An analysis of emergency department use by patients with minor illness

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.

Emergency Department Utilization in the U.S. Military Health System

INTRODUCTION

Emergency department (ED) utilization represents an expensive and growing means of accessing care for a variety of conditions. Prior studies have characterized ED utilization in the general population. We aim to identify the clinical conditions that drive ED utilization in a universally insured population and the impacts of care setting on ED use and admissions in the U.S. Military Health System.

METHODS

We queried TRICARE claims data from October 1, 2012, to September 30, 2015, to identify all ED visits for adult patients (age 18-64). The primary presenting diagnoses of all ED visits and those leading to admission are presented with descriptive statistics. Logistic regression was used to identify clinical and sociodemographic factors associated with admission from the ED.

RESULTS

A total of 4,687,205 ED visits were identified, of which 46% took place in the DoD healthcare facilities (direct care). The most common diagnoses across all ED visits were abdominal pain, chest pain, headache, nausea and vomiting, and urinary tract infection. A total of 270,127 (5.8%) ED visits led to inpatient admission. The most common diagnoses leading to admission were chest pain, abdominal pain, depression, conditions relating to acute psychological stress, and pneumonia. For patients presenting with 1 of the 10 most common ED diagnoses, those who were seen at a civilian ED were significantly less likely to be admitted (3.4%) compared to direct care facilities (4.1%) in an adjusted logistic regression model (Adjusted Odds Ratio 0.40 [95% CI: 0.40-0.41], P < .001).

CONCLUSIONS

Ultimately, we show that abdominal pain and chest pain are the most common reasons for presentation to the ED in the Military Health System and the most common presenting diagnoses for admission from the ED. Among patients presenting with the most common ED conditions, direct care EDs were significantly more likely to admit patients than civilian facilities.

Non-urgent visits to emergency departments: a qualitative study in Iran exploring causes, consequences and solutions

OBJECTIVE

To explore the causes and consequences of non-urgent visits to emergency departments in Iran and then suggest solutions from the healthcare providers' viewpoint.

DESIGN

Qualitative descriptive study with in-depth, open-ended, and semistructured interviews, which were inductively analysed using qualitative content analysis.

SETTING

A territorial, educational and military hospital in Iran.

PARTICIPANTS

Eleven healthcare providers including eight nurses, two emergency medicine specialists and one emergency medicine resident.

RESULTS

Three overarching themes of causes and consequences of non-urgent visits to the emergency department in addition to four suggested solutions were identified. The causes have encompassed the specialised services in emergency department, demand-side factors, and supply-side factors. The consequences have been categorised into three overarching themes including the negative consequences on patients, healthcare providers and emergency departments as well as the health system in general. The possible solutions for limiting and controlling non-urgent visits also involved regulatory plans, awareness-raising plans, reforms in payment mechanisms, and organisational arrangements.

CONCLUSION

We highlighted the need for special attention to the appropriate use of emergency departments in Iran as a middle-income country. According to the complex nature of emergency departments and in order to control and prevent non-urgent visits, it can be suggested that policy-makers should design and implement a combination of the possible solutions.

[Patients with chronic diseases in emergency rooms in Germany : Cross-sectional analysis of consultations, reasons for use, and discharge diagnosis]

BACKGROUND

The number of patients in emergency rooms without a medical emergency is increasing. Outpatient services for mutual support and relief between the in-patient and out-patient sector are not yet fully established.

AIM OF THE WORK

The aim was to determine the extent to which patients in emergency rooms have real medical emergencies by comparing patients with at least two and those with a maximum of one chronic illness. An additional aim was to identify factors influencing the previous use of outpatient structures.

MATERIAL AND METHODS

The study participants included emergency room patients from the cross-sectional study "PiNo-Nord." All persons in five emergency rooms in northern Germany between October 2015 and July 2016 who were not treated as "immediate" or "very urgent" were interviewed. An exploratory data analysis and multivariate logistic regression were performed.

RESULTS

The 293 patients with ≥2 chronic diseases were just as often a medical emergency compared to the 847 patients with a maximum of 1 chronic disease. The most frequent occasions for consultation were musculoskeletal trauma (33%, n = 293 vs. 42%, n = 847) or trauma of the skin (11%, n = 293 vs. 13%, n = 847). In both groups, the general practitioner or specialist caregiver, as well as diagnostic or treatment options, rarely played a role in visiting the emergency department. The strongest predictors of previous outpatient treatment were the duration of the appeal in the last six months, a high subjective treatment urgency, the presence of at least two chronic conditions, and a consultation event concerning the musculoskeletal injuries.

CONCLUSIONS

In both patient groups, no evidence of unnecessary visits to the emergency room was found. For the most part, outpatient structures are used in advance and the emergency department is only visited in the event of an actual medical emergency.

