Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

BACKGROUND

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

METHOD

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

RESULTS

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

CONCLUSION

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Public Beliefs About Accessibility and Quality of Emergency Departments in Germany

Background

It is well established that emergency department (ED) crowding leads to worse health outcomes. Although various patient surveys provide information about reasons to visit EDs, less is known in terms of beliefs about EDs among the general population. This study examines public beliefs regarding accessibility and quality of EDs and their associations with social characteristics (gender, age, education, immigration background) as well as knowledge about emergency care services and health literacy.

Methods

We conducted a cross-sectional study based on a random sample of 2,404 adults living in Hamburg, Germany, in winter 2021/2022. We developed eight statements regarding accessibility and quality of EDs leading to two scales (Cronbach's α accessibility = 0.76 and quality of care = 0.75). Descriptive statistics of the eight items are shown and linear regression were conducted to determine associations of the two scales with social characteristics as well as knowledge about emergency care services and health literacy (HLS-EU-Q6).

Results

Nearly 44% of the respondents agreed that "you can always go to an ED, if you do not get a short-term appointment with a general practitioner or specialist." And 38% agreed with the statement, "If you do not have the time during normal practice hours due to your work, you can always go to an ED." In terms of quality, 38% believed that doctors in EDs are more competent than doctors in general practice, and 25% believed that doctors in EDs are more competent than doctors in specialized practices. In the fully adjusted model, public beliefs about emergency care accessibility and quality of EDs were significantly associated with all social characteristics and knowledge of emergency care options with the strongest associations between knowledge and accessibility (β = -0.17; P < 0.001) and between education and quality (β = -0.23; P < 0.001).

Conclusion

We found endorsement of public beliefs about accessibility and quality of EDs that can lead to inappropriate utilization. Our results also suggest that knowledge of different emergency services plays an important role. Therefore, after system-related reorganizations of emergency care, information campaigns about such services tailored to socially deprived populations may help alleviate the issue of crowding.

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.

Variations in the intended utilization of emergency care in case of gastrointestinal diseases

Frequent utilization of emergency care and overcrowded emergency departments (EDs) are highly relevant topics due to their harmful consequences for patients and staff. The present study examines variations of intended health care use in urgent and non-urgent cases among the general population. In a cross-sectional telephone survey, a sample of N = 1,204 adults residing in Hamburg, Germany, was randomly drawn. At the beginning of the survey, one of 24 different vignettes (case stories) describing symptoms of inflammatory gastrointestinal diseases were presented to the participants. The vignettes varied in sex (male/female), age (15, 49, 72 years), daytime (Tuesday morning, Tuesday evening), and urgency (low, high). Participants were asked in an open-ended question about their primal intended utilization if they or their children would be affected by such symptoms. Overall, about 14 % chose emergency facilities (ED, ambulance, emergency practice) despite presentation of non-urgent conditions (n = 602). Intended emergency care use varied considerably even if the degree of urgency was comparable. Adolescence, male sex, and symptoms occurring in the evening were associated with increased ED and ambulance use. Inappropriate utilization of ED and ambulance (analyses regarding utilization due to non-urgent problems) was more often observed among male respondents and those with a migration background (1st generation). Information campaigns focused on emergency care use and reorganisation of emergency care wards are possible interventions.

Comparison of Outpatient Department-Referred and Self-Referred Patients in the Emergency Department

BACKGROUND

Patients present to emergency departments (EDs) from a variety of backgrounds, which may help inform decision making.

OBJECTIVE

This study investigated the clinical characteristics and outcomes of outpatient department (OPD)-referred patients and self-referred patients in the ED.

METHODS

We selected nontrauma ED adult patients from a tertiary teaching hospital in Taiwan between August 1, 2020, and October 31, 2020. The acuity levels were determined by dichotomizing the triage classification scores. After propensity score matching, we compared the hospitalization, mortality, and length of ED stay of OPD-referred and self-referred patients. We categorized the patients into "emergency" or "urgent" subgroups according to their triage information and then analyzed the effects of different severity levels. Statistical significance was set at p < 0.05.

RESULTS

A total of 564 OPD-referred and 11,959 self-referred patients were included. After propensity score matching, the OPD-referred patients (n = 564), compared with self-referred patients (n = 564), had a higher admission rate (49.8% vs. 28.9%; p < 0.001; odds ratio [OR] 2.44). Among the emergency subgroup patients, there was no significant difference between OPD-referred patients (n = 131) and self-referred patients (n = 138) regarding the admission rate (p = 0.257) or the mortality rate (p = 0.253). Among the urgent subgroup patients, OPD-referred patients (n = 433), compared with self-referred patients (n = 426), had a significantly higher admission rate (46.0% vs. 20.2%; p < 0.001; OR 3.36), but not mortality rate (2.1% vs. 0.5%; p = 0.064). Regarding the length of ED stay, OPD-referred and self-referred patients had a significant difference only in the "urgent and discharged" subgroup (5.8 vs. 2.3 h; p < 0.001).

CONCLUSIONS

OPD-referred ED patients might have more severe and complex conditions and need comprehensive care management.

[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.

Patients pathways before and after treatments in emergency departments: A retrospective analysis of secondary data in Germany

Increasing emergency department (ED) utilization induces considerable pressure on ED staff and organization in Germany. Reasons for certain ED attendances are seen partly in insufficient continuity of care outside of hospitals. To explore the health care patterns before and after an ED attendance in Germany, we used claims data from nine statutory health insurance funds, covering around 25 % of statutory health insurees (1). We descriptively analyzed ED attendances for adult patients in 2016 according to their sociodemographic characteristics and diagnoses (2). Based on the ED attendance as initial event, we investigated health care provider utilization 180 days before and after the respective ED treatment and are presented by means of Sankey diagrams. In total, 4,757,536 ED cases of 3,164,343 insured individuals were analyzed. Back pain was the most frequent diagnosis in outpatient ED cases (5.0 %), and 80.2 % of the patients visited primary care physicians or specialists 180 days before and 78.8 % 180 days after ED treatment. Among inpatient cases, heart failure (4.6 %) was the leading diagnosis and 74.6 % used primary care physicians or specialists 180 days before and 65.1 % 180 days after ED treatment. The ED re-attendance slightly increased for back pain (4.9 % to 7.9 %) and decreased for heart failure (13.4 % to 12.6 %).

Motives behind low-acuity geriatric emergency medicine attenders: a picture from free healthcare system

BACKGROUND

Current evidence about the low-acuity ED visits of old patients has been generated in various healthcare systems; however, this is not a well-researched area in middle-income countries by patients' perspectives.

METHODS

A study of 231 patients attending the ED of a tertiary public hospital was conducted using a structured questionnaire from June to August 2021. Eligible patients were community-dwelling, aged > 65 years, who presented with lower clinical urgency. The questionnaire tool was developed using questions from available studies on health service utilization. Additional commentary was obtained from the patients regarding on the reasons for attending the ED and was administered on weekdays between 8:00 am and 5:30 pm.

