ED patients: how nonurgent are they? Systematic review of the emergency medicine literature

Factors associated with hospital revisitation within 7 days among patients discharged at triage: a case-control study

BACKGROUND AND IMPORTANCE

Existing data are limited for determining the medical conditions best suited for an emergency department (ED) redirection strategy in a heterogeneous, nonurgent patient population.

OBJECTIVE

The aim was to establish factors associated with hospital revisits within 7 days among patients discharged or redirected by a triage team.

DESIGN, SETTINGS, AND PARTICIPANTS

An observational single-center case-control study was conducted at the Tampere University Hospital ED for the full calendar year of 2019. The cases comprised unplanned hospital revisits within 7 days of being discharged or redirected by triage, while the controls were discharged or redirected but did not revisit.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was an unplanned hospital revisit within 7 days. A subgroup analysis was conducted for revisits leading to hospitalization. Basic demographics, comorbidities before triage, and triage visit characteristics were considered as predictive factors for the revisit. A backward stepwise conditional logistic regression analysis was performed.

MAIN RESULTS

During the calendar year of 2019, there were a total of 92 406 ED visits. Of these, 7216 (7.8%) visits were discharged or redirected by triage, and 6.5% (n = 467) of all these patients revisited. Of the revisiting patients, 25% (n = 117) were hospitalized. In multivariable analysis, higher age was associated with both revisitation [odds ratio (OR): 1.01, 95% confidence interval (CI): 1.00-1.02] and hospitalization (OR: 1.02, 95% CI: 1.00-1.04). Furthermore, using other visits as a reference, abdominal pain was associated with revisitation and hospitalization (OR: 3.70, 95% CI: 2.24-6.11 and OR: 5.28, 95% CI: 2.08-13.4, respectively).

CONCLUSION

Higher age and abdominal pain were associated with hospital revisitation and hospitalization within 7 days among patients directly discharged or redirected by the triage team. Regardless of the triage system in use, there might be patient groups that should be evaluated more cautiously if a triage-based discharge or redirection strategy is to be considered.

Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area

OBJECTIVES

Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area.

METHODS

This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status.

RESULTS

A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status.

CONCLUSIONS

One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Influence of appropriate emergency department utilization and verbal communication on physicians' (dis)satisfaction with doctor-patient interactions with special consideration of migrational backgrounds

In recent years, utilization of emergency departments (EDs) has increased continuously, both in Germany and internationally. Inappropriate use of EDs is believed to be partly responsible for this trend. The topic of doctor-patient interaction (DPI) has received little attention in research. However, successful DPI is not only important for adherence and treatment success, but also for the satisfaction of medical staff. This non-interventionl cross-sectional study attempts to identify factors influencing physicians' satisfaction with DPIs, with a particular focus on the appropriate utilization of EDs and verbal communication. We carried out tripartite data collection in three EDs of major referral hospitals in Berlin between July 2017 and July 2018. Migration experience, communication and language problems, level of education, and a large gap between physicians' and patients' perceived urgency regarding the utilization of EDs influence the quality of the doctor-patient relationships and interactions.

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

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

Perspectives of emergency department physicians and nurses on reasons for preventable emergency department visits by patients with cancer

BACKGROUND

Patients with cancer frequently visit the emergency department (ED) for medical care, yet approximately half of ED visits for patients with cancer are thought to be preventable. Preventable ED visits are associated with increased healthcare costs and poor patient experiences and outcomes. The voices of ED providers who work with patients with cancer in their everyday practices have not been solicited as it pertains to preventable visits.

OBJECTIVES

The purpose of this study is to describe the perspectives of ED physicians and nurses on reasons for preventable ED visits by patients with cancer.

METHODS

A qualitative descriptive design guided the study. We conducted 23 semi-structured interviews with ED physicians and nurses to query them about their perspectives on the reasons for preventable ED visits by patients with cancer. Content analysis was conducted to list and describe the reasons they discussed.

RESULTS

Participants identified five "medical" and five "non-medical" causes of preventable ED visits. Medical reasons included uncontrolled cancer pain, gastrointestinal symptoms, anemia, fever, and on-going undiagnosed signs and symptoms. Non-medical reasons include patient hesitancy to contact primary care providers, lack of availability or responsiveness of primary providers, lack of access, lack of care coordination, and fears about diagnosis and treatment.

CONCLUSION

The voices of ED providers should be included in discussions about the problem of preventable ED visits by patients with cancer. The reasons supplied by the participants suggest that solutions to the problem will need to occur at the patient, provider, system, and societal levels.

Health Status of Nonemergency Patients in the Emergency Department Using the EQ-5D

Background

Emergency department (ED) overcrowding is influenced by several factors including the hospital's capacity, staff, patient discharges, and community resources. The number of annual ED visits has increased, with patients' medical needs exceeding emergency capacity, resulting in a widespread concern about emergency room overcrowding. Nonemergency patients tend to use large amounts of emergency medical resources, which is one reason for ED overcrowding. Most patients consider their medical cases urgent, whereas medical professionals consider many cases to be nonemergency. Only a few studies have examined self-rated health among nonemergency patients.

Methods

This cross-sectional study was conducted in the ED of a tertiary hospital in China using the European Quality of Life Five-Dimensional Questionnaire to investigate the health status of nonemergency patients.

Results

Among the 545 respondents, 246 (45.14%) self-assessed their health as excellent, 186 (34.13%) as very good, 70 (12.84%) as good, 32 (5.87%) as average, and 11 (2.02%) as poor. Problems related to pain/discomfort were reported by 317 (58.17%) participants, 214 (39.27%) responded that they had problems related to daily activities, 212 (38.90%) responded that they felt anxious or depressed, 211 (38.35%) responded that they had problems related to self-care, and some or extreme problems related to mobility were stated by 193 people (35.41%).

Conclusions

Nonemergency patients generally reported good health. Pain/discomfort was the most significant factor affecting the health of nonemergency patients, followed by limitation of daily activities. The duration of illness onset and self-rated health status were common factors influencing the health status of nonemergency patients. This trial is registered with ChiCTR1900023578.

Assisted teleconsultation in an outpatient pharmacy: Results of a pilot study in Geneva, Switzerland

INTRODUCTION

Assisted teleconsultation (ATC) is the act of telemedicine involving on one side a patient in the presence of a healthcare professional, and an expert on the other side. ATC in outpatient pharmacies may be an alternative to the emergency room for patients with a semi-urgent medical problem. This project aimed at pilot testing the ATC in an outpatient pharmacy to assess its feasibility and to collect initial real-world data.