Systematic Review of Community Paramedicine and EMS Mobile Integrated Health Care Interventions in the United States

Emergency medical services (EMS) in the United States are frequently used for nonurgent medical needs. Use of 911 and the emergency department (ED) for primary care-treatable conditions is expensive, inefficient, and undesirable for patients and providers. The objective is to describe the outcomes from community paramedicine (CP) and mobile integrated health care (MIH) interventions related to the Quadruple Aim. Three electronic databases were searched for peer-review literature on CP-MIH interventions in the United States. Eight articles reporting data from 7 interventions were included. Four studies reported high levels of patient satisfaction, and only 3 measured health outcomes. No study reported provider satisfaction measures. Reducing ED and inpatient utilization were the most common study outcomes, and programs generally were successful at reducing utilization. With reduced utilization, costs should be reduced; however, most studies did not quantify savings. Future studies should conduct economic analyses that not only compare the intervention to traditional EMS services, but also measure potential cost savings to the EMS agencies running the intervention. Most cost savings from reduced utilization will be to insurance companies and patients, but more efficient use of EMS agencies' resources could lead to cost savings that could offset intervention implementation costs. The other 3 aims (health, patient satisfaction, and provider satisfaction) were reported inconsistently in these studies and need to be addressed further. Given the small number of heterogeneous studies reviewed, the potential for CP-MIH interventions to comprehensively address the Quadruple Aim is still unclear, and more research on these programs is needed.

A multifaceted primary care practice-based intervention to reduce ED visits and hospitalization for complex medical patients: A mixed methods study

BACKGROUND

The management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices.

METHODS AND FINDINGS

An interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP's experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care.

CONCLUSIONS

This multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.

Patients Attending Emergency Departments

BACKGROUND

The number of patients in emergency departments has risen steadily in recent years, with a particular increase in patients not requiring urgent treatment. The aim of this study is to characterize this group of patients with respect to their sociodemographic features, health status, and reasons for attending an emergency department.

METHODS

PiNo Nord is a cross-sectional observational study representing two full working weeks in five different hospitals. Patients were questioned in personal interviews, and medical diagnoses were documented. The data were analyzed with multivariate logistic regressions in mixed multilevel models. Predictors for the subjectively perceived treatment urgency were identified by stepwise backward selection.

RESULTS

The 1175 patients questioned had an average age of 41.8 years and 52.9% were male. 54.7% said the degree of their treatment urgency was low. 41.3% had visited the emergency department on their own initiative, 17.0% on the advice or referral of their primary care physician, and 8.0% on the advice or referral of a specialist. The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR] 2.18), skin conditions (OR 2.15), and the momentary unavailability of a primary care physician (OR 1.70).

CONCLUSION

More than half of the patients do not think their condition requires urgent treatment and thus do not meet the definition of a medical emergency. Patients' reasons for visiting the emergency department are varied; aside from the treatment urgency of the health condition itself, the reason may lie in perceived structural circumstances and individual preferences.

Emergency Departments as the Health Safety Nets of Society: A Descriptive and Multicenter Analysis of Social Worker Support in the Emergency Room

Introduction

Social Work (SW) referrals made in the emergency department (ED) highlight the weaknesses in the existing support system for vulnerable and disadvantaged patients. SW personnel play a pivotal role in some EDs but are not integrated into the team in several jurisdictions. Our objective was to provide a detailed description of the need for SW support in the ED setting by describing SW consultation patterns in an urban ED location.

Methods

A three-year analysis of ED SW referrals made through a network of four acute care hospitals serving a city population of 1.2 million inhabitants where social workers operate from 8 a.m. to 10 p.m. The study design was descriptive reporting proportions. The descriptors of interest were the types of ED patients receiving SW consultations and the reasons for patient referral to the SW Department.

Results

During the study period, there were 46,970 SW consultations, representing 8.02% of the 572,804 patients who visited the ED across Calgary, yielding 42.9 referrals per day to social workers through the ED. Consultations for domestic violence were three times more prevalent for women (6% of referrals). However, domestic violence consultations were still an active issue for men (1.9%). Comparisons by age group yielded illness adjustments (15.3%), discharge planning (31.2%), and legal decision making (23.9%) as the most common reasons for referral of patients over 75 years old; 92.8% of patients over 75 years were admitted following the SW consultation. Reasons for deferral of patients under 30 years of age were illness adjustments (12.2%), discharge planning (16.4 %), and legal decision making (1.4%); 57.3% of patients under 30 years were admitted following the consultation. Addiction/drug use and homelessness were more common in those under the age of 30, comprising 24.1% and 15.4% of the SW referrals, respectively, compared to 1.6% and 0.4% of referrals for those over age 75, respectively.

Conclusions

The demand for SW support is significant and complex in these large urban EDs. However, the impact on patient care and resource use is substantial, and the data indicates that SW integration may be of universal benefit to EDs. Further studies are warranted to accurately characterize the amount and type of SW necessary for optimal patient outcomes and hospital resource use.