RESULTS

The study included 221 patients over 65 years of age, with a mean age of 72.21 ± 4.2. A total of 58.4% of the patients thought that they should be examined urgently, 15.4% had symptoms that had lasted more than one month, and 59% requested emergency imaging. Patients preferred the ED via treatment, imaging, transportation opportunities of emergency department, past negative experiences, and access problems with family medicines or appointment problems with specialist outpatient clinics with expectations of continuity of care.

CONCLUSION

Old individuals have unique healthcare needs, and the motives behind this group of patients with low-acuity problems to apply to the ED is complex. As one of the key objectives of healthcare policies is to make sure that patients are assessed at proper time and place, studies that consider patient perspectives might lead to accurate conclusions for this aim.

Do patients referred to emergency departments after being assessed in primary care differ from other ED patients? Retrospective analysis of a random sample from two German metropolitan EDs

BACKGROUND

To assess differences between patients referred to emergency departments by a primary care physician (PCP) and those presenting directly and the impact of referral on the likelihood of admission.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

EDs of two nonacademic general hospitals in a German metropolitan region.

PARTICIPANTS

Random sample of 1500 patients out of 80,845 presentations during the year 2019.

RESULTS

Age was 55.8 ± 22.9 years, and 51.4% was female. A total of 34.7% presented by emergency medical services (EMS), and 47.7% were walk-ins. One-hundred seventy-four (11.9%) patients were referred by PCPs. Referrals were older (62.4 ± 20.1 vs 55.0 ± 23.1 years, p < .001) and had a higher Charlson Comorbidity Index (CCI) (3 (1-5) vs 2 (0-4); p < .001). Referrals received more ultrasound examinations independently from their admission status (27.6% vs 15.7%; p < .001) and more CT and laboratory investigations. There were no differences in sex, Manchester Triage System (MTS) category, or pain-scale values. Referrals presented by EMS less often (9.2% vs 38.5%; p < .001). Admission rates were 62.6% in referrals and 37.1% in non-referrals (p < .001). Referral (OR 3.976 95% CI: 2.595-6.091), parenteral medication in ED (OR 2.674 (1.976-3.619)), higher MTS category (1.725 (1.421-2.093)), transport by EMS (1.623 (1.212-2.172)), abnormal vital parameters (1.367 (0.953-1.960)), higher CCI (1.268 (1.196-1.344)), and trauma (1.268 (1.196-1.344)) were positively associated with admission in multivariable analysis, whereas ultrasound in ED (0.450 (0.308-0.658)) and being a nursing home resident (0.444 (0.270-0.728)) were negatively associated.

CONCLUSION

Referred patients were more often admitted. They received more laboratory investigations, ultrasound examinations, and computed tomographies. Difficult decisions regarding the necessity of admission requiring typical resources of EDs may be a reason for PCP referrals.

Synergism of an Urgent Care Walk-in Clinic With an Emergency Department

BACKGROUND

The overutilization of hospital emergency departments by low-urgency patients is seen as a growing problem in health-care delivery, and a variety of solutions are under discussion. We studied the change in utilization of a hospital emergency department (ED) by low-urgency patients after an urgent care walk-in clinic (WIC) was opened in the immediate vicinity.

METHODS

A prospective, single-center pre-post comparative study was carried out at the University Medical Center Hamburg-Eppendorf (UKE). The ED patient collective consisted of adult walk-in patients who presented to the ED between 4 pm and midnight. The "pre" period consisted of August and September 2019, and the "post" period was from November 2019 (after the opening of the WIC) to January 2020.

RESULTS

The study patients consisted of 4765 ED walk-in patients and 1201 WIC patients. 956 (80.5%) of the WIC patients had been referred onward to the WIC after initially presenting to the ED; from this group, 790 patients (82.6%) received definitive care in the WIC. The number of outpatients treated in the ED fell by 37.3% (95% confidence interval [30.9; 43.8]), from 851.5 to 536.7 per month. The most marked decreases were in the areas of dermatology (from 62.5 to 14.3 patients per month), neurology (45.5 to 25), ophthalmology (115 to 64.7), and trauma surgery (211 to 128.7). No decrease was seen in urology, psychiatry, or gynecology. For patients presenting without any referral document, the mean length of stay fell by a mean of 17.6 [7.4; 27.8] minutes from its "pre" value of 172.3 minutes. The rate of patients who left during treatment fell from 76.5 to 28.3 patients per month (p < 0.001).

CONCLUSION

A GP-led urgent care walk-in clinic next door to an interdisciplinary hospital emergency department is a resource-saving treatment option for walk-in patients who present to the emergency department. Most of the patients referred from the ED to the WIC were able to receive definitive care there.

Identification of low-acuity attendances in routine clinical information documented in German Emergency Departments

INTRODUCTION

It has not yet been possible to ascertain the exact proportion, characterization or impact of low-acuity emergency department (ED) attendances on the German Health Care System since valid and robust definitions to be applied in German ED routine data are missing.

METHODS

Internationally used methods and parameters to identify low-acuity ED attendances were identified, analyzed and then applied to routine ED data from two EDs of the tertiary care hospitals Charité-Universitätsmedizin Berlin, Campus Mitte (CCM) and Campus Virchow (CVK).

RESULTS

Based on the three routinely available parameters `disposition´, `transport to the ED´ and `triage´ 33.2% (n = 30 676) out of 92 477 presentations to the two EDs of Charité-Universitätsmedizin Berlin (CVK, CCM) in 2016 could be classified as low-acuity presentations.

CONCLUSION

This study provides a reliable and replicable means of retrospective identification and quantification of low-acuity attendances in German ED routine data. This enables both intra-national and international comparisons of figures across future studies and health care monitoring.

Increasing emergency number utilisation is not driven by low-acuity calls: an observational study of 1.5 million emergency calls (2018-2021) from Berlin

BACKGROUND

The Emergency Medical Service (EMS) in Germany is increasingly challenged by strongly rising demand. Speculations about a greater utilisation for minor cases have led to intensive media coverage, but empirical evidence is lacking. We investigated the development of low-acuity calls from 2018 to 2021 in the federal state of Berlin and its correlations with sociodemographic characteristics.

METHODS

We analysed over 1.5 million call documentations including medical dispatch codes, age, location and time using descriptive and inferential statistics and multivariate binary logistic regression. We defined a code list to classify low-acuity calls and merged the dataset with sociodemographic indicators and data on population density.