METHODS

After initial evaluation and triage by the pharmacist, ATC was proposed to patients consulting at one outpatient pharmacy for semi-urgent medical problems. Prospective data on patients, consultation reasons, teleconsultation duration, patient's orientation and pharmacist' satisfaction were prospectively collected.

RESULTS

Between December 2020 and June 2021, 39 consultations took place, 12 with video and 27 with telephone. Patients' median age was 37 years (IQR 26-50), 59% were women. Near half of the consultations (19) happened during the weekend. Mean ATC duration was 22 min (IC95% 18.6-26.1). Twenty-nine (74%) consultations ended with a prescription, 8 (21%) with medical recommendations and 2 (5%) with an emergency care referral. Without teleconsultation, 34 (87%) patients would have consulted a physician for their problem, and 24 (62%) would have been to the emergency room (self-reported). Fourteen (36%) consultations involved ENT, ophthalmologic and dermatologic complaints.

CONCLUSION

A young population with semi-urgent medical problems can be managed in the pharmacy using ATC with a primary care physician. Financial, technical and training aspects should be developed and optimized in the future.

[Motives of patients presenting independently at the emergency department-a prospective monocentric observational study]

BACKGROUND

In the ongoing professional, societal, and political discussion, the hypothesis is repeatedly put forward that a large portion of patients who independently visit the emergency department could also be treated in other care settings such as by a general practitioner, the statutory medical on-call service, or in emergency clinics. Various reasons are cited for why these alternative care settings are not utilized in these cases.

OBJECTIVES

This study investigates the motives of patients who presented independently at the emergency department, as well as the socio-demographic parameters of this study cohort.

MATERIALS AND METHODS

The survey was carried out as part of a prospective monocentric observational study of internal medicine patients at a university emergency department.

RESULTS

A total of 1086 patients were included in the study. In total, 33% of the study participants visited the emergency department based on a physician's recommendation or referral instead of opting for an alternative care option. The main reason for visiting the emergency department was the subjectively assessed urgency of their symptoms. Among the patients who presented independently at the emergency department, 28% required further inpatient care during the course of treatment. Awareness of alternative care pathways, such as utilizing emergency medical services, seeking care from the statutory medical on-call service, or visiting an emergency clinic, was low.

CONCLUSIONS

Emergency departments remain an important point of contact for patients who present there independently, without being brought by emergency medical services. The motives behind why patients choose a visit to the emergency department over treatment in an alternative care setting vary. If alternatives are to be used instead of emergency departments, structures first need to be established or expanded.

Assessment of a multi-center tele-urgent care program to decrease emergency department referral rates in the Veterans Health Administration

The use of emergency departments for non-emergent issues has led to overcrowding and decreased the quality of care. Telemedicine may be a mechanism to decrease overutilization of this expensive resource. From April to September 2020, we assessed (a) the impact of a multi-center tele-urgent care program on emergency department referral rates and (b) the proportion of individuals who had a subsequent emergency department visit within 72 h of tele-urgent care evaluation when they were not referred to the emergency department. We then performed a chart review to assess whether patients presented to the emergency department for the same reason as was stated for their tele-urgent care evaluation, whether subsequent hospitalization was needed during that emergency department visit, and whether death occurred. Among the 2510 patients who would have been referred to in-person emergency department care, but instead received tele-urgent care assessment, one in five (21%; n = 533) were subsequently referred to the emergency department. Among those not referred following tele-urgent care, 1 in 10 (11%; n = 162) visited the emergency department within 72 h. Among these 162 individuals, most (91%) returned with the same or similar complaint as what was assessed during their tele-urgent care visit, with one in five requiring hospitalization (19%, n = 31) with one individual (0.01%) dying. In conclusion, tele-urgent care may safely decrease emergency department utilization.

Association of the affordable care act with racial and ethnic disparities in uninsured emergency department utilization

BACKGROUND

Disparities in uninsured emergency department (ED) use are well documented. However, a comprehensive analysis evaluating how the Affordable Care Act (ACA) may have reduced racial and ethnic disparities is lacking. The goal was to assess the association of the ACA with racial and ethnic disparities in uninsured ED use.

METHODS

This study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for Georgia, Florida, Massachusetts, and New York from 2011 to 2017. Participants include non-elderly adults between 18 and 64 years old. Outcomes include uninsured rates of ED visits by racial and ethnic groups and stratified by medical urgency using the New York University ED algorithm. Visits were aggregated to year-quarter ED visits per 100,000 population and stratified for non-Hispanic White, non-Hispanic Black, and Hispanic non-elderly adults. Quasi-experimental difference-in-differences and triple differences regression analyses to identify the effect of the ACA and the separate effect of the Medicaid expansion were used comparing uninsured ED visits by race and ethnicity groups pre-post ACA.

RESULTS

The ACA was associated with a 14% reduction in the rate of uninsured ED visits per 100,000 population (from 10,258 pre-ACA to 8,877 ED visits per 100,000 population post-ACA) overall. The non-Hispanic Black compared to non-Hispanic White disparity decreased by 12.4% (-275.1 ED visits per 100,000) post-ACA. About 60% of the decline in the Black-White disparity was attributed to disproportionate declines in ED visit rates for conditions classified as not-emergent (-93.2 ED visits per 100,000), and primary care treatable/preventable (-64.1 ED visits per 100,000), while the disparity in ED visit rates for injuries and not preventable conditions also declined (-106.57 ED visits per 100,000). All reductions in disparities were driven by the Medicaid expansion. No significant decrease in Hispanic-White disparity was observed.

CONCLUSIONS

The ACA was associated with fewer uninsured ED visits and reduced the Black-White ED disparity, driven mostly by a reduction in less emergent ED visits after the ACA in Medicaid expansion states. Disparities between Hispanic and non-Hispanic White adults did not decline after the ACA. Despite the positive momentum of declining disparities in uninsured ED visits, disparities, especially among Black people, remain.

Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland

BACKGROUND

Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland.

METHODS

The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.

RESULTS

The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.

CONCLUSIONS

Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Community paramedicine in Central Oregon: A promising model to reduce non-urgent emergency department utilization among medically complex Medicaid beneficiaries

Background

Community paramedicine has emerged as a promising model to redirect persons with nonmedically emergent conditions to more appropriate and less expensive community-based health care settings. Outreach through community paramedicine to patients with a history of high hospital emergency department (ED) use and chronic health conditions has been found to reduce ED use. This study examined the effect of community paramedicine implemented in 2 rural counties in reducing nonemergent ED use among a sample of Medicaid beneficiaries with complex medical conditions and a history of high ED utilization.

Methods

A cluster randomized trial approach with a stepped wedge design was used to test the effect of the community paramedicine intervention. ED utilization for non-urgent care was measured by emergency medicine ED visits and avoidable ED visits.

