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Frith M, Randall S, Savira F, Swann J, White N, Giddy A, McLean K, Peeters A, Robinson S. Evaluation of the priority primary care centre program to reduce emergency department burden in regional Victoria, Australia: a mixed-method study. BMJ Open 2023; 13:e075773. [PMID: 37945302 PMCID: PMC10649696 DOI: 10.1136/bmjopen-2023-075773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/10/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION In Australia, the Victorian State Government has established a number of priority primary care centres (PPCCs) across the state to address the increasing demand for emergency departments (EDs). PPCCs are general practitioner-led, free-of-charge services that aim to provide care for conditions that require urgent attention but do not require the high-acuity care of an ED. This study aims to evaluate the implementation processes, outcomes and the impact of the PPCC on reducing ED demand within Barwon, Warrnambool and Grampians Health Services in the Western region of Victoria, Australia. METHODS AND ANALYSIS This is a convergent mixed-method study. Qualitative data collection will be undertaken through semistructured interviews to understand the experiences of PPCC patients, PPCC clinical staff, PPCC managerial and administrative staff and ED clinical staff. A documentary analysis will be conducted on the materials relating to the implementation of the PPCC. The quantitative component will involve interrupted time series analysis of de-identified administrative data, comprising ED presentation records and PPCC clinical records. Implementation science frameworks will be integrated throughout the study. The RE-AIM framework is a guide used for the planning and evaluation of programmes through five outcomes: reach, effectiveness, adoption, implementation and maintenance. The Consolidated Framework for Implementation Research will be integrated. ETHICS AND DISSEMINATION This study has received ethical approval from Deakin University HREC (Ref No. 2023-046) and Barwon Health HREC (Ref No. 94374). Findings will be disseminated as reports, presentations and peer-reviewed journal articles.
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Affiliation(s)
- Madison Frith
- Deakin Health Economics, Deakin University, Institute for Health Transformation, Burwood, Victoria, Australia
| | - Sean Randall
- Deakin Health Economics, Deakin University, Institute for Health Transformation, Burwood, Victoria, Australia
| | - Feby Savira
- Deakin Health Economics, Deakin University, Institute for Health Transformation, Burwood, Victoria, Australia
| | - Jamie Swann
- Health Analytics and Research, Western Victorian Primary Health Network, Ballarat, Victoria, Australia
| | - Naomi White
- Regional Parnterships and Public Health, Western Victorian Primary Health Network, Ballarat, Victoria, Australia
| | - Andrew Giddy
- Strategy and Engagement, Western Victorian Primary Health Network, Ballarat, Victoria, Australia
| | - Kirsty McLean
- Emergency Nursing, Grampians Health Ballarat, Ballarat, Victoria, Australia
| | - Anna Peeters
- Institute of Health Transformation, Deakin University, Melbourne, Victoria, Australia
| | - Suzanne Robinson
- Deakin Health Economics, Deakin University, Institute for Health Transformation, Burwood, Victoria, Australia
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Calastri C, Hess S, Wilson B. How did the use of ED change during the first wave of the SARS-CoV-2 pandemic in the UK: an observational study. Emerg Med J 2023:emermed-2021-212058. [PMID: 37185304 DOI: 10.1136/emermed-2021-212058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/16/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The COVID-19 pandemic has been linked to a sharp drop in ED attendance, but the exact reasons for this are unclear. The aim of this study was to investigate differences between individuals attending the ED before and during the pandemic and the reasons for their choices. METHODS Two population-based online surveys were conducted before (2019) and during (2020) the pandemic. Participants were recruited by a survey panel to be representative of the UK population aged 18-45 years. Both surveys asked about the circumstances and reasons for the last ED attendance, with specific pandemic-related questions in the second one. Comparisons of characteristics and symptoms of individuals attending during the pandemic were compared with those attending in prior years using χ2 tests. We determined the proportion of patients who had symptoms during the pandemic but did not attend, and the reasons for that choice. RESULTS Young and high-income people, those with chronic illnesses and those with influenza-like symptoms were more likely to attend the ED during lockdown than before. 18% of respondents had experienced urgent symptoms during the pandemic; 60% of these individuals chose not to go to the ED. While about 30% of this group stated they believed their symptoms were not serious enough, 85% of these individuals mentioned fear of infection or worry about overburdening the system as a reason for not attending. Individuals attending during the pandemic were more likely to consider their visit unnecessary compared with those attending previously. CONCLUSIONS The study suggests that the decision to use the ED has a discretionary component. This could potentially contribute to unnecessary visits, and raises concerns that some patients who should present at the ED do not go. More effective communication about who should visit EDs during a pandemic, and the safety of doing so, is needed.