RESULTS

The number of emergency calls (phone number 112 in Germany) increased by 9.1% from 2018 to 2021; however, the proportion of low-acuity calls did not increase. The regression model shows higher odds of low-acuity for young to medium age groups (especially for age 0-9, OR 1.50 [95% CI 1.45-1.55]; age 10-19, OR 1.77 [95% CI 1.71-1.83]; age 20-29, OR 1.64 [95% CI 1.59-1.68] and age 30-39, OR 1.40 [95% CI 1.37-1.44]; p < 0.001, reference group 80-89) and for females (OR 1.12 [95% CI 1.1-1.13], p < 0.001). Odds were slightly higher for calls from a neighbourhood with lower social status (OR 1.01 per index unit increase [95% CI 1.0-1.01], p < 0.05) and at the weekend (OR 1.02 [95% CI 1.0-1.04, p < 0.05]). No significant association of the call volume with population density was detected.

CONCLUSIONS

This analysis provides valuable new insights into pre-hospital emergency care. Low-acuity calls were not the primary driver of increased EMS utilisation in Berlin. Younger age is the strongest predictor for low-acuity calls in the model. The association with female gender is significant, while socially deprived neighbourhoods play a minor role. No statistically significant differences in call volume between densely and less densely populated regions were detected. The results can inform the EMS in future resource planning.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

OBJECTIVES

Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment.

DESIGN

Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.

SETTING

The study was carried out in three EDs in the city centre of Berlin, Germany.

PARTICIPANTS

Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).

INTERVENTION

In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.

RESULTS

Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.

CONCLUSIONS

Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.

TRIAL REGISTRATION NUMBER

DRKS00023480.

Apart from the Medical Complaints, Why do Patients Use Emergency Medical Services? Results of a Patient Survey

INTRODUCTION

Many countries face an increased use of emergency medical services (EMS) with a decreasing percentage of life-threatening complaints. Though there is a broad discussion among experts about the cause, patients' self-perceived, non-medical reasons for using EMS remain largely unknown.

METHODS

The written survey included EMS patients who had≥1 case of prehospital emergency care in 2016. Four German health insurance companies sent out postal questionnaires to 1312 insured patients. The response rate was 20%; 254 questionnaires were eligible for descriptive and interferential analyses (t-tests, chi2-tests, logistic models).

RESULTS

The majority of respondents indicated that their EMS use was due to an emergency or someone else's decision (≥84%; multiple checks allowed); 56% gave need for a quick transport as a reason. Other frequently stated reasons addressed the health care system (e. g., complaints outside of physicians' opening hours) and insecurity/anxiety about one's state of health (>45% of the respondents). "Social factors" were similarly important (e. g., 42% affirming, "No one could give me a ride to the emergency department or doctor's office."). Every fifth person had contact with other emergency care providers prior to EMS use. Respondents negating an emergency as a reason were less likely to confirm wanting immediate medical care on site or quick transports compared to those affirming an emergency. Patients using EMS at night more often denied having an emergency compared to patients with access to care during the day.

CONCLUSION

The study identified a bundle of reasons leading to EMS use apart from medical complaints. Attempts for needs-oriented EMS use should essentially include optimization of the health care and social support system and measures to reduce patients' insecurity.

Emergency Departments as Care Providers for Patients with Cardiac Ambulatory Care Sensitive and Mental Health Conditions: Qualitative Interview and Focus Group Study with Patients and Physicians

Mental health conditions are frequent among patients with somatic illnesses, such as cardiac diseases. They often remain undiagnosed and are related to increased utilization of outpatient services, including emergency department care. The objective of this qualitative study was to investigate the significance of the emergency department in the patients' course of treatment and from the physicians' perspective. An improved understanding of the subjective needs of this specific patient group should provide hints for targeted treatment. This study is part of the prospective EMASPOT study, which determined the prevalence of mental health conditions in emergency department patients with cardiac ambulatory care sensitive conditions. The study on hand is the qualitative part, in which 20 semi-structured interviews with patients and a focus group with six ED physicians were conducted. Data material was analyzed using the qualitative content analysis technique, a research method for systematically identifying themes or patterns. For interpretation, we used the "typical case approach". We identified five "typical patient cases" that differ in their cardiac and mental health burden of disease, frequency and significance of emergency department and outpatient care visits: (1) frequent emergency department users with cardiac diseases and mental health conditions, (2) frequent emergency department users without cardiac diseases but with mental health conditions, (3) needs-based emergency department users with cardiac diseases; (4) targeted emergency department users as an alternative to specialist care and (5) patients surprised by initial diagnose of cardiac disease in the emergency department. While patients often perceived the emergency department visit itself as a therapeutic benefit, emergency department physicians emphasized that frequent examinations of somatic complaints can worsen mental health conditions. To improve care, they proposed close cooperation with the patients' primary care providers, access to patients' medical data and early identification of mental health conditions after cardiac diagnoses, e.g., by an examination tool.

Immobilität als Grund der Vorstellung in einer Krankenhausnotaufnahme?

Hintergrund

Die zunehmende Belastung von Krankenhausnotaufnahmen (KHN) durch wenig dringliche Patienten wirft Fragen nach Fehlsteuerungen bzw. Versorgungsdefiziten in anderen Bereichen auf.

Methode

Retrospektive Datenanalyse einer Zufallsstichprobe aus allen Fällen des Jahres 2019 zweier KHN in einer Metropolregion. Wir untersuchten Patienten, die ambulant versorgt, aber mit einem Krankentransportmittel (KT) wieder aus der Notaufnahme abtransportiert wurden.

Ergebnisse

1500 Patienten (767 [51,1 %] weiblich; Alter 56 ± 22,7 Jahre) aus einer Grundgesamtheit von 80.845 Patienten wurden analysiert. 888 (59,2 %) wurden ambulant versorgt. Jeweils 9 (0,5 %), 193 (12,9 %), 684 (45,6 %), 508 (33,9 %) und 48 (3,2 %) waren den Manchester-Triage-System-Kategorien Rot, Orange, Gelb, Grün bzw. Blau zugeordnet. Von 880 ambulanten Patienten wurden 731 (83,2 %) selbstständig und 149 (16,8 %) mit einem KT entlassen. Über die Hälfte der per KT entlassenen Patienten war mit urologischen Problemen, Extremitätenproblemen und nach Stürzen vorgestellt worden. Die liegend transportierten ambulant versorgten Patienten hatten ein höheres Alter (76,2 ± 16,2 vs. 45,1 ± 20,5 Jahre; p < 0,001), einen höheren Charlson Comorbidity Index (5 [3–6] vs. 0 [0–2]; p < 0,001), erhielten seltener eine CT-Diagnostik und häufiger lediglich eine einfache medizinische Maßnahme ohne diagnostischen Aufwand (24,8 % vs. 4,6 %; p < 0,001). Sie wurden zu einem größeren Anteil mehrfach vorgestellt (28,9 % vs. 8,5 %; p < 0,001). Der Anteil an Heimbewohnern war höher (59,5 % vs. 0 %; p < 0,001).