Results

The community paramedicine intervention reduced ED utilization among a sample of 102 medically complex Medicaid beneficiaries with a history of high ED utilization. In the unadjusted models, emergency medical ED visits decreased by 13.9% (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.76-0.98) or 6.1 visits saved for every 100 people. Avoidable emergency department visits decreased by 38.9% (IRR, 0.61; 95% CI, 0.44-0.84) or 2.3 visits saved for every 100 people.

Conclusion

Our results suggest community paramedicine is a promising model to achieve a reduction in ED utilization among medically complex patients by managing complex health conditions in a home-based setting.

Mothers' Knowledge of Infants' Fever Management: A National Prospective Study

OBJECTIVES

The aim of this study was to describe mothers' knowledge of infant fever management after birth and six months later and its association with sociodemographic characteristics, perceived support, sources of consultation and health education; and to assess determinants of change in mother's knowledge from birth to six months.

METHODS

Mothers (n = 2804) answered a self-reporting questionnaire after giving birth in maternity wards in six hospitals in Israel; six months later follow- up interviews were conducted by telephone.

RESULTS

The mothers' knowledge level of infant fever management was low after birth (mean = 50.5, range 0-100, SD = 16.1), and rose to a moderate level six months later (mean = 65.2, SD = 15.0). Mothers having their first born, with lower household income or education were less knowledgeable about infant fever management after birth. However, these mothers showed the largest improvement after six months. Mothers' perceived support or sources of consultation and health education (partner, family, friends, nurses, and physicians) were not associated with their knowledge at either time. Moreover, mothers stated self-learning from internet and other media as often as receiving health education by health professionals.

CONCLUSIONS FOR PRACTICE

Public health policy for health professionals in hospitals and community clinics is essential to promote clinical interventions promoting mothers' knowledge of infant fever management. Efforts should focus at first time mothers, those with non-academic education, and those with a moderate or low household income. Public health policy enhancing communication with mothers regarding fever management in hospitals and community health settings, as well as accessible means of self-learning is warranted.

Standard nurse phone triage versus tele-emergency care pilot on Veteran use of in-person acute care: An instrumental variable analysis

OBJECTIVES

Use of acute care telemedicine is growing, but data on quality, utilization, and cost are limited. We evaluated a Veterans Affairs (VA) tele-emergency care (tele-EC) pilot aimed at reducing reliance on out-of-network (OON) emergency department (ED) care, a growing portion of VA spending. With this service, an emergency physician virtually evaluated selected Veterans calling a nurse triage line.

METHODS

Calls to the triage line occurring January-December 2021 and advised to seek care acutely within 24 h were included. We described tele-EC user characteristics, common triage complaints, and patterns in referral to and management by tele-EC. The primary outcome was acute care visits (ED, urgent care, and hospitalizations at VA and OON sites) within 7 days of the index call. Secondary outcomes included mortality, OON acute care spending, and the effect of tele-EC visit modality (phone vs. video). We used both standard regression and instrumental variable (IV) analysis, using the tele-EC physician schedule as the instrument.

RESULTS

Of 7845 eligible calls, 15.5% had a tele-EC visit, with case resolution documented in 57%. Compared to standard nurse triage, tele-EC users were less likely to be Black, had more prior ED visits, and were triaged as higher acuity. Calls concerning dizziness/syncope, blood in stool, and chest pain were most likely to have a tele-EC visit. Tele-EC was associated with fewer ED visits than standard nurse triage in both regression (average marginal effect [AME] -16.8%, 95% confidence interval [CI] -19.2 to -14.4) and IV analyses (AME -17.5%, 95% CI -25.1 to -9.8), lower hospitalization rate (AME -3.1%, 95% CI -6.2 to -0.0), and lower OON spending (AME -$248, 95% CI -$458 to -$38).

CONCLUSIONS

Among Veterans initially advised to seek care within 24 h, use of tele-EC compared to standard phone triage led to decreased ED visits, hospitalizations, and OON spending within 7 days.

Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US

IMPORTANCE

An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented.

OBJECTIVE

To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated.

MAIN OUTCOMES AND MEASURES

The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization.

RESULTS

Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization.

CONCLUSIONS AND RELEVANCE

In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits

Background

Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits.

Methods

We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category.

Results

There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults.

Conclusion

Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta

OBJECTIVES

This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence.

METHODS

A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence.

RESULTS

There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC.

CONCLUSIONS

There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.

Triaging and referring in adjacent general and emergency departments (the TRIAGE-trial): A process evaluation of medical staff experiences in a nurse-led triage system

AIMS

This process evaluation aims at identifying the facilitators and inhibitors that influenced the successful uptake of a nurse-led triage system streaming low-risk patients from an emergency department (ED) to the general practitioner (GP).

DESIGN & METHODS

Semi-structured interviews with ED nurses (n = 12), ED doctors (n = 6) from the ED of a Belgian general hospital and GPs (n = 5) affiliated with the adjacent GP cooperative (GPC). The process evaluation ran in parallel with the TRIAGE trial that started in March 2019 and ended 31st of December 2019. The first set of interviews was conducted in June 2019 and the second set in January 2020. Data were analysed based on grounded theory.

RESULTS

Through a deductive framework, facilitators and inhibitors could be identified on three levels: the organisational, group and individual level. Main inhibitors are the degree of risk aversion of individual nurses, possible language barriers during delivery of the triage advice and the non-adapted ED infrastructure. Training on both the use of the triage protocol and effective delivery of the triage advice, in combination with periodical feedback from the GPC were the most important facilitators.

CONCLUSION

Based on the process evaluation we can conclude that a consensus exists among stakeholders that the ED Nurses are considered ideally positioned to perform the triage of walk-in patients, although a certain degree of experience is necessary. Although the extended triage protocol and GPC referral increases the complexity and duration of triage and entails a higher workload for the triage nurses, ED nurses found it did lead to a lower (perceived) workload for the ED in general.

Algorithms Identifying Low Acuity Emergency Department Visits: A Review and Validation Study

OBJECTIVE

To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low acuity emergency department (ED) visits.

DATA SOURCES

Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).

STUDY DESIGN

We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreement using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference.

DATA COLLECTION

We used 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk.

PRINCIPAL FINDINGS

We identified 15 papers with an original list of ICD codes used to identify preventable or low acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization.

CONCLUSIONS

Existing algorithms that identify low acuity ED visits lack congruence and are imperfect predictors of visit acuity.