Non-urgent use of emergency departments: populations most likely to overestimate illness severity

Patients' overestimation of their illness severity appears to contribute to the national epidemic of emergency department (ED) overcrowding. This study aims to elucidate which patient populations are more likely to have a higher estimation of illness severity (EIS). The investigator surveyed demographic factors of all non-urgent patients at an academic ED. The patients and physicians were asked to estimate the patients' illness severity using a 1-10 scale with anchors. The difference of these values was taken and compared across patient demographic subgroups using a 2-sample t-test. One hundred and seventeen patients were surveyed. The mean patient EIS was 5.22 (IQR 4), while the mean physician EIS was less severe at 7.57 (IQR 3), a difference of 2.35 (p < 0.0001). Patient subgroups with the highest EIS compared to the physicians' EIS include those who were self-referred (difference of 2.65, p = 0.042), with income ≤ $25,000 (difference of 2.96, p = 0.004), with less than a college education (difference of 2.83, p = 0.018), and with acute-on-chronic musculoskeletal pain (difference of 4.17, p = 0.001). If we assume the physicians' EIS is closer to the true illness severity, patients with lower socioeconomic status, lower education status, who were self-referred, and who suffered from acute-on-chronic musculoskeletal pain are more likely to overestimate their illness severity and may contribute to non-urgent use of the ED. They may benefit from further education or resources for care to prevent ED misuse. The large difference of acute-on-chronic musculoskeletal pain may reflect a physician's bias to underestimate the severity of a patients' illness in this particular population.

Emergency Department Misuse and Administrative Interventions

Introduction

Notwithstanding the primary mission of managing sudden unexpected illnesses, major injuries and life-threatening conditions, emergency departments have been forced to deal with primary care and even social problems nowadays. Emergency department (ED) overcrowding is a worldwide problem. Hong Kong is not immune, although the causes may be somewhat different. Excessive and unlimited patient volume threatens quality and timely emergency care. A review of the epidemiology of local ED attendance, causes of ED overcrowding and possible solutions may guide the future direction of healthcare in Hong Kong.

Methods

Medical literature on ED overcrowding and ED misuse were searched from the Medline, HealthSTAR and EMBASE. Relevant full text articles were retrieved through hospital library network. Local emergency medicine publications including the Hong Kong Journal of Emergency Medicine and Emergi-News were reviewed. Local statistics were obtained from the Hong Kong Government information website, Hospital Authority Executive Information System (EIS) and Hospital Authority Accident & Emergency Service data files.

Results

There has been a steadily rising trend of ED attendance per thousand population. Causes of ED overcrowding include easy access, quality emergency care, barriers to primary care, barriers to specialist care, patient education, human right and free service. There are two approaches to the problem - decreasing the demand or increasing the funding. Usual administrative measures aim at reducing inappropriate use of ED service. These include improved community and primary care, improved specialist support, patient education, financial barriers, patient refusal and even lowering ED service standard. Another approach is augmenting the resources and productivity of emergency departments to cater for the increasing demand.

Conclusions

There is no single effective solution that will apply in all circumstances. Broadly speaking, overcrowding is the result of inadequate funding for emergency health care services during a period of increasing demand.

Trends and Weekly Cycles in a Large Swiss Emergency Centre: A 10 Year Period at the University Hospital of Bern

Popular demand for high quality care has increased in recent years. This is also the case for medical services and support at all times of the day and night is nowadays required. During the last ten years, there has been a marked increase in the demands on hospital emergency hospitals, particularly in the Western industrialized countries. The present retrospective study investigates how the demands on a large Swiss university centre have changed over a period of 10 years. Patient numbers are differentiated by age, gender, nationality, weekday and mode of referral. A retrospective analysis was performed of the data of the patients admitted to the Emergency Centre of Bern University Medical Hospital (Inselspital) during the ten-year period from 2004 up to and including 2013 and who were treated as emergencies. A total of 264,272 patients were included in the study. It was shown that there was an uninterrupted annual increase from 23,555 patients in 2004 to 34,918 patients in 2013 (+48%). Most patients came to the Emergency Centre on Mondays, followed by Fridays. Because of the marked increase in life expectancy and the resulting demographic changes, there has been a marked increase in the number of older patients coming to the Emergency Centre for acute medical care. It was found that there were disproportionately high numbers of patients aged 20 to 49 years who were not Swiss citizens. In contrast, most patients over 60 were Swiss. In the coming years, emergency centres will have to adapt to the continued increase in patient numbers. This trend will continue, so that it is essential to consider the sociodemographic structure of a region when planning the availability of emergency medical care.

Utilization of Ophthalmology-Specific Emergency Department Services

OBJECTIVE

To describe utilization trends of an ophthalmology-specific emergency department (ED).

METHODS

Prospective cohort study of new patients presenting in the ophthalmology ED for at least a 30-day period in the spring of each year for five consecutive years (2010-14) at a university referral center. A data form, including information about the ED visit and patient demographics, was included in each patient chart. Data were analyzed with Pearson chi-square test and multiple logistic regression.

RESULTS

A total of 5323 chart data forms were completed. An average of 42.2 new patients per day presented to the ophthalmology ED. Most common diagnoses were viral conjunctivitis (8.7%), dry eye syndrome (6.6%), and corneal abrasion (6.6%). Non-emergent visits accounted for 35.8% of surveys completed. Factors associated with non-emergent visits included female gender, age 65 years or older, weekday visits, and patient symptom duration greater than one week (p < 0.0001 for each factor). When compared to all other insurance categories combined, patients who were members of the regional public assistance program were the most likely to present with a non-emergency (48.5% versus 34.9%, p < 0.001), while Workers' Compensation patients were least likely to present with a non-emergency (16% versus 36.5%, p < 0.001).