Schlussfolgerung

Etwa ein Zehntel der insgesamt in den KHN versorgten Patienten blieb ambulant und wurde mit einem KT entlassen. Mehr als die Hälfte wurde aus stationären Pflegeeinrichtungen vorgestellt. Ein Großteil erhielt einfache Leistungen und kaum Diagnostik und hatte eine niedrige Triagedringlichkeit.

Intended healthcare utilisation in cases of severe COVID-19 and inflammatory gastrointestinal disease: results of a population survey with vignettes

OBJECTIVES

To examine variations in intended healthcare utilisation in severe cases of COVID-19 and inflammatory gastrointestinal disease (IGD).

DESIGN

Representative cross-sectional telephone survey.

SETTING AND PARTICIPANTS

1207 randomly drawn adults of the city of Hamburg, Germany, between November 2020 and January 2021.

OUTCOME MEASURES

Different vignettes with severe symptoms were presented varying in sex, age (child, middle-aged person, older person), daytime (Tuesday morning or Tuesday evening) and disease (COVID-19 or IGD), while the degree of urgency was equivalent for all cases. The respondents were asked for the intended healthcare utilisation resulting in three different alternatives: general practitioner (GP)/paediatrician, medical on-call service ('116117') and emergency care (accident and emergency department, emergency practice, rescue service). In multivariate analyses, associations of characteristics of the vignettes and participants (sex, age, education, migration background) with intended healthcare utilisation were tested. In a further step, analyses were conducted separately for IGD and COVID-19.

RESULTS

Regarding the vignettes' characteristics, intended utilisation of GP/paediatrician is associated with female sex, higher age, daytime (morning) and COVID-19 symptoms, the medical on-call service with male sex, daytime (evening) and COVID-19 symptoms and the emergency medicine with younger age, daytime (evening) and IGD. Women chose more often the GP/paediatrician, men preferred emergency medicine. Only in case of IGD, higher educated persons more often chose the medical on-call service while people with a migration background decided less often for medical on-call service and emergency medicine.

CONCLUSIONS

Despite comparable urgency, the findings suggest variations of intended healthcare utilisation depending on various characteristics of the vignettes and respondents. Depending on the type of disease inequalities vary. Overall, information about healthcare alternatives in severe cases has to be improved and clear pathways to facilitate healthcare utilisation has to be further developed.

[Emergency medical service, medical on-call service, or emergency department : Germans unsure whom to contact in acute medical events]

BACKGROUND

In medical events, patients have to independently decide whom to contact: emergency medical services, medical on-call service or emergency department.

OBJECTIVES

Are Germans able to assess the urgency of medical events and choose the correct resource?

MATERIALS AND METHODS

In 2018 a nationwide anonymous telephone survey was done in Gabler-Haeder design. In all, 708 interviewees were presented with six medical scenarios. Participants were asked to rate urgency and to assess whether medical help was necessary within minutes to hours. Telephone numbers of emergency medical services and medical on-call service were inquired.

RESULTS

Urgency of different scenarios was often misjudged: in cases with high, medium, and low urgency the misjudgement rate were 20, 50, and 27%, respectively. If medical help was rated as necessary, some participants chose the wrong service: 25% would not call an ambulance in stroke or myocardial infarction. In cases with medium urgency, more respondents chose to consult an emergency department (38%) than to call medical on-call service (46%).

CONCLUSIONS

Knowledge regarding different options for treatment of medical events and competence to assess urgency seem to be too low. Beside efforts to increase health literacy, one solution might be to introduce a joint telephone number for emergency medical services and medical on-call service with a uniform assessment tool and appropriate allocation.

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients' perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany

BACKGROUND

Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends.

METHODS

The follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial.

RESULTS

Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged.

CONCLUSIONS

Most patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients' views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate.

TRIAL REGISTRATION

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

The Manchester Triage System in a Pediatric Emergency Department of an Austrian University Hospital: A Retrospective Analysis of Urgency Levels

OBJECTIVES

The Manchester Triage System (MTS) has entered widespread international use in emergency departments (EDs). This retrospective study analyzes urgency of patient visits (PV) at the ED of the Clinic for Pediatrics at the Medical University of Innsbruck.

METHODS

We collected demographic and outcome information, including PV urgency levels (UL) according to the MTS, for 3 years (2015-2018), separating PV during regular office hours (ROH; 8:00 am to 5:00 pm) from PV during afternoon and night hours (5:00 pm to 8:00 am), and PV on weekdays from PV on weekends and bank holidays (WE).

RESULTS

A total of 56,088 PV were registered with a UL. Most (68.4%) PV were classified as nonurgent. During ROH, more PV per hour (PV/h) were recorded than during afternoon and night hours (3.0 PV/h vs 1.6 PV/h), with a higher proportion of less urgent cases during ROH. On WE, the amount of PV/h was higher than on weekdays (3.6 PV/h vs 2.8 PV/h), with a higher proportion of nonurgent cases (74.6% vs 68.6%). Likelihoods of inpatient admission and hospital stay lengths increased in step with UL.

CONCLUSIONS

The MTS proved useful for delineating UL distributions. The MTS analyses may be of value in managing EDs. Prompted by the results of our study, a general practice pediatric care unit was established to support the ED during WE.

Is subjectively perceived treatment urgency of patients in emergency departments associated with self-reported health literacy and the willingness to use the GP as coordinator of treatment? Results from the multicentre, cross-sectional, observational study PiNo Bund

OBJECTIVES

Aim of this study was to analyse if subjectively perceived treatment urgency of patients in emergency departments is associated with self-reported health literacy and the willingness to use the general practitioner (GP) as coordinator of treatment.

DESIGN

A multicentre, cross-sectional, observational study.

SETTING

Emergency departments in five hospitals. Each hospital was visited 14 times representing two 8-hour shifts on each day of the week. Calendar dates were randomly assigned.

PARTICIPANTS

All patients of legal age registered at the emergency department or hospital reception desk. Exclusion criteria included immediate or very urgent need of treatment, high level of symptom burden and severe functional impairments in terms of hearing, vision and speech. We conducted standardised personal interviews. Additionally, clinical data were extracted from patient records.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our target variable was subjectively perceived treatment urgency. Predictor variables included age, sex, education, health-related quality of life (EuroQol Five-Dimension Scale, value set UK), anxiety and depression (Hospital Anxiety and Depression Scale), somatic symptoms (Patient Health Questionnaire, 15 items version), self-reported health literacy (European Health Literacy Questionnaire, 16 questions version) and the commitment to the GP (Fragebogen zur Intensität der Hausarztbindung, 'F-HaBi'). Data were analysed by multilevel, multivariable linear regression adjusted for random effects at the hospital level.