Non-compliance with a nurse's advice to visit the primary care provider: an exploratory secondary analysis of the TRIAGE-trial

Background

During the cluster randomised TRIAGE-trial, a nurse advised 13% of low-risk patients presenting at an emergency department in Belgium to visit the adjacent general practitioner cooperative. Patients had the right to refuse this advice. This exploratory study examines the characteristics of refusers by uncovering the determinants of non-compliance and its impact on costs, as charged on the patient’s invoice.

Methods

Bivariate analyses with logistic regressions and T-tests were used to test the differences in patient characteristics, patient status, timing characteristics, and costs between refusers and non-refusers. A chi-square automatic interaction detection analysis was used to find the predictors of non-compliance.

Results

23.50% of the patients refused the advice to visit the general practitioner cooperative. This proportion was mainly influenced by the nurse on duty (non-compliance rates per nurse ranging from 2.9% to 52.8%) and the patients’ socio-economic status (receiving increased reimbursement versus not OR 1.37, 95%CI: 0.96 to 1.95). Additionally, non-compliance was associated (at the 0.10 significance level) with being male, not living nearby and certain reasons for encounter. Fewer patients refused when the nurse perceived crowding level as quiet relative to normal, and more patients refused during the evening. The mean cost was significantly higher for patients who refused, which was a result of more extensive examination and higher out-of-pocket expenses at the ED.

Conclusions

The nurse providing the advice to visit the general practitioner cooperative has a central role in the likelihood of patients’ refusal. Interventions to reduce non-compliance should aim at improving nurse-patient communication. Special attention may be required when managing patients with a lower socio-economic status. The overall mean cost was higher for refusers, illustrating the importance of compliance.

Trial registration

The trial was registered on registration number NCT03793972 on 04/01/2019.

Pathways to the emergency department - a national, cross-sectional study in Sweden

Background

Swedish Emergency Departments (EDs) see 2.6 million visits annually. Sweden has a strong tradition of health care databases, but information on patients’ pathways to the ED is not documented in any registry.

The aim of this study was to provide a national overview of pathways, degree of medical acuteness according to triage, chief complaints, and hospital admission rates for adult patients (≥18 years) visiting Swedish EDs during 24 h.

Methods

A national cross-sectional study including all patients at 43 of Sweden’s 72 EDs during 24 h on April 25th, 2018. Pathway to the ED, medical acuteness at triage, admission and basic demographics were registered by dedicated assessors present at every ED for the duration of the study. Descriptive data are reported.

Results

A total of 3875 adult patients (median age 59; range 18 to 107; 50% men) were included in the study. Complete data for pathway to the ED was reported for 3693 patients (98%). The most common pathway was self-referred walk-in (n = 1310; 34%), followed by ambulance (n = 920; 24%), referral from a general practitioner (n = 497; 1 3%), and telephone referral by the national medical helpline “1177” (n = 409; 10%). In patients 18 to 64 years, self-referred walk-in was most common, whereas transport by ambulance dominated in patients > 64 years.

Of the 3365 patients who received a medical acuteness level at triage, 4% were classified as Red (Immediate), 18% as Orange (very urgent), 47% as Yellow (Urgent), 26% as Green (Standard), and 5% as Blue (Non-Urgent).

Abdominal or chest pain were the most common chief complaints representing approximately 1/3 of all presentations.

Overall, the admission rate was 27%. Arrival by ambulance was associated with the highest rate of admission (53%), whereas walk-in patients and telephone referrals were less often admitted.

Conclusion

Self-referred walk-in was the overall most common pathway followed by ambulance. Patients arriving by ambulance were often elderly, critically ill and often admitted to in-patient care, whereas arrival by self-referred walk-in was more common in younger patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00619-3.

How accurate is telephone triage in out-of-hours care? An observational trial in real patients

OBJECTIVES

Patients in Belgium needing out-of-hours medical care have two options: the emergency department (ED) or a general practitioner (GP) on call. Currently, there is no triage system in Belgium, so patients do not know where they should go. However, patients who could be managed by a GP frequently present themselves at an ED without referral. GPs often organise themselves in a General Practitioners Cooperative (GPC). This study assesses the accuracy of a newly developed telephone triage guideline.

METHODS

Observational real-time simulation: all walk-in patients at two GPCs and three EDs were asked to call a triage telephone number with their current medical problem. The operator handling this call registered an urgency level and a resource (ED, GP or ambulance) to deploy. The treating physician's opinion was used a the gold standard for correct triage. Patients were not informed about the outcome of the triage and continued the standard care path they had chosen.

RESULTS

The overall sensitivity of the telephone triage for detecting patients who could be managed by a GP was 82% with a specificity of 53%. The correctness of the advice given by the operator according to the physicians was 71%, with 12% underestimation of urgency and 17% overestimation. At the GPC, the sensitivity for detecting patients requiring GP management/care was 91% with a specificity of 36%. At the ED, the sensitivity for detecting GP patients was 67% with a specificity of 48%.

CONCLUSION

This study evaluates a new guideline for telephone triage, showing potential overtriage for patients wanting to attend the GPC, with possible inefficiency, and potential undertriage for patients wanting to attend the ED, with possible safety issues.

Safety of Triage Self-assessment Using a Symptom Assessment App for Walk-in Patients in the Emergency Care Setting: Observational Prospective Cross-sectional Study

Background

Increasing use of emergency departments (EDs) by patients with low urgency, combined with limited availability of medical staff, results in extended waiting times and delayed care. Technological approaches could possibly increase efficiency by providing urgency advice and symptom assessments.

Objective

The purpose of this study is to evaluate the safety of urgency advice provided by a symptom assessment app, Ada, in an ED.

Methods

The study was conducted at the interdisciplinary ED of Marburg University Hospital, with data collection performed between August 2019 and March 2020. This study had a single-center cross-sectional prospective observational design and included 378 patients. The app’s urgency recommendation was compared with an established triage concept (Manchester Triage System [MTS]), including patients from the lower 3 MTS categories only. For all patients who were undertriaged, an expert physician panel assessed the case to detect potential avoidable hazardous situations (AHSs).

Results

Of 378 participants, 344 (91%) were triaged the same or more conservatively and 34 (8.9%) were undertriaged by the app. Of the 378 patients, 14 (3.7%) had received safe advice determined by the expert panel and 20 (5.3%) were considered to be potential AHS. Therefore, the assessment could be considered safe in 94.7% (358/378) of the patients when compared with the MTS assessment. From the 3 lowest MTS categories, 43.4% (164/378) of patients were not considered as emergency cases by the app, but could have been safely treated by a general practitioner or would not have required a physician consultation at all.