CONCLUSIONS

Over one-third of new patient visits were non-emergent. Factors predictive of non-emergent patient visits were female gender, age 65 years or older, duration of symptoms greater than one week, weekday visits, and the form of insurance coverage.

Demographic factors influencing nonurgent emergency department utilization among a Medicaid population

To use administrative medical encounter data to examine nonurgent emergency department (ED) utilization as it relates to member characteristics (i.e., age, gender, race/ethnicity, urbanicity and federal poverty level (FPL)). This 1 year cross-sectional study used medical claims from a managed care organization for Medicaid members enrolled from October 1, 2010 - September 30, 2011. ED encounters occurring during the study period were classified as either urgent or nonurgent using ICD-9 diagnosis codes obtained from medical claims. Examples of urgent diagnoses include head traumas, burns, allergic reactions, poisonings, preterm labor or maternal/fetal distress. A total of 187,263 members aged 2 to 65 years were retained for study. A zero-inflated Poisson regression model examined the influence of member-level characteristics on nonurgent ED utilization, while simultaneously adjusting for all factors. Females were 41 % more likely to have a nonurgent ED visit (p ≤ 0.0001). Members ages 50-65 were least likely to have a nonurgent ED visit (p ≤ 0.0001). White members had higher odds of having at least one nonurgent ED visit (p ≤ 0.0002). Rural members were 7.7 % less likely to have a nonurgent ED visit. Members in the 400 % + FPL category were less likely to seek nonurgent care from an ED (p ≤ 0.0001). A nonurgent ED visit occurs when care is sought at an ED that could have been handled in a primary care setting. Approximately 30-50 % of all ED visits in the United States are considered nonurgent. This study supports the need to determine factors associated with misuse of ED services for nonurgent care. Demographic factors significantly impacting nonurgent ED utilization include gender, age, race/ethnicity, urbanicity and percent of the FPL. Results may be useful in ED utilization management efforts.

Paediatric emergency department referrals from primary care

Background Over the last decade, paediatric referrals from general practitioners (GPs) to the emergency department (ED) have increased by 60% in Australia. Objective To investigate the characteristics of Victorian children referred by GPs to the ED with lower-urgency conditions. Method Data were collected from four hospital EDs in Victoria, May–November 2014. Parents attending the ED with their child triaged as lower urgency were surveyed. Descriptive, frequency, and bivariate analyses were performed. Results Of the 1150 responses, 28% (320) visited their GP before attending ED. Of these 66% (212), were referred by their GP. A greater proportion with injury than illness (84% vs 59%; P < 0.0001) was referred to the ED if they had first visited their GP. Conclusion Motivations of GPs to send lower-urgency injured and ill children to ED are not well understood. The high number of referrals from GPs to the ED for lower urgency conditions suggests attention by policy makers and health professionals must be paid to the current patterns of care of children in general practice. What is known about the topic? Paediatric referrals in Australia from GPs to EDs have increased in the last decade, along with the absolute number of children in Victoria presenting to the ED. What does this paper add? A significant number of children (66%) who attend the GP before visiting the ED are referred to the ED for their lower urgency condition. What are the implications for practitioners? It may be appropriate for GPs to be further supported to manage lower urgency conditions, through better resources or education.

Emergency care for children in the United States

A formal emergency care system for children in the United States began in the 1980s with the establishment of specialized training programs in academic children's hospitals. The ensuing three decades have witnessed the establishment of informal regional networks for clinical care and a federally funded research consortium that allows for multisite research on evidence-based practices. However, pediatric emergency care suffers from problems common to emergency departments (EDs) in general, which include misaligned incentives for care, overcrowding, and wide variation in the quality of care. In pediatric emergency care specifically, there are problems with low-volume EDs that have neither the experience nor the equipment to treat children, poor adherence to clinical guidelines, lack of resources for mental health patients, and a lack of widely accepted performance metrics. We call for policies to address these issues, including providing after-hours care in other settings and restructuring payment and reimbursement policies to better address patients' needs.

Time intervals and associated factors of emergency treatment: first insight into Pakistani system

The objective of this study is to determine the time interval from decision to seek medical help and arrival of the patients to the emergency department (ED). The duration of stay in ED was also calculated. This study also assesses factors responsible delayed presentation to hospital. This prospective study was conducted during day timings (9 am to 3 pm) from May 2012 to August 2012 in ED at Civil Hospital, Karachi. Patients older than 18 years and meeting the inclusion criteria were considered to be eligible for the study. Statistical analysis was done using SPSS version 17. The study sample consisted of 4,226 patients with a response rate of 96.5%. The median decision time was 146 minutes (IQR = 74–339), median transit time was 84 minutes (IQR = 42–188), median physician time was 58 minutes (IQR = 47–103), median diagnostic time was 148 minutes (IQR = 135–192), median transfer time was 155 minutes (IQR = 118–274) and the median ED LOS was 327 minutes (IQR = 209–488). Patient beliefs regarding spontaneous resolution of the symptoms was the most common reason (44.8%) cited for increased time spent in taking decision to seek medical help. Mode of transportation other than ambulance and traffic gridlock were the most common reasons found to be significantly associated with increased transit time (p < 0.05). The time intervals calculated from our study were found to be higher than studies reported from countries. This calls for urgent intervention for formulation of triage systems to improve patient treatment and satisfaction.