RESULTS

Our sample comprised 276 patients with a mean age of 50.1 years and 51.8% women. A low treatment urgency (defined as 0-5 points on a Numerical Rating Scale) was reported by 111 patients (40.2%). In the final model, lower subjective treatment urgency was associated with male sex (β=0.84; 95% CI 0.11/1.57, p=0.024), higher health-related quality of life (-2.27 to -3.39/-1.15, p<0.001), lower somatic symptoms score (0.09, 0.004/0.17, p=0.040), higher anxiety score (-0.13 to -0.24/-0.01, p=0.027) and lower commitment to the GP (0.08, 0.01/0.14, p=0.029).

CONCLUSIONS

A lower level of subjectively perceived treatment urgency was predicted by a lower willingness to use the GP as coordinator of treatment. Self-reported health literacy did not predict the patients' urgency rating.

Exploring Negative Spillover Effects on Stakeholders: A Case Study on Social Media Talk about Crisis in the Food Industry Using Data Mining

Focusing on public-centered, social-mediated crisis communication, the current exploratory study drew on situational crisis communication theory to formulate a comprehensive view of consumer reactions to crisis. Data mining and automated content analysis techniques were utilized to analyze social media posts by the public during a crisis in the cereals industry. Two path analyses showed that: (a) crisis-related social media posts tended to skip over competitor brand products, followed by two major reaction paths—(1) a rational path based on guilt attribution that justifies implications for the company and (2) an emotional path associated with public distrust; and (b) public self-blame spilled over to other stakeholders such as the government and economic system. The results give voice to issues that concern the public during crises, both as individuals and as a community. They highlight the fact that sustainable crisis management should involve additional stakeholders. Conclusions and implications for society and practice are suggested.

[Am I an emergency patient? Emergency perception and decision-making competence in acute situations: a qualitative study of ED patients]

BACKGROUND

The number of patients visiting emergency departments (ED) due to acute but less than urgent treatment needs is increasing. A deeper understanding of emergency perception and decision-making competencies of patients is fundamentally important for developing strategies to reduce ED utilization. The aim of this study was to assess ED patients' subjective understanding of an emergency in general as well as relating to their own specific consultation. Additionally, the patients' perspective on the ability to make appropriate decisions in acute situations should be explored.

METHODS

Seventeen qualitative semi-structured patient interviews were conducted and analyzed using qualitative content analysis.

RESULTS

The majority of participants attributed their ED consultation to a subjectively perceived emergency situation. Interviewees mostly understood an emergency as a serious or life-threatening constellation associated with impending long-term health damage. They believed that uncertainty concerning the interpretation of their symptoms and associated anxiety may particularly promote situations in which referring to an ED appears to be the only alternative. Patients' health competencies were assessed negatively by a majority of interviewees with regard to assessment of complaints and decision-making in acute situations ("insecure patients"). In contrast, few patients, including those with chronic disease and experience in dealing with health problems, were considered to have a high level of competence ("confident patients").

CONCLUSION

Improving patients' health literacy skills to strengthen their assessment of acute situations and their decision-making is important in order to promote appropriate ED utilization.

Allgemeinmedizin in der Notaufnahme – Welche Patienten? Welche Beschwerden?

Hintergrund

Vor dem Hintergrund des zunehmenden Anteils ambulant verbleibender Patienten wurde die Fachdisziplin Allgemeinmedizin in die zentrale Notaufnahme (ZNA) einer Universitätsklinik integriert. In der ZNA werden der Allgemeinmedizin diejenigen Patienten zugewiesen, die sich mit Beratungsanlässen aus dem allgemeinmedizinischen Spektrum vorstellen sowie bei Ersteinschätzung eine niedrige Behandlungsdringlichkeit aufweisen. Ziel war es, diese Patienten hinsichtlich ihrer Beratungsanlässe zu charakterisieren.

Methodik

Deskriptive Auswertung auf Basis der klinischen Routinedaten sowie eines selbst entwickelten Erhebungsbogens.

Ergebnisse

Etwa 80 % der Patienten suchten die Notaufnahme ohne ärztliche Einweisung auf. Die fünf häufigsten Beratungsanlässe waren Bauchschmerzen, Rückenschmerzen, Brustschmerzen, Schmerzen der unteren Extremitäten sowie Übelkeit und/oder Erbrechen. Bei knapp 25 % der Patienten setzten die Beschwerden erst am Tag der Vorstellung ein, bei etwa 33 % bestanden diese seit mehr als einer Woche. Die Hälfte der Patienten war wegen der Beschwerden bereits in ambulanter ärztlicher Behandlung, bei Patienten mit einer Beschwerdedauer von länger als einer Woche lag dieser Anteil bei mehr als 80 %. Patienten mit den Beratungsanlässen Fieber oder Verschlechterung des Allgemeinzustands wurden anteilig am häufigsten stationär aufgenommen. Von den Selbstzuweisern konnten knapp 94 % in die ambulante Versorgung entlassen werden.

Diskussion

Patienten suchen auch mit nichtakuten Beschwerden und trotz vorangegangener ambulanter ärztlicher Behandlung die Notaufnahme auf. Die häufigsten Beratungsanlässe allgemeinmedizinisch versorgter Patienten in der ZNA decken sich nur zum Teil mit denen der hausärztlichen Versorgung.

Mixed Methods Study of Nurse Assessment of Patient Preferences for Engagement During Hospitalization

BACKGROUND

Global health care initiatives emphasize the importance of engaging patients in their health care to improve the patient's experience and outcomes. Assessing patient preferences for engagement is critical, as there are many ways patients can engage in their care and preferences vary across individuals.

OBJECTIVE

The primary purpose of this study was to evaluate the effect of implementation of the Patient Preferences for Engagement Tool 13-Item Short Form (PPET13) during hospitalization on patient and nurse experience of engagement. Readmissions and emergency department (ED) usage within 30 days postdischarge was also examined.

METHODS

The mixed methods study was conducted within two medical units in the United States between December 2018 and May 2019. Pre-implementation group patients completed a demographic survey and the Patient Experience of Engagement Survey (PEES) on discharge. Implementation group patients completed the PPET13 within 24 hr of admission with their nurse and the demographic survey and PEES on discharge. A focus group with nurses who implemented the PPET13 was conducted following the implementation period. Data analysis included confirmatory factor analysis, multiple and logistic regression, and qualitative content analysis.

RESULTS

There was significant improvement in PEES during the implementation phase. The PEES score was a significant predictor of ED visits, but not 30-day readmissions. Nurses were not always certain how to best integrate patient preferences for engagement into their care delivery and suggested integrating the PPET13 into the electronic health record to assist with streamlining the assessment and communicating preferences across the care team.

DISCUSSION

Assessing patients' preferences for engagement using the PPET13 was associated with an improved experience of engagement, which was found to mediate the relationship between utilization of PPET13 and ED usage within 30 days postdischarge. Use of a PPET, such as the PPET13, can help inform the delivery of individualized engagement strategies to improve patient and family engagement and outcomes; however, nurses need formalized education on how to tailor their care to meet the individual engagement preferences of their patients.