Conclusions

The app provided urgency advice after patient self-triage that has a high rate of safety, a rate of undertriage, and a rate of triage with potential to be an AHS, equivalent to telephone triage by health care professionals while still being more conservative than direct ED triage. A large proportion of patients in the ED were not considered as emergency cases, which could possibly relieve ED burden if used at home. Further research should be conducted in the at-home setting to evaluate this hypothesis.

Trial Registration

German Clinical Trial Registration DRKS00024909; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00024909

Factors associated with choice of health service delivery for after-hours, urgent, non-life-threatening conditions: a patient survey

The objective of this study was to determine factors associated with patient or carer choice of presentation to an emergency department, an urgent care clinic and an after-hours general practice on Sundays in south-east Queensland. The design of the study was a cross-sectional survey of patients or carers. The study setting was an emergency department, an urgent care clinic and an after-hours general practice. Patients or carers of patients were invited to take part in the study while they were waiting to consult the doctor. Patients were more likely to present to community clinics (i.e. urgent care clinic and an after-hours general practice) if they usually came to the facility (P < 0.001), were concerned about cost (P < 0.001), were influenced by the perceived severity of the sickness (P < 0.001), were unable to get an appointment elsewhere (P < 0.001), thought that there would be less waiting time (P < 0.001) and thought there was better doctor explanation (P = 0.007). This research was limited to 337 surveys. Larger studies could further explore insights gained from this study. The results suggest that public health campaigns could focus on promoting community clinic care for urgent non-life-threatening conditions. These campaigns should include information on waiting times, need for referral, conditions safely managed, range of services provided and quality of service. Designing community facilities for hospital avoidance of patients with non-life-threatening urgent conditions could involve public health campaigns, facility upgrades, and subsidies for transport and attendance.

A Retrospective Study of Disparities in an Academic Ophthalmic Emergency Department

Purpose Emergency medicine is a common access point to health care; disparities in this care by demographic characteristics, including race and ethnicity, may affect outcomes. The Massachusetts Eye and Ear (MEE) Emergency Department (ED) is a subspecialty emergency department; data from this site can be utilized to better understand social determinants of quality ophthalmic care.

Design This is a retrospective cross sectional cohort study in the MEE ED examining patient visits from June 1, 2016 to June 30, 2019.

Methods Using the electronic medical record system, all unique visits were identified between June 1, 2016 and June 30, 2019 (inclusive); patient demographics (sex, race, ethnicity [Hispanic vs. non-Hispanic], primary care provider [PCP] status, insurance type, zip code, primary language), date of visit, triage category and outcomes (final diagnosis, visit duration, and next visit at MEE within 3 months of the ED visit) were collected. Kaplan-Meier plots were used to visualize likelihood of follow-up visit to MEE for urgent patients based on demographics. Multivariate linear regression was used to examine factors affecting visit durations, as stratified by urgency, and Cox proportional hazards regression was used to establish hazard ratios for next visit to MEE.

Results Of the 46,248 ophthalmology ED initial visits, only triage status, season of visit, out-of-state residency, Medicare coverage, and Medicaid coverage led to statistically significant differences in visit durations for urgent visits compared with the respective reference groups. Similar trends persisted within the non-urgent visit cohort for visit durations. Residency, insurance coverage, season of visit, race, PCP status, and sex were identified as statistically significant predictors of the likelihood of a follow-up visit.

Conclusion Data from an ophthalmic emergency department suggest that demographic factors do impact patient visit duration and time to follow-up visit. These findings suggest a continued need for attention to social determinants of health and equitable care of patients within ophthalmology.

Health and Culture: The Association between Healthcare Preferences for Non-Acute Conditions, Human Values and Social Norms

Preference for professional vs. non-professional or informal healthcare for non-acute medical situations influences healthcare use and varies strongly across countries. Important individual and country-level drivers of these preferences may be human values (the fundamental values that individuals hold and guide their behavior) and country-level characteristics such as social tightness (societal pressure for “acceptable” behavior). The aim of this study was to examine the relation of these individual and country-level characteristics with healthcare preferences. We examined European Social Survey data from 23,312 individuals in 16 European countries, using a multi-level, random effect approach, including individual and country-level factors. Healthcare preferences were explained by both human values (i.e., Schwartz values) and societal tightness (i.e., tightness-looseness scores by Gelfand). Stronger conservation increased, whereas self-transcendence and openness to change decreased preference for professional healthcare. In socially tight countries, we found a higher preference for professional healthcare. Furthermore, we found interactions between social tightness and human values. These results suggest that professional healthcare preference is related to both people’s values and societal tightness. This improved understanding is useful for both predicting and channeling healthcare seeking behavior across and within nations.

Performance of a new symptom checker in patient triage: Canadian cohort study

BACKGROUND

Computerized algorithms known as symptom checkers aim to help patients decide what to do should they have a new medical concern. However, despite widespread implementation, most studies on symptom checkers have involved simulated patients. Only limited evidence currently exists about symptom checker safety or accuracy when used by real patients. We developed a new prototype symptom checker and assessed its safety and accuracy in a prospective cohort of patients presenting to primary care and emergency departments with new medical concerns.

METHOD

A prospective cohort study was done to assess the prototype's performance. The cohort consisted of adult patients (≥16 years old) who presented to hospital emergency departments and family physician clinics. Primary outcomes were safety and accuracy of triage recommendations to seek hospital care, seek primary care, or manage symptoms at home.

RESULTS

Data from 281 hospital patients and 300 clinic patients were collected and analyzed. Sensitivity to emergencies was 100% (10/10 encounters). Sensitivity to urgencies was 90% (73/81) and 97% (34/35) for hospital and primary care patients, respectively. The prototype was significantly more accurate than patients at triage (73% versus 58%, p<0.01). Compliance with triage recommendations in this cohort using this iteration of the symptom checker would have reduced hospital visits by 55% but cause potential harm in 2-3% from delay in care.

INTERPRETATION

The prototype symptom checker was superior to patients in deciding the most appropriate treatment setting for medical issues. This symptom checker could reduce a significant number of unnecessary hospital visits, with accuracy and safety outcomes comparable to existing data on telephone triage.

Emergency Department Utilization Following Hepatopancreatic Surgery Among Medicare Beneficiaries

BACKGROUND

Care delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge.

METHODS

The Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated.

RESULTS

Among 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07-1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32-1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10-1.23) and patients not discharged home (OR 1.41, 95%CI 1.33-1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87-0.97 and OR 0.22, 95%CI 0.20-0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days.

CONCLUSION

More than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Acceptability of emergency department triage nurse's advice for patients to attend general practice: A cross-sectional survey

OBJECTIVES

Demand for ED care is increasing at a rate higher than population growth. Strategies to attenuate ED demands include diverting low-acuity general practice-type ED attendees to alternate primary healthcare settings. The present study assessed the ED attendees' receptiveness to accept triage nurse's face-to-face advice to explore alternate options for medical care and what factors influence the level of acceptance.