Self-referral and serious illness in children with fever

OBJECTIVE

The goal of this study was to evaluate parents' capability to assess their febrile child's severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers.

METHODS

This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006-2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms).

RESULTS

Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75-2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers.

CONCLUSIONS

Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child's illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.

Utilization of emergency department in patients with non-urgent medical problems: patient preference and emergency department convenience

BACKGROUND/PURPOSE

We investigated the factors associated with emergency department (ED) use among patients with non-urgent medical problems, with a focus on convenience and preference to use the ED instead of primary care clinics.

METHODS

A five-level triage system was adopted by research nurses to decide each patient's triage level and the maximum time to physician interview. Patients who had a maximum time to physician interview of more than 60 minutes were assumed to be non-urgent in this study.

RESULTS

More than half of ED visits were considered to be non-urgent. Non-urgent patients were more likely to be unmarried, government employees, visit the ED due to trauma, have a history of chronic illness, and present in the day time or at the weekend. ED visits were also more likely to occur in patients who took less than 15 minutes to reach the ED, chose the ED for its convenience, agreed that they could have chosen another facility for their visit, did not agree that the ED was convenient for receiving medical care. Multivariate logistic regression showed that marital status, time of presentation, time needed to get to the ED, and occupation were associated with non-urgent ED visits.

CONCLUSION

Preference for using EDs for medical care and their convenience might contribute to non-urgent ED visits. A five-level triage system reliably stratified patients with different admission rates and utilization of medical resources, and could be helpful for reserving limited medical resources for more urgent patients.

Access and care issues in urban urgent care clinic patients

Background

Although primary care should be the cornerstone of medical practice, inappropriate use of urgent care for non-urgent patients is a growing problem that has significant economic and healthcare consequences. The characteristics of patients who choose the urgent care setting, as well as the reasoning behind their decisions, is not well established. The purpose of this study was to determine the motivation behind, and characteristics of, adult patients who choose to access health care in our urgent care clinic. The relevance of understanding the motivation driving this patient population is especially pertinent given recent trends towards universal healthcare and the unclear impact it may have on the demands of urgent care.

Methods

We conducted a cross-sectional survey of patients seeking care at an urgent care clinic (UCC) within a large acute care safety-net urban hospital over a six-week period. Survey data included demographics, social and economic information, reasons that patients chose a UCC, previous primary care exposure, reasons for delaying care, and preventive care needs.

Results

A total of 1, 006 patients were randomly surveyed. Twenty-five percent of patients identified Spanish as their preferred language. Fifty-four percent of patients reported choosing the UCC due to not having to make an appointment, 51.2% because it was convenient, 43.9% because of same day test results, 42.7% because of ability to get same-day medications and 15.1% because co-payment was not mandatory. Lack of a regular physician was reported by 67.9% of patients and 57.2% lacked a regular source of care. Patients reported delaying access to care for a variety of reasons.

Conclusion

Despite a common belief that patients seek care in the urgent care setting primarily for economic reasons, this study suggests that patients choose the urgent care setting based largely on convenience and more timely care. This information is especially applicable to the potential increase in urgent care volume in a universal healthcare system. Additionally, this study adds to the body of literature supporting the important role of timely primary care in healthcare maintenance.

Affiliation with a primary care provider in New Zealand: who is, who isn't

AIMS

New Zealand has a mixed public-private funded primary care system. In the last decade, considerable effort has gone into reducing the financial barriers to primary care, with some targeting of greater public funding of practices in more deprived areas. In this paper we explore the association of socio-demographic factors with affiliation with a primary care provider (PCP), and specifically examine the association with deprivation. Affiliation refers to having a doctor, nurse or medical centre one could go to if need arises.

METHODS

We used data from the third wave (2004-2005) of an ongoing 8-year panel study of 22,000 adults that includes a health add-on. This paper utilises demographic, socio-economic and health behaviour characteristics of those who reported affiliation with a PCP at wave 3. Affiliation itself was measured with the question: "do you have a doctor, nurse or medical centre you usually go to, if you need to see a doctor?" Logistic regression is used to determine the independent association of a range of socio-demographic factors with affiliation with a PCP.

RESULTS

Of the total of 18,320 respondents, 1530 (8.3%) reported no affiliation with a PCP. The odds of affiliation was significantly lower for males compared to females (OR 0.45, 95% CI: 0.39-0.50), never married compared to currently married (OR 0.48, 95% CI: 0.41-0.57), Asians compared to New Zealand Europeans (OR 0.47, 95% CI: 0.38-0.57), current smokers compared to never smokers (OR 0.79, 95% CI: 0.68-0.91) and those with post-school education compared to no education (OR 0.65, 95% CI: 0.55-0.76) and higher for older adults aged 65 years and over compared to young adults aged 15-24 years old (OR 5.14, 95% CI: 3.59-7.36), those reporting poor self-assessed health compared to those reporting good health (OR 1.45, 95% CI: 1.06-1.98), and those reporting one or more co-morbid conditions compared to no co-morbid conditions (OR 2.02, 95% CI: 1.78-2.29). However, there was no significant difference in affiliation with a PCP between those living in the most deprived areas and the least deprived areas.