Drivers of general practice-type presentations to the emergency department in a remote outback community

OBJECTIVE

To estimate the number of general practice-appropriate attendances in a remote emergency department and explore the reasons for patients' choice of service.

DESIGN

A four-step case study approach was adopted, focusing on hospital emergency department (ED) attendances that were potentially manageable in general practice.

SETTING

A large, remote community with substantial populations of Indigenous peoples and fly-in, fly-out mining industry workers. The ED is experiencing rapid growth in demand for services for lower urgency.

PARTICIPANTS

Patients attending the emergency department with lower urgency problems.

INTERVENTIONS

ED attendance data for 2016 were reviewed to identify lower urgency presentations. Patient records for 400 randomly selected presentations were subject to deeper analysis. A prospective survey was conducted over 6 months of 369 ED patients with lower urgency presentations.

MAIN OUTCOME MEASURES

The proportion of patients attending the ED with GP-appropriate problems and influences on their decisions to attend the ED.

RESULTS

About 48% of all attendances met the agreed definition of GP-appropriate problems. About half of presentations were during the normal work hours and about half of patients stated that GP services were unavailable. Younger age, lack of information about local GP services, and perceptions of convenience contributed significantly to seeking ED care.

CONCLUSION

Increasing the availability of GP services alone is unlikely to be sufficient to change service utilisation. Strategies should include raising community awareness of how and when to utilise the appropriate service, understanding different models of care, and the need to register with a general practice.

Optimization of Patient Flow in Urgent Care Centers Using a Digital Tool for Recording Patient Symptoms and History: Simulation Study

Background

Crowding can negatively affect patient and staff experience, and consequently the performance of health care facilities. Crowding can potentially be eased through streamlining and the reduction of duplication in patient history-taking through the use of a digital symptom-taking app.

Objective

We simulated the introduction of a digital symptom-taking app on patient flow. We hypothesized that waiting times and crowding in an urgent care center (UCC) could be reduced, and that this would be more efficient than simply adding more staff.

Methods

A discrete-event approach was used to simulate patient flow in a UCC during a 4-hour time frame. The baseline scenario was a small UCC with 2 triage nurses, 2 doctors, 1 treatment/examination nurse, and 1 discharge administrator in service. We simulated 33 scenarios with different staff numbers or different potential time savings through the app. We explored average queue length, waiting time, idle time, and staff utilization for each scenario.

Results

Discrete-event simulation showed that even a few minutes saved through patient app-based self-history recording during triage could result in significantly increased efficiency. A modest estimated time saving per patient of 2.5 minutes decreased the average patient wait time for triage by 26.17%, whereas a time saving of 5 minutes led to a 54.88% reduction in patient wait times. Alternatively, adding an additional triage nurse was less efficient, as the additional staff were only required at the busiest times.

Conclusions

Small time savings in the history-taking process have potential to result in substantial reductions in total patient waiting time for triage nurses, with likely effects of reduced patient anxiety, staff anxiety, and improved patient care. Patient self-history recording could be carried out at home or in the waiting room via a check-in kiosk or a portable tablet computer. This formative simulation study has potential to impact service provision and approaches to digitalization at scale.

Barriers to Integration of Primary Care into Emergency Care: Experiences in Germany

Introduction

In response to emergency department over-crowding primary care practitioners (PCPs) have been incorporated into care pathways to provide integrated care. We consider why a pilot project of PCP-led streaming in a German emergency department failed, the challenges encountered transplanting models between differing systems and cultures, and if the concept constitutes integrated care.

Theory and Methods

The original design was a mixed methods data gather around PCP-streaming of non-urgent self-referrers in an emergency department.

Results

The demand for the PCP-streaming was low, which was at odds with pre-study estimates. The study was stopped prematurely without adequate data; this is an opinion-based article.

Discussion

A fundamental of emergency care is a central emergency department. An emergency department can be the fulcrum from which urgent inter-disciplinary hospital care is initiated and coordinated. Objective triage is fundamental to this and regional healthcare planning. With such fundamentals in place, PCP integration has the potential to facilitate and provide integrated care. Relevant elements of the Rainbow Model of Integrated Care frame the discussion.

Conclusion

The key element deficient in each barrier to our project, yet present in successful studies, was normative integration.

[Assessment of validity of the German version of the Manchester Triage System]

BACKGROUND

The Manchester Triage System (MTS) was first introduced in 1996. Since then, the original English MTS version has undergone multiple evaluations of its validity and reliability. Due to translation and differing algorithms, only contradictory data regarding accuracy are available for the German MTS version. The aim of this study was to assess the validity of the current German version of the MTS in a retrospective observational setting.

MATERIALS AND METHODS

All surgical and medical patients presenting at the emergency department of an Austrian regional hospital between 1 and 30 July 2020 were included in this study. Data of vital parameters at the time of triage, overall hospitalisation rate, length of hospitalisation, mortality rate as well as referral and discharge modalities were collected.

RESULTS

A total of 773 patients were included in the study after primary triage. There was a significant correlation between risk level and both hospitalisation rate (p < 0.001) and the length of hospitalisation (p = 0.001). Interestingly, this correlation was lower in patients over 70 years (r² = 0.101 vs. 0.045). Vital signs and mortality rate did not correlate significantly with the initial risk level. The average time for one triage process was 2.1 ± 3.9 min.

CONCLUSION

The German version of the MTS shows good correlation with central risk surrogates, but this correlation is weaker in the subgroup of elderly patients. As the original English version, it does not predict long-term mortality. In clinical practice, the German version of the MTS is as good as the original version in enabling the urgency of treatment to be rapidly assessed so that resource allocation can be optimised.

[Health literacy and nonurgent emergency department visits]

Hintergrund

Die Anzahl an Patienten in Notaufnahmen steigt seit Jahren an. Im Besonderen wächst der Anteil an Patienten mit einem nichtdringlichen Behandlungsbedarf. Bislang ist unklar, ob dies in Deutschland auch auf eine eingeschränkte Gesundheitskompetenz zurückgeführt werden kann.

Ziel der Arbeit

Ziel der Studie war es, die Gesundheitskompetenz (GK) von Notfallpatienten mit nichtdringlichem Behandlungsbedarf zu erfassen, mit allgemeinen Bevölkerungsdaten zur GK zu vergleichen und Zusammenhänge mit der subjektiv empfundenen notfallmedizinischen Versorgung zu betrachten.

Material und Methode

Es wurde eine Querschnittsbefragung in der zentralen Notaufnahme und der angeschlossenen kassenärztlichen Bereitschaftspraxis (KVB-Praxis) des Universitätsklinikums Augsburg durchgeführt. Insgesamt wurden 448 Patienten mit nichtdringlichem Versorgungsbedarf befragt.