METHODS

The ED attendees of four major public hospital EDs in Brisbane were surveyed between August and October 2018, using a questionnaire informed by Health Belief Model's cues to action.

RESULTS

Of the 514 valid responses, 81% of respondents were very likely/likely to accept the triage nurse's advice to see a general practitioner. Self-perceived urgency of presenting condition/s (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97), not having confidence in general practitioner (OR 0.37, 95% CI 0.21-0.66) and having a medical record at the hospital (OR 0.60, 95% CI 0.36-0.99) were negatively associated with the likelihood of accepting the advice. For every point increase in perceived seriousness, the odds of accepting the advice decreased by 16% (95% CI 6-25%).

CONCLUSION

Most of the participants believed that EDs were for emergent care and they attended the ED because they perceived their presenting condition/s to be serious and/or urgent. The acceptability of face-to-face advice by triage nurse to seek help in general practice was influenced by perceived threats of the illness, and the underlying beliefs about availability, accessibility, suitability and affordability of the service.

Triaging and referring in adjacent general and emergency departments (the TRIAGE trial): A cluster randomised controlled trial

OBJECTIVES

To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC).

METHODS

Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard).

RESULTS

In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised.

CONCLUSIONS

ED nurses using a new tool safely diverted 9.5% of the included patients to primary care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03793972.

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.

Young adults' healthcare utilisation and healthcare needs: Perceptions and experiences of healthcare providers

Background

Health care in many countries entails long waiting times. Avoidable healthcare visits by young adults have been identified as one probable cause.

Objective

The aim of this study was to explore healthcare providers' experiences and opinions about young adults' healthcare utilisation in the first line of care.

Method

This study used latent qualitative conventional content analysis with focus groups. Four healthcare units participated: two primary healthcare centres and two emergency departments. This study included 36 participants, with 4–7 participants in each group, and a total of 21 registered nurses and 15 doctors. All interviews followed an interview guide.

Results

Data were divided into eight categories, which all contained the implicit theme of distribution of responsibility between the healthcare provider and the healthcare user. Young adult healthcare consumers were considered to be highly influenced by external resources, often greatly concerned with small/vague symptoms they had difficulty explaining and unable to wait with. The healthcare provider's role was much perceived as being part of a healthcare structure—a large organisation with multiple units—and having to meet different priorities while also considering ethical dilemmas, though feeling supported by experience.

Conclusion

Healthcare personnel view young adults as transferring too much of the responsibility of staying healthy to the healthcare system. The results of this study show that the discussion of young adults unnecessarily seeking health care includes an underlying discussion of scarcity of resources.

Patient or Public Contribution

The conduct of this study is based on interviews with young adult patients about their experiences of seeking healthcare.

Retrospective Analysis of Adult Patients Presenting to the Acute Care Setting Requesting Prescriptions

Introduction

Patient visits to the emergency department (ED) or urgent care centre (UCC) for the sole purpose of requesting prescriptions are challenging for the patient, the physician, and the department. The primary objective of this study was to determine the characteristics of these patients, the nature of their requests, and the response to these requests. Our secondary objective was to determine the proportion of these medication requests that had street value.

Methods

This was a retrospective, electronic chart review of all adult patients requesting a prescription from a two-site ED and/or an UCC in a medium-sized Canadian city between April 1, 2014–June 30, 2017. Recorded outcomes included patient demographic data and access to a family doctor, medication requested, whether or not a prescription was given, and ED length of stay. Medication street value was determined using a local police service listing.

Results

A total of 2,265 prescriptions were requested by 1,495 patients. The patient median [interquartile range] age was 43 [32–54] years. A family doctor was documented by 55.4% (939/1,694) of patients. The two most commonly requested categories of medications were opioid analgesics 21.2% (481/2,265) and benzodiazepine anxiolytics 11.7% (266/2,265). Of patients requesting medication, 50.5% (755/1,495) requested medications without street value including some with potential to cause serious adverse health effects if discontinued. The requested prescription was received by 19.9% (298/1,495) of patients; 15.3% (173/1,134) returned for further prescription requests. The 90th percentile length of stay was 3.2 and 5.6 hours at the UCC and ED, respectively.

Conclusion

Patients who presented to the ED or UCC sought medications with and without street value in almost equal measure. A more robust understanding of these patients and their requests illustrates why a ‘one-size-fits-all’ response to these requests is inappropriate and signals some fault lines within our local healthcare system.

[Overcrowding of emergency services in the city of Bogotá: a systemic understanding of the problem]

Emergency overcrowding is often associated with issues of inefficiency in care. However, this work focuses on another relevant aspect, namely care of non-urgent patients. In order to understand the dynamics associated with this aspect, a conceptual model of systems dynamics is constructed, based on the characterization of users and their decision criteria. A descriptive study was conducted based on a structured survey; additionally, binomial logistic regression and analysis of variance were used to estimate probability of emergency department visits and to define differences among users. The following criteria are relevant: service effectiveness, availability of medications and exams, and proximity to the emergency center. The waiting time is more significant for pediatric patients and the availability of medications and exams is also more prevalent for middle-income users; the latter attributes less importance to cost compared to low income. The model shows that resources create a virtuous or a vicious cycle of users waiting for care in both emergency and priority care (PC) centers. The proposal suggested is for segregation for pediatric users in PC centers and the promotion of user confidence in alternative options to emergency centers.

The impact of urgent care centers on nonemergent emergency department visits

OBJECTIVE

To estimate the impact of urgent care centers on emergency department (ED) use.

DATA SOURCES

Secondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.

STUDY DESIGN

We used a difference-in-differences design to examine ZIP code-level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.

DATA COLLECTION/EXTRACTION METHODS

Urgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.

PRINCIPAL FINDINGS

We found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.

CONCLUSIONS

During the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.

Understanding young adults' reasons for seeking 'clinically unnecessary' urgent and emergency care: A qualitative interview study

Background

Studies have identified young adults as more likely to use emergency departments for ‘clinically unnecessary’ problems, with limited similar evidence for emergency ambulance use. Media portrayals depict young adults as motivated by ‘convenience’, but little research has explored the reasons for their help‐seeking behaviour.

Methods

Qualitative interviews with 16 young adults (18‐30) considered by clinicians to have made unnecessary use of emergency ambulance, emergency department or an urgent GP appointment. Data analysis was informed by interpretive phenomenological analysis.