CONCLUSIONS

Affiliation to a PCP is a measure of potential access to primary care. Overall, our data provide some support for the hypothesis that people with high health needs have high rates of affiliation with a PCP (e.g., elderly, women, Māori and those in poor health). The results also suggest that current health policies in New Zealand, with their emphasis on a strong primary health care system, are ensuring that people with greater health care needs are affiliated with a PCP.

Calibrating urgency: triage decision-making in a pediatric emergency department

Triage, the first step in the assessment of emergency department patients, occurs in a highly dynamic environment that functions under constraints of time, physical space, and patient needs that may exceed available resources. Through triage, patients are placed into one of a limited number of categories using a subset of diagnostic information. To facilitate this task and standardize the triage decision process, triage guidelines have been implemented. However, these protocols are interpreted differently by highly experienced (expert) nurses and less experienced (novice) nurses. This study investigates the process of triage; the factors that influence triage decision-making, and how the guidelines are used in the process. Using observations and semi-structured interviews of triage nurses, data was collected in the pediatric emergency department of a large Canadian teaching hospital. Results show that in emergency situations (1) triage decisions were often non-analytic and based on intuition, particularly with increasing expertise, and (2) guidelines were used differently by nurses during the triage process. These results suggest that explicit guideline information becomes internalized and implicitly used in emergency triage practice as nurses gain experience. Implications of these results for nursing education and training, and guideline development for emergency care are discussed.

The Impact of Health Insurance Status on Emergency Room Services

This study presents evidence from a major hospital that the uninsured received less care than privately insured patients when they came for emergency treatment, even when the insured and uninsured had similar diagnoses. Uninsured emergency patients were also less likely to be admitted to the hospital than insured emergency patients. Among those treated and released, the uninsured have lower discharge costs than privately insured patients. Among those patients admitted to the hospital, however, the costs of treatment were quite similar for insured and uninsured patients alike.

Are the uninsured responsible for the increase in emergency department visits in the United States?

STUDY OBJECTIVE

The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits.

METHODS

Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance.

RESULTS

The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74).

CONCLUSION

The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.

Quality of primary care and subsequent pediatric emergency department utilization

OBJECTIVE

Our objective was to determine whether parent-reported, high-quality primary care was associated with decreased nonurgent pediatric emergency department utilization.

METHODS

A retrospective analysis of prospectively collected data for a cohort of children from the 2000-2001 and 2001-2002 Medical Expenditure Panel Survey panels was performed. Baseline parent-reported quality of primary care with respect to family-centeredness, timeliness, and realized access (a measure of the child's ability to receive necessary care and referrals) was assessed by using composite scores from the Consumer Assessment of Healthcare Providers and Systems survey. The primary outcomes were the numbers of subsequent nonurgent and urgent emergency department visits per child.

RESULTS

Of 8823 children included, 70.0% rated family-centeredness, 88.2% rated realized access, and 55.6% rated timeliness as high quality. After adjustment for demographic factors and health status, high-quality family-centeredness was associated with a 42% reduction in nonurgent emergency department visits for publicly insured children and a 49% reduction for children < or = 2 years of age. Greater realized access was associated with a 44% reduction in nonurgent emergency department visits for children 3 to 11 years of age and a 56% reduction for children > or = 12 years of age. Greater realized access was also associated with decreased nonurgent emergency department visits for publicly and privately insured children (37% and 35%, respectively). There was no significant association between timeliness and nonurgent emergency department utilization, nor was any quality-of-care domain associated with urgent emergency department utilization.

CONCLUSIONS

Parent-reported, high-quality family-centeredness and a high level of realized access to primary care were associated with decreased subsequent nonurgent emergency department visits for children. Parent reports of health care quality in these domains provide important complementary information on health care quality.

Delayed access to health care and mortality

OBJECTIVE

To measure the relationship between time spent waiting for health care services and patients' mortality.

DATA SOURCE

Data on the number of days until the next available appointment at 89 Veterans Affairs (VA) medical centers in 2001 were extracted from a VA administrative database. These facility-level data were merged with individual-level data for a sample of veterans who visited a VA geriatric outpatient clinic in 2001. The merged dataset includes facility-level data on waiting times and individual-level data on demographics, health status (e.g., diagnoses), and mortality.

STUDY DESIGN

This was a retrospective observational study using secondary data from administrative sources. The dependent variable was mortality within a 6-month follow-up period. The main explanatory variable of interest was VA facility-level wait times for outpatient visits measured in number of days. Random effects logistic regression models were risk adjusted for prior individual health status and facility-level differences in case mix.

PRINCIPAL FINDINGS

Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality (odds ratio=1.21, p=0.027) compared with veterans who visited a VA medical center with facility-level wait times of <31 days.