Ergebnisse

Es zeigt sich, dass die GK der Notfallpatienten schlechter ausfällt als die der deutschen Gesamtpopulation. Patienten mit niedriger GK nehmen eine höhere subjektive Behandlungsdringlichkeit wahr, kennen signifikant seltener alternative Anlaufstellen zur Behandlung und möchten nach hausärztlicher Versorgung häufiger in der Notaufnahme oder der KVB-Praxis eine zweite Meinung einholen.

Diskussion

Die Ergebnisse zeigen einen Handlungsbedarf für eine Verbesserung der Gesundheitskompetenz auf. Dabei sind insbesondere die aktuellen strukturellen Veränderungen der Notfallversorgung in Deutschland zu berücksichtigen.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

Background

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

Methods

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

Results

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (OR_ON 3.6, 95% CI 3.21–3.30; OR_OFF 3.18, 95% CI 3.04–3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9–47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6–79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

Conclusions

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

Predictive Modeling of 30-Day Emergency Hospital Transport of German Patients Using a Personal Emergency Response: Retrospective Study and Comparison with the United States

BACKGROUND

Predictive analytics based on data from remote monitoring of elderly via a personal emergency response system (PERS) in the United States can identify subscribers at high risk for emergency hospital transport. These risk predictions can subsequently be used to proactively target interventions and prevent avoidable, costly health care use. It is, however, unknown if PERS-based risk prediction with targeted interventions could also be applied in the German health care setting.

OBJECTIVE

The objectives were to develop and validate a predictive model of 30-day emergency hospital transport based on data from a German PERS provider and compare the model with our previously published predictive model developed on data from a US PERS provider.

METHODS

Retrospective data of 5805 subscribers to a German PERS service were used to develop and validate an extreme gradient boosting predictive model of 30-day hospital transport, including predictors derived from subscriber demographics, self-reported medical conditions, and a 2-year history of case data. Models were trained on 80% (4644/5805) of the data, and performance was evaluated on an independent test set of 20% (1161/5805). Results were compared with our previously published prediction model developed on a data set of PERS users in the United States.

RESULTS

German PERS subscribers were on average aged 83.6 years, with 64.0% (743/1161) females, with 65.4% (759/1161) reported 3 or more chronic conditions. A total of 1.4% (350/24,847) of subscribers had one or more emergency transports in 30 days in the test set, which was significantly lower compared with the US data set (2455/109,966, 2.2%). Performance of the predictive model of emergency hospital transport, as evaluated by area under the receiver operator characteristic curve (AUC), was 0.749 (95% CI 0.721-0.777), which was similar to the US prediction model (AUC=0.778 [95% CI 0.769-0.788]). The top 1% (12/1161) of predicted high-risk patients were 10.7 times more likely to experience an emergency hospital transport in 30 days than the overall German PERS population. This lift was comparable to a model lift of 11.9 obtained by the US predictive model.

CONCLUSIONS

Despite differences in emergency care use, PERS-based collected subscriber data can be used to predict use outcomes in different international settings. These predictive analytic tools can be used by health care organizations to extend population health management into the home by identifying and delivering timelier targeted interventions to high-risk patients. This could lead to overall improved patient experience, higher quality of care, and more efficient resource use.

Forced Centralized Allocation of Patients to Temporarily 'Closed' Emergency Departments

BACKGROUND

Because insufficient data are available, the overall number of patients treated in German emergency departments can only be estimated. It is evident, however, that case numbers have been rising steadily in recent years, and that a lack of capacity is now leading with increasing freuqency to forced centralized allocation of patients by the emergency medical services (EMS) to emergency departments that are, officially, temporarily "closed".

METHODS

Trends in patient allocation of this type in greater Munich, Germany, over the years 2013-2019 were analyzed for the first time on the basis of data from 904 997 cases treated by the emergency rescue services.

RESULTS

From 2014 to 2019, the number of forced centralized patient allocations rose approximately by a factor of nine, from 70 to 634 per 100 000 persons per year. In the same period, the overall number of cases treated by the emergency rescue services rose by 14.5%. Peak values for forced centralized allocations were reached in the first quarter of each calendar year (2015: 1579, 2017: 2435, 2018: 3161, 2019: 3990). Of all medical specialties, internal medicine was the most heavily affected (more than 59% of the total). Especially in the years 2017-2019, the free availability of internal medicine declined in hospitals participating in the common greater Munich reporting system.

CONCLUSION

The reasons for the sharp rise in forced centralized allocations are unclear. This observed trend seems likely to persist over the coming years, in view of the current staff shortage, the aging population, and diminishing hospital capacities. The relevant decision-makers must collaborate to create emergency plans that will prevent care bottlenecks so that patients will not be endangered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Medical Emergencies During the COVID-19 Pandemic

BACKGROUND

In this study, we investigate the number of emergency room consultations during the COVID-19 pandemic of 2020 in Germany compared to figures from the previous year.

METHODS

Case numbers from calendar weeks 1 through 22 of the two consecutive years 2019 and 2020 were obtained from 29 university hospitals and 7 non-university hospitals in Germany. Information was also obtained on the patients' age, sex, and urgency, along with the type of case (outpatient/inpatient), admitting ward, and a small number of tracer diagnoses (I21, myocardial infarction; J44, COPD; and I61, I63, I64, G45, stroke /TIA), as well as on the number of COVID-19 cases and of tests performed for SARS-CoV-2, as a measure of the number of cases in which COVID-19 was suspected or at least included in the differential diagnoses.

RESULTS

A total of 1 022 007 emergency room consultations were analyzed, of which 546 940 took place in 2019 and 475 067 in 2020. The number of consultations with a positive test for the COVID-19 pathogen was 3122. The total number of emergency room consultations in the observation period was 13% lower in 2020 than in 2019, with a maximum drop by 38% coinciding with the highest number of COVID-19 cases (calendar week 14; 572 cases). After the initiation of interpersonal contact restrictions in 2020, there was a marked drop in COVID-19 case numbers, by a mean of -240 cases per week per emergency room (95% confidence interval [-284; -128]). There was a rise in case numbers thereafter, by a mean of 17 patients per week [14; 19], and the number of cases of myocardial infarction returned fully to the level seen in 2019.

CONCLUSION

In Germany, the COVID-19 pandemic led to a significant drop in medical emergencies of all kinds presenting to the nation's emergency departments. A recovery effect began to be seen as early as calendar week 15, but the levels seen in 2019 were not yet reached overall by calendar week 22; only the prevalence of myocardial infarction had renormalized by then. The reasons for this require further investigation.

What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany

BACKGROUND

While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit.

METHODS

Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research).

RESULTS

Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED.

CONCLUSIONS

With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.

Recent trends and variations in general practitioners' involvement in accident care in Switzerland: an analysis of claims data

Background

As in other countries, there is concern and some fragmentary evidence that GPs’ central role in the Swiss healthcare system as the primary provider of care might be changing or even be in decline. Our study gives a systematic account of GPs’ involvement in accident care from 2008 to 2016 and identifies changes in GPs’ involvement in this typical field of primary care: how frequently GPs were involved along the care pathway, to what extent they figured as initial care provider, and what their role in the care pathway was.