Findings

A number of interrelated factors contributed to participants’ decisions. They were anxious about the seriousness of their symptoms, sometimes exacerbated by reduced coping capacity due to poor mental health or life stresses. They looked to others to facilitate their decision making, who sometimes encouraged urgent contact. They wanted to avoid impact on existing day‐to‐day commitments including work or study. They had strong views about different health services, sometimes based on frustration with lack of resolution of on‐going health problems. Convenience was not identified as a significant factor, although some actions could be interpreted in this light if the context was not considered.

Conclusions

Young adults make ‘clinically unnecessary’ use of urgent and emergency care for more than convenience. Their decisions need to be understood in relation to the complexity of their experience, including lack of confidence in making health‐related decisions, lowered coping capacity and concern to maintain normal daily life.

Emergency department visits for infectious oral conditions in Massachusetts, 2014 through 2018

BACKGROUND

The authors aimed to measure population-based preventable emergency department (ED) visits related to infectious oral conditions (IOCs) in Massachusetts and to examine the associated sociodemographic factors to support prevention efforts.

METHODS

A statewide retrospective analysis of ED visits related to IOCs in Massachusetts from 2014 through 2018 was conducted using a Center for Health Information and Analysis database. The authors described patients' characteristics, dental diagnoses frequencies, emergency severity, lengths of stay, associated treatment, and costs. Multilevel logistic regression was used to assess factors associated with IOC visits.

RESULTS

IOC visits in 2014 through 2018 were 1.2% (149,777) of the total ED visits, with an estimated cost of $159.7 million. There was an annual decline in the prevalence of IOC visits from 2014 through 2018. After adjusting for sociodemographic factors, odds of IOC were higher among males (adjusted odd ratio [AOR], 1.26; 95% CI, 1.24 to 1.27), non-Hispanic Blacks compared with non-Hispanic Whites (AOR, 1.03; 95% CI, 1.02 to 1.06), people residing in dental health care professional shortage areas (AOR, 1.06; 95% CI, 1.04 to 1.07), public insurance beneficiaries (AOR, 1.90; 95% CI, 1.87 to 1.93), or uninsured (AOR, 2.60; 95% CI, 2.54 to 2.66) compared with privately insured.

CONCLUSIONS

There was an annual decline in the prevalence of IOC visits from 2014 through 2018. Higher odds of IOC visits were associated with young adults, Black patients, uninsured people, public insurance beneficiaries, and people who reside in dental health care professional shortage areas.

PRACTICAL IMPLICATIONS

The authors provided statewide data to support proposed policies to improve oral health care in Massachusetts. IOCs are mostly preventable, but well-coordinated care between medicine and dentistry is integral for prevention.

Health Literacy and Emergency Department Utilization Among Community Adults With Mental and Chronic Health Conditions

Reducing unnecessary emergency department (ED) utilization is a national health care priority. Low health literacy is a little explored but suggested cause of excess ED utilization. This study investigated the association between health literacy and ED utilization among a community sample of adults with common mental and chronic health conditions. Cross-sectional health interview survey data from Schenectady, New York, were used. Adults (aged ≥18 years) who were diagnosed with anxiety/emotional disorders, depression, asthma, or diabetes were included in the study. Health literacy was assessed using the three-question screener developed and validated by L. D. Chew et al. (2004). ED visits in the previous 12 months specific to these health conditions were analyzed. Multivariable regression models were fitted for each condition with incremental covariate adjustments of demographics, health care access, and number of comorbidities. Odds ratio (OR) and 95% confidence intervals (CI) were reported. Sample sizes were 404, 509, 409, and 237 for anxiety/emotional disorders, depression, asthma, and diabetes, respectively. Inadequate health literacy was significantly higher among individuals who had depression and visited an ED compared with individuals with depression without an ED visit (28.1% vs. 16.9%, p = 0.029). Significant and independent associations between inadequate health literacy and ED utilization was found among adults with anxiety/emotional disorder (fully-adjusted OR 2.22 [CI: 1.03, 4.76]) and among adults with depression (fully-adjusted OR 2.29 [CI: 1.18, 4.44]). No significant association was found among adults with asthma or diabetes. This study presented evidence that inadequate health literacy is common and independently associated with ED utilization among adults with mental health conditions. It supports an initiative to prioritize individuals with mental health conditions, and systematically screen, identify, and provide assistance to those with inadequate health literacy to reduce excess ED utilization. Several existing health literacy screening tools suitable for an emergency care setting are suggested.

Identification of new demands regarding prehospital care based on 35,188 missions in 2018

BACKGROUND

Population ageing and increased prevalence of chronic diseases result in the emergence of new demands in prehospital care. The prehospital system is facing an increase of cases without acute threat to life (so-called "non-urgent"), which generates tension due to a higher number of admissions to emergency departments and a greater use of prehospital resources. Our aim is to understand this transition in prehospital activities and to delineate the primary missions performed by paramedics in 2018 with a focus on the population concerned, the severity of cases encountered and the typology of health issues.

METHOD

The study is retrospective, and descriptive, using a statistical description of 35,188 primary missions realized in 2018 in the State of Vaud (Switzerland). The characteristics taken into consideration are the age and gender of patients, as well as the health issue, the severity of cases based on National Advisory Committee for Aeronautics score (NACA score), and the time and place of intervention.

RESULTS

The results describe the primary missions in the State of Vaud in 2018 and show that 87% of missions concern "non-urgent" situations (without acute threat to life). Over half of patients are 65 or older, the highest proportion of health issues, 49%, are medical and only 23% of missions are for traumas. Mission related to mental health issues reach 7% and those for intoxication 6%. Most missions take place between 7:00 am and 6:00 pm (67%), and around 12% of missions lead to the non-transport of the patient.

CONCLUSION

The prehospital sector is confronted with a major transition in terms of patient care. An increase of non-urgent cases is observed, associated with the care of persons aged 65 or more. Our results question the adequacy between the needs in terms of prehospital care and the paramedic profession as it is currently defined, as well as the place of this profession within the health network. Reflecting upon the role of paramedics with respect to the socio-demographic evolution of populations appears necessary, to analyse the adequacy of the paramedics' skills to respond to the current needs.

First Nations emergency care in Alberta: descriptive results of a retrospective cohort study

Background

Worse health outcomes are consistently reported for First Nations people in Canada. Social, political and economic inequities as well as inequities in health care are major contributing factors to these health disparities. Emergency care is an important health services resource for First Nations people. First Nations partners, academic researchers, and health authority staff are collaborating to examine emergency care visit characteristics for First Nations and non-First Nations people in the province of Alberta.

