GP registration; time, day, quarter, year; and UCC of attendance-and the outcome of onwards referral to the co-located EDs or other hospital specialty departments.

RESULTS

Of 243 042 included attendances, 74.1% were managed solely within the UCCs without same day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a 10 year increase in a patient's age. Men, patients registered with a GP and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs.

CONCLUSIONS

The majority of patients, across each category of all explanatory variables, were managed solely within the UCCs, although a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.

Rural Health and the Nonemergency Use of Emergency Medical Services

The use of emergency department (ED) services for nonemergent conditions is common and seems to be growing. At a time when health care reform efforts are focused on delivering the right care, at the right time, and in the right place, understanding access barriers to health care and the impact of these barriers on the achievement of health equity for everyone is critical to achieving identified Healthy People 2020 national objectives. This article describes motivations for nonemergent use of ED services by individuals living in rural southeastern United States.

Emergency Department Non-Urgent Visits and Hospital Readmissions Are Associated with Different Socio-Economic Variables in Italy

Objective

The aim of this paper was to evaluate socio-economic factors associated to poor primary care utilization by studying two specific subjects: the hospital readmission rate, and the use of the Emergency Department (ED) for non-urgent visits.

Methods

The study was carried out by the analysis of administrative database for hospital readmission and with a specific survey for non-urgent ED use.

Results

Among the 416,698 sampled admissions, 6.39% (95% CI, 6.32–6.47) of re-admissions have been registered; the distribution shows a high frequency of events in the age 65–84 years group, and in the intermediate care hospitals (51.97%; 95%CI 51.37–52.57). The regression model has shown the significant role played by age, type of structure (geriatric acute care), and deprivation index of the area of residence on the readmission, however, after adjusting for the intensity of primary care, the role of deprivation was no more significant. Non-urgent ED visits accounted for the 12.10%, (95%CI 9.38–15.27) of the total number of respondents to the questionnaire (N = 504). The likelihood of performing a non-urgent ED visit was higher among patients aged <65 years (OR 3.2, 95%CI 1.3–7.8 p = 0.008), while it was lower among those perceiving as urgent their health problem (OR 0.50, 95%CI 0.30–0.90).

Conclusions

In the Italian context repeated readmissions and ED utilization are linked to different trajectories, besides the increasing age and comorbidity of patients are the factors that are related to repeated admissions, the self-perceived trust in diagnostic technologies is an important risk factor in determining ED visits. Better use of public national health care service is mandatory, since its correct utilization is associated to increasing equity and better health care utilization.