CONCLUSIONS

Our findings support the largely assumed association between long wait times for outpatient health care and negative health outcomes, such as mortality. Future research should focus on the causes of long waits for health care (e.g., physician reimbursement levels), the consequences of long waits in other populations, and effective policies to decrease long waits for health care services.

Emergency outpatient services in the city of Berlin: factors for appropriate use and predictors for hospital admission

OBJECTIVES

To determine the proportion of patients making inappropriate use of medical care at hospital emergency rooms. To identify the factors that influence appropriateness of use and the probability of subsequent hospital admission.

METHODS

Data were collected from 815 patients at three gynaecological/internal medicine emergency clinics in Berlin, Germany using multiple data sources: (i) standardized interviews covered service use history, psychosocial variables, migration history and sociodemographics; (ii) medical data were retrieved from patients' medical records, including case histories, diagnoses and therapies; (iii) emergency room physicians were asked to evaluate patients' language comprehension, physician-patient relationship and treatment urgency. Statistical analyses included chi tests, correlational and logistic regression analyses.

RESULTS

According to a self-constructed index measuring appropriateness of emergency service use, about half of the patients' visits would have to be classified as inappropriate. Age, chronic illness and the time of day of the emergency service attendance were significantly associated with appropriateness of use. The probability of a hospital admission following the emergency treatment increased with patients' age and the physician's evaluation of treatment urgency. Remarkably, and contrary to the results of international studies, the patient's ethnicity played no significant role with respect to the appropriateness of use of emergency outpatient services or the likelihood of subsequent hospital admission.

Cervical cancer among Hispanic women: assessing the impact on farmworkers

The purpose of this paper was to review the literature on Hispanic populations to outline: 1) demographics; 2) general health status; 3) cervical cancer incidence and mortality; 4) Pap smear screening rates; and 5) barriers to preventive care services. The methods: MEDLINE, Med66, Med75, and Med85 files, from 1966 to 1999, were searched for key words Hispanic health, cervical cancer and Hispanics, cervical cancer and Mexico, migrants and health, agricultural occupational health, farmworkers and cancer, and farmworker health. AGRICOLA (1982-98) was searched for key words farmworker health, agricultural workers and health, and agriculture and cancer. The results show that Hispanic immigrant women may have cervical cancer incidence rates ranging between the California rates for 1991-93 (19.8/100,000) and for Mexico in 1990 (115-220 per 100,000). Mortality rates for the same periods were 3.9/100,000 and 16.11/100,000 respectively. While survey results report Hispanic Pap smear rates above 70%, these surveys count urban women who do not share the barriers to care experienced by poor rural Hispanics. Since validated self-reports of survey responses are 20-50% lower than reported lower rates and Pap smear screening persist in Hispanic Pap evaluations and are reflected in higher morbidity and mortality from cervical cancer. That targeted community interventions have been successful in raising Pap smear rates among poor Spanish-speaking women. Such interventions should be a priority for preventive health care policy and practice.

Customer satisfaction

PURPOSE

This paper seeks to present an analysis of the literature examining objective information concerning the subject of customer service, as it applies to the current medical practice. Hopefully, this information will be synthesized to generate a cogent approach to correlate customer service with quality.

DESIGN/METHODOLOGY/APPROACH

Articles were obtained by an English language search of MEDLINE from January 1976 to July 2005. This computerized search was supplemented with literature from the author's personal collection of peer-reviewed articles on customer service in a medical setting. This information was presented in a qualitative fashion.

FINDINGS

There is a significant lack of objective data correlating customer service objectives, patient satisfaction and quality of care. Patients present predominantly for the convenience of emergency department care. Specifics of satisfaction are directed to the timing, and amount of "caring". Demographic correlates including symptom presentation, practice style, location and physician issues directly impact on satisfaction. It is most helpful to develop a productive plan for the "difficult patient", emphasizing communication and empathy. Profiling of the customer satisfaction experience is best accomplished by examining the specifics of satisfaction, nature of the ED patient, demographic profile, symptom presentation and physician interventions emphasizing communication--especially with the difficult patient.

ORIGINALITY/VALUE

The current emergency medicine customer service dilemmas are a complex interaction of both patient and physician factors specifically targeting both efficiency and patient satisfaction. Awareness of these issues particular to the emergency patient can help to maximize efficiency, minimize subsequent medicolegal risk and improve patient care if a tailored management plan is formulated.

Association between primary care practice characteristics and emergency department use in a medicaid managed care organization

BACKGROUND

Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes.

OBJECTIVES

We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices.

RESEARCH DESIGN

This was a cohort study.

SUBJECTS

A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included.

MEASURES

Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics.

RESULTS

On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants.

DISCUSSION

Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use.

CONCLUSIONS

Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.

Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study

STUDY OBJECTIVE

We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit.

METHODS

This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year.

RESULTS

Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use.

CONCLUSION

ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.

Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Characteristics of fire station walk-in patients

OBJECTIVE

To characterize the use of fire stations for walk-in health care and compare utilization patterns of fire stations in lower-income areas with those in higher-income areas.

METHODS

The study was a retrospective review of emergency medical services (EMS) medical forms of patients who presented directly to a fire station for medical care during a 12-month period.