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Affiliation(s)
- Chiara Calastri
- Institute for Transport Studies and Choice Modelling Centre, University of Leeds, Leeds, UK
| | - Stephane Hess
- Institute for Transport Studies and Choice Modelling Centre, University of Leeds, Leeds, UK
| | - Brad Wilson
- Bradford Institute for Health Research, Bradford, UK
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North F, Garrison GM, Jensen TB, Pecina J, Stroebel R. Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits. Health Serv Res Manag Epidemiol 2023; 10:23333928231214169. [PMID: 38023369 PMCID: PMC10664417 DOI: 10.1177/23333928231214169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/30/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. Methods We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. Results There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Conclusion Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.
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Affiliation(s)
- Frederick North
- Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
| | | | - Teresa B Jensen
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert Stroebel
- Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
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Scantlebury A, Adamson J, Salisbury C, Brant H, Anderson H, Baxter H, Bloor K, Cowlishaw S, Doran T, Gaughan J, Gibson A, Gutacker N, Leggett H, Purdy S, Voss S, Benger JR. Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study. BMJ Open 2022; 12:e063495. [PMID: 36127084 PMCID: PMC9490584 DOI: 10.1136/bmjopen-2022-063495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. DESIGN Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. SETTING AND PARTICIPANTS Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. RESULTS There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). CONCLUSIONS We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. TRIAL REGISTRATION NUMBER ISCRTN5178022.
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Affiliation(s)
| | - Joy Adamson
- Department of Health Sciences, University of York, York, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Heather Brant
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Helen Anderson
- Department of Health Sciences, University of York, York, UK
| | - Helen Baxter
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
| | - Sean Cowlishaw
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - James Gaughan
- Department of Health Sciences, University of York, York, UK
| | - Andy Gibson
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Voss
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Jonathan Richard Benger
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
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Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Cronin S, Wallace E, McCarthy G, Galvin R. The “better data, better planning” census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland. BMC Health Serv Res 2022; 22:471. [PMID: 35397588 PMCID: PMC8994521 DOI: 10.1186/s12913-022-07841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of “Corridor Medicine” and “Trolley Crises” have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland. Methods This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Results Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the “best place” for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan. Conclusions This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07841-6.
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Oliver D. David Oliver: Needs, wants, and demands for care. BMJ 2022; 376:o173. [PMID: 35082118 DOI: 10.1136/bmj.o173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Dundar C, Yaylaoglu SD. Non-emergent care visits in a turkish tertiary care emergency department after 2008 health policy changes: review and analysis. Arch Public Health 2022; 80:31. [PMID: 35039087 PMCID: PMC8762921 DOI: 10.1186/s13690-022-00787-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/09/2022] [Indexed: 11/21/2022] Open
Abstract
Background The Turkish government liberalized national healthcare policies in 2008 enabling Turkish citizens to seek general care in hospital emergency departments (ED). The number of ED visits has exceeded the total population every year for the last ten years. To explain this phenomenon and to identify trends and risk factors for non-emergent visits, we retrospectively reviewed the ED records of a tertiary hospital and the Turkish Ministry of Health bulletin. Methods This retrospective record-based study was conducted at a tertiary hospital in Samsun province of Turkey. A total of 87,528 records of adult patients who visited the ED between January 1 and December 31, 2017, were included in this study. We evaluated the pattern of ED use for non-emergent patients by age, gender, nationality, time of visit, means of arrival, ICD (International Classification of Diseases) diagnostic codes, triage codes, number of repeated and out-of-hours visits. We used the Turkish Ministry of Health statistics bulletins to compare the number of ED visits across the country by year. Results The non-emergent visit rate in ED was found 9.9%. The rate of non-emergent ED visits was significantly higher in the 18-44 age group, in the female gender, and in those who arrived at the ED without an ambulance. The number of non-emergent visits was very similar between weekends and weekdays but was significantly higher in working hours on weekdays than out-of-hours (p<0.001). The most frequent diagnostic code was “Pain, unspecified” (R52) and the rate of repeat visits was 14.8% of non-emergent ED visits. According to binary logistic analysis, non-emergency visits were associated with 18-44 age group (OR = 2.75), female gender (OR = 1.11) and non-ambulance transportation (OR = 9.86). Conclusions Our results showed that the 18-44 age group and female gender seek care in the ED for non-emergent problems more than the other parts of the population. The numbers of ED visits in the last decade continued to increase regardless of population growth. The health policy changes may have facilitated access to rapid physical and laboratory examination but also an exacerbation of the free-rider problem in ED services.