Methods

Using a claims dataset from the largest Swiss accident insurer with two million accident cases, we constructed individual care pathways, i.e., when and from which providers patients received care. We calculated probabilities for the involvement of various care provider groups, for initial care provision, and for the role of GPs in patients’ care pathways, adjusted for injury and patient characteristics using multinomial regression.

Results

In 2014, GPs were involved in 70% of all accident cases requiring outpatient care but no inpatient stay, and provided initial care in 56%. While involvement stayed at about the same level for accidents occurring from 2008 to 2014, the share of accidents where GPs provided initial care decreased by 4 percentage points. The share of cases where GPs acted as sole care provider decreased by 7 percentage points down to 44%. At the same time, accident cases involving care from an ED at any point in time increased from 38 to 46% and the share receiving initial care from an ED from 30 to 35 percentage points – apparently substituting for the declining involvement of GPs in initial care. GPs’ involvement in accident care is higher in rural compared to urban regions, among elderly compared to younger patients, and among Swiss compared to non-Swiss citizens.

Conclusions

GPs play a key role in accident care with considerable variation depending on region and patient profile. From 2008 to 2014, there is a remarkable decline in GPs’ provision of initial care after an accident. This is a strong indication that the GPs’ role in the Swiss healthcare system is changing.

[Even low-acuity patients prefer hospital-based emergency care : A survey of non-urgent patients in an emergency department with unique regional position]

BACKGROUND

Besides increasing numbers of cases in German emergency departments (ED), the spectrum of attending patients is also changing. Patients with acute illnesses tend to prefer EDs to ambulatory care as primary contact point. This study examines the motives for use and use behavior of low-urgent ED-patients.

METHODS

Anonymous patient survey in the ED of Wolfsburg Hospital between 12/2015 and 03/2016 with descriptive analysis. All patients with low urgency (Manchester-Triage-System (MTS), levels blue and green) were eligible.

RESULTS

81.5% of respondents (729 evaluable out of 7000 questionnaires distributed) attended the ED between 8:00 a. m. and 5:00 p. m., 70.1 % of them were walk-in patients. The motive most frequently cited was that they would receive better care in the ED (48.3 %). Contrary to acuity assessment, 67.8 % of respondents considered themselves a medium to life-threatening emergency. As alternative option, 49.2 % would choose a nearby clinic in the region for their complaints.

CONCLUSION

Self-assessed urgency differs with acuity assessment according to MTS. Patients who fear an acute threat to their health do not use services provided in the ambulatory sector such as the emergency practice of the Association of Statutory Health Insurance Physicians in the immediate proximity sufficiently. Previous approaches for patient navigation do not seem to be successful in this setting. Strengthening of EDs as a single 24/7 access point for emergency care with simultaneous abolition of parallel care structures should be discussed.

Patient motives for contacting out-of-hours care in Denmark: a cross-sectional study

BACKGROUND

Patients in need of acute health care do not always contact the most suitable health care service provider. Contacting out-of-hours primary care for an urgent problem may delay care, whereas contacting emergency medical services for a non-urgent problem could ultimately affect patient safety. More insight into patient motives for contacting a specific health care provider may help optimise patient flows. This study aims to explore patient motives for contacting out-of-hours primary care and the emergency medical services in Denmark.

METHODS

We conducted a cross-sectional observational study by sending a questionnaire to patients contacting out-of-hours primary care and emergency medical services, both of which can be directly contacted by patients, in two of five Danish regions in 2015. As we aimed to focus on the first access point, the emergency department was not included. The questionnaire included items on patient characteristics, health problem and 26 pre-defined motives. Descriptive analyses of patient characteristics and motives were conducted, stratified by the two health care service providers. Factors associated with contacting each of the two service providers were explored in a modified Poisson regression analysis, and adjusted risk ratios were calculated.

RESULTS

Three key motives for contacting the two service providers were identified: 'unpleasant symptoms', 'perceived need for prompt action' and 'perceived most suitable health care provider'. Other important motives were 'need arose outside office hours' and 'wanted to talk to a physician' (out-of-hours primary care) and 'expected need for ambulance' and 'worried' (emergency medical services). Higher probability of contacting the emergency medical services versus out-of-hours primary care was seen for most motives relating to own assessment and expectations, previous experience and knowledge, and own needs and wishes. Lower probability was seen for most motives relating to perceived barriers and benefits.

CONCLUSIONS

Patient motives for contacting the two health care service providers were partly overlapping. The study contributes with new knowledge on the complex decision-making process of patients in need of acute health care. This knowledge could help optimise existing health care services, such as patient safety and the service level, without increasing health care costs.

Evaluation of a Rural Emergency Medical Service Project in Germany: Protocol for a Multimethod and Multiperspective Longitudinal Analysis

BACKGROUND

German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases.

OBJECTIVE

The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services.

METHODS

We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes.

RESULTS

We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018.

CONCLUSIONS

Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons' individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14358.

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.

Ambulatory care-sensitive emergency department cases: a mixed methods approach to systemize and analyze cases in Germany

BACKGROUND

Internationally, emergency departments (ED) are treating increasing numbers of patients with conditions that could have been managed appropriately in ambulatory care (AC) settings. The aim of our study was to develop the first consensus-based list of AC-sensitive conditions commonly seen in German EDs and explore predictors of these visits.

METHODS

Our study used a Delphi survey of 30 physicians to compile a list of conditions they agreed were amenable to AC treatment. The group identified reasons why patients visit EDs instead of AC. We used the results to inform spatial regression models analysing the association of patient characteristics and attributes of AC with AC-sensitive ED visits based on 2015 district-level data.

RESULTS

Our study provides a list of AC-sensitive conditions based on the German ED context. Results suggest that, up to the age of 70 years, the older the patients, the less likely they seek EDs for these conditions. Results of our regression analyses suggest that AC-sensitive ED rates were significantly higher in districts with lower physician density. Patients' urgency perception and preferences were identified as main drivers of AC-sensitive ED visits.

CONCLUSION

Future policy measures should aim to help guide patients through the healthcare system so that they receive the best care in place that is most appropriate in terms of quality, safety and continuity of care. A list of AC-sensitive ED conditions can be used as a monitoring instrument and for further analyses of routine data to inform policy makers seeking to improve resource use and allocation.

Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis

BACKGROUND

To enhance the acute care delivery system, a comprehensive understanding of the patient's perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary.

METHODS

We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses.

RESULTS

Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: "it's urgent because it hurts," and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: "my doctor said he was booked up and he instructed me to go to the ED." The third domain was related to multiple advantages associated with ED care: "my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support." In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers.

CONCLUSIONS

In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.

[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.