RESULTS

During the study period, there were a total of 56,600 EMS calls by the studied fire department, with 155 visits by persons presenting to 19 fire stations in the 12 zip code areas. Of these, 131 were eligible for inclusion in our study. Of the 131 visits, 76 of 131 (58%) occurred in zip codes where more than 20% of residents lived below poverty level. Patients presenting to the fire station for medical care were disproportionately male, 84 of 131 (64%), aged 31-50 years, 61 of 131 (47%). Leading chief complaints were abrasion/laceration/hematoma, 20 of 131 (15%), shortness of breath, 18 of 131 (14%), loss of consciousness/syncope/dizziness/weakness, 17 of 131 (13%), musculoskeletal pain, 17 of 131 (13%), and chest pain, 14 of 131 (11%). Suicide, assault, alcohol, or substance intoxication (SAAD) was associated with 47 of 131 (36%) visits. Following evaluation at the fire station, 97 of 131 (82%) were transported by EMS; few patients were transported by private vehicle (n = 11) or did not need transport (n = 12).

CONCLUSIONS

In the authors' EMS system, the use of fire stations for walk-in health occurs disproportionately in areas of poverty. SAAD features are present in more than one third of the visits.

Access to care: a review of the emergency medicine literature

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.

Frequent use of the hospital emergency department is indicative of high use of other health care services

STUDY OBJECTIVE

We sought to determine the proportion of emergency department patients who frequently use the ED and to compare their frequency of use of other health care services at non-ED sites.

METHODS

A computerized patient database covering all ambulatory visits and hospital admissions at all care facilities in the county of Stockholm, Sweden, was used. Frequent ED patients were defined as those making 4 or more visits in a 12-month period.

RESULTS

Frequent users comprised 4% of total ED patients, accounting for 18% of the ED visits. The ED was the only source of ambulatory care for 13% of frequent versus 27% of rare ED users (1 ED visit). Primary care visits were made by 72% of frequent ED users versus 57% by rare ED visitors. The corresponding figures for hospital admission were 80% and 36%, respectively. Frequent ED visitors were also more likely to use other care facilities repeatedly: their odds ratio (adjusted for age and sex) was 3.43 (95% confidence interval [CI] 3.10 to 3.78) for 5 or more primary care visits and 29.98 (95% CI 26.33 to 34.15) for 5 or more hospital admissions. In addition, heavy users had an elevated mortality (standardized mortality ratio 1.55; 95% CI 1.26 to 1.90).

CONCLUSION

High ED use patients are also high users of other health care services, presumably because they are sicker than average. A further indication of serious ill health is their higher than expected mortality. This knowledge might be helpful for care providers in their endeavors to find appropriate ways of meeting the needs of this vulnerable patient category.

Delay in seeking emergency care

OBJECTIVE

To determine whether patient clinical and socioeconomic characteristics predict patient delay in coming to the emergency department (ED).

METHODS

Adult ED patients at five urban teaching hospitals were surveyed regarding self-reported delay in coming to the ED. Delay was measured by self-perception as well as by the number of days ill and unable to work. Patient socioeconomic and clinical characteristics were obtained by survey questionnaire and chart review. Cross-sectional analysis within a prospective study of 4,094 consecutive patients was performed using a subset of 1,920 patients (84% eligible rate) to whom questionnaires were administered.

RESULTS

Overall, 32% of the patients completing the survey reported delay in seeking ED care. Of these patients reporting delay, 71% thought their problem would go away or was not serious. Patients who were older, had higher acuity, or were frequent ED users reported less delay in coming to the ED, while patients without a regular physician or who were African American reported more delay. Perception of increased number of days ill prior to visiting the ED was reported by frequent ED users and those with worse baseline physical function, while patients who had higher acuity reported fewer days ill prior to coming to the ED.

CONCLUSIONS

A patient's decision to delay coming to the ED often reflects a belief that his or her illness is either self-limited or not serious. The decision to delay correlates with patient characteristics and access to a regular physician. The correlates of delay in seeking ED care may depend on the delay measure used. Better understanding of patients at risk for delaying care may influence interventions to reduce delay.

The LUNAR project: A description of the population of individuals who seek health care at emergency departments

INTRODUCTION

Although little information exists about the consumers of emergency services and their illness behaviors, such information is essential for decision making by providers, administrators, and policy makers. The purpose of the LUNAR Project was to describe the population of individuals who seek health care at emergency departments.

METHODS

After they attended a training course, 90 emergency nurses served as site coordinators in 89 emergency departments in 35 states. A standardized protocol was used to collect data retrospectively from 140 randomly selected patient records at each site. The final sample included 12,422 ED patients.

RESULTS

Overall, 52% of the patient visits were for nonurgent care, 40% were for urgent care, and 8% were for emergent care. Most visits occurred between 10 AM and 8 PM and peaked at 6 PM. Children and younger adults were the largest consumers of services, primarily for nonurgent care. The most frequent reasons for visits were fever, chest pain, and abdominal pain, and the most common discharge diagnoses were middle ear infection, chest pain, and acute upper respiratory infection.

DISCUSSION

The profile of ED patients showed a need for new types of services to provide nonurgent care and new interventions for preventing illnesses and injuries commonly treated in the emergency department.