Methods

We conducted a population-based retrospective cohort study examining all Alberta emergency care visits from April 1, 2012 to March 31, 2017 by linking administrative data. Patient demographics and emergency care visit characteristics for status First Nations persons in Alberta, and non-First Nations persons, are reported. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage and Acuity Scale). Means, medians, standard deviations and interquartile ranges describe continuous variables (e.g., age).

Results

The dataset contains 11,686,288 emergency care visits by 3,024,491 unique persons. First Nations people make up 4% of the provincial population and 9.4% of provincial emergency visits. The population rate of emergency visits is nearly 3 times higher for First Nations persons than non-First Nations persons. First Nations women utilize emergency care more than non-First Nations women (54.2% of First Nations visits are by women compared to 50.9% of non-First Nations visits). More First Nations visits end in leaving without completing treatment (6.7% v. 3.6%).

Conclusions

Further research is needed on the impact of First Nations identity on emergency care drivers and outcomes, and on emergency care for First Nations women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06415-2.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

An emergency department optimized protocol for qualitative research to investigate care seeking by patients with non-urgent conditions

AIM

To describe a tailored qualitative research methodology for exploring the complex interaction of factors driving non-urgent care seeking in the emergency department.

DESIGN

Qualitative descriptive design with a literature informed semi-structured interview and analysis structure. Triangulation with the State-Trait Anxiety Inventory allows expedited exploration of biopsychosocial factors. Consolidated criteria for reporting qualitative research requirements integrated.

METHODS

With a short 10- to 15-min interview and a low-inference analysis process, this methodology offers a structured way to explore the "go to ED" decision, to understand the patient perspective on their healthcare needs and feed into the development of suitable local services that meet patient healthcare needs.

RESULTS

This methodology offers a structured way for clinician-researchers to explore the factors that influence patients seeking care in the emergency departments for non-urgent conditions that are specific to their local health service environment. The described methodology is accessible to novice qualitative researchers and includes the semi-structured interview, coding and analysis frameworks.

Use and Misuse of Emergency Room for Children: Features of Walk-In Consultations and Parental Motivations in a Hospital in Southern Italy

Objective: Inappropriate use of the emergency department (ED) represents a major worldwide issue both in pediatric and adult age. Herein, we aim to describe features of pediatric visits to the ED of Salerno University Hospital and to evaluate parental reasons behind the decision to walk in. Materials and Methods: We performed a retrospective observational study evaluating ED encounters for children from January 2014 to December 2019. The appropriateness of visits was measured with a national tool assessing every ED encounter, namely, "the Mattoni method," which consists of the combination of the triage code assigned, the diagnostic resources adopted, and the consultation outcomes. Moreover, 64 questionnaires were collected from a sample of parents in the waiting rooms in January 2020. Results: A total number of 42,507 visits were recorded during the study period (19,126 females; mean age ± SD: 4.3 ± 3.8 years), the majority of whom were inappropriate (75.8% over the considered period; 73.6% in 2014; 74.6% in 2015; 76.3% in 2016; 76.7% in 2017; 77.9% in 2018; 75.5% in 2019). Most of the inappropriate consultations arrived at the ED by their own vehicle (94.4%), following an independent decision of the parents (97.2%), especially in the evening and at night on Saturdays/Sundays/holidays (69.7%). A multivariate analysis revealed the following: patients of younger age (OR: 1.11, 95% C.I. 1.06-1.16; p < 0.0019), night visits (OR 1.39; 95% C.I.: 1.32-1.47; p < 0.001), patients living in the municipality of Salerno (OR 1.28; 95% C.I.: 1.22-1.34; p < 0.001), weekend day visits (OR 1.48; 95% C.I.: 1.41-1.56; p < 0.001), and independent parental decision without previous contact with primary care pediatrician (OR 3.01; 95% C.I.: 2.64-3.44; p < 0.001) were all significant independent predictors of inappropriate consultation. The most frequent trigger of ED encounters was fever (51.4%). Hospital admission made up 17.6% of all consultations. The questionnaire showed that most parents were aware of the lack of urgency (20.3%) or minor urgency (53.1%) of the visit. The reasons for walking in were the impossibility to receive a home consultation (70%), the difficulty of contacting their family pediatrician during weekends and holidays (54.4%), as well as the search for a quick, effective, diagnosis and therapy (48.4%). Conclusions: The study suggests a highly inappropriate use of ED for children in our region. This issue deserves considerable attention by health care system leaders in order to optimally integrate hospitals and primary care.

Trends and Characteristics of Emergency Medical Services in Italy: A 5-Years Population-Based Registry Analysis

Background: Emergency Medical Services (EMS) plays a fundamental role in providing good quality healthcare services to citizens, as they are the first responders in distressing situations. Few studies have used available EMS data to investigate EMS call characteristics and subsequent responses. Methods: Data were extracted from the emergency registry for the period 2013–2017. This included call and rescue vehicle dispatch information. All relationships in analyses and differences in events proportion between 2013 and 2017 were tested against the Pearson’s Chi-Square with a 99% level of confidence. Results: Among the 2,120,838 emergency calls, operators dispatched at least one rescue vehicle for 1,494,855. There was an estimated overall incidence of 96 emergency calls and 75 rescue vehicles dispatched per 1000 inhabitants per year. Most calls were made by private citizens, during the daytime, and were made from home (63.8%); 31% of rescue vehicle dispatches were advanced emergency medical vehicles. The highest number of rescue vehicle dispatches ended at the emergency department (74.7%). Conclusions: Our data showed that, with some exception due to environmental differences, the highest proportion of incoming emergency calls is not acute or urgent and could be more effectively managed in other settings than in an Emergency Departments (ED). Better management of dispatch can reduce crowding and save hospital emergency departments time, personnel, and health system costs.

Trends in outpatient emergency department visits during the COVID-19 pandemic at a large, urban, academic hospital system

Background

The coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic.

Methods

We conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions.

Results

While outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (−8.1%) than in 2019. The largest decrease occurred in April 2020 (−30.4%), followed by the May to August period (−12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020.

Conclusions

Overall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.

Feasibility of a Telemedicine Urgent Care Program to Address Patient Complaints on First Contact

Many health systems employ nurse telephone advice services to facilitate remote triage of patients to appropriate level of care. However, the effectiveness of these programs to reduce ED and subsequent health care utilization remains to be demonstrated. We describe a novel virtual urgent care program implemented within a Veterans Affairs (VA) health care system that interfaces with a nurse telephone advice line and leverages telemedicine tools to rapidly address and resolve nonemergent conditions. During a 4-month pilot period, 104 unique patients received care through the program, and over 85% of patients achieved timely resolution for their urgent complaints on first contact with the health care system. Demonstrating feasibility for such a program has potential implications for the optimization of remote triage and urgent care services to improve health care utilization and outcomes.