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Affiliation(s)
- Cihad Dundar
- Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
| | - Seydanur Dal Yaylaoglu
- Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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8
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Long J, Knowles E, Bishop-Edwards L, O'Cathain A. Understanding young adults' reasons for seeking 'clinically unnecessary' urgent and emergency care: A qualitative interview study. Health Expect 2021; 24:1535-1544. [PMID: 34118177 PMCID: PMC8369113 DOI: 10.1111/hex.13301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/03/2021] [Accepted: 05/27/2021] [Indexed: 01/15/2023] Open
Abstract
Background Studies have identified young adults as more likely to use emergency departments for ‘clinically unnecessary’ problems, with limited similar evidence for emergency ambulance use. Media portrayals depict young adults as motivated by ‘convenience’, but little research has explored the reasons for their help‐seeking behaviour. Methods Qualitative interviews with 16 young adults (18‐30) considered by clinicians to have made unnecessary use of emergency ambulance, emergency department or an urgent GP appointment. Data analysis was informed by interpretive phenomenological analysis. Findings A number of interrelated factors contributed to participants’ decisions. They were anxious about the seriousness of their symptoms, sometimes exacerbated by reduced coping capacity due to poor mental health or life stresses. They looked to others to facilitate their decision making, who sometimes encouraged urgent contact. They wanted to avoid impact on existing day‐to‐day commitments including work or study. They had strong views about different health services, sometimes based on frustration with lack of resolution of on‐going health problems. Convenience was not identified as a significant factor, although some actions could be interpreted in this light if the context was not considered. Conclusions Young adults make ‘clinically unnecessary’ use of urgent and emergency care for more than convenience. Their decisions need to be understood in relation to the complexity of their experience, including lack of confidence in making health‐related decisions, lowered coping capacity and concern to maintain normal daily life.
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Affiliation(s)
- Jaqui Long
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Alicia O'Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Burton C, Stone T, Oliver P, Dickson JM, Lewis J, Mason SM. Frequent attendance at the emergency department shows typical features of complex systems: analysis of multicentre linked data. Emerg Med J 2021; 39:3-9. [PMID: 34039641 DOI: 10.1136/emermed-2020-210772] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/21/2021] [Accepted: 04/06/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Frequent attendance at the ED is a worldwide problem. We hypothesised that frequent attendance could be understood as a feature of a complex system comprising patients, healthcare and society. Complex systems have characteristic statistical properties, with stable patterns at the level of the system emerging from unstable patterns at the level of individuals who make up the system. METHODS Analysis of a linked dataset of routinely collected health records from all 13 hospital trusts providing ED care in the Yorkshire and Humber region of the UK (population 5.5 million). We analysed the distribution of attendances per person in each of 3 years and measured the transition of individual patients between frequent, infrequent and non-attendance. We fitted data to power law distributions typically seen in complex systems using maximum likelihood estimation. RESULTS The data included 3.6 million attendances at EDs in 13 hospital trusts. 29/39 (74.3%) analyses showed a statistical fit to a power law; 2 (5.1%) fitted an alternative distribution. All trusts' data fitted a power law in at least 1 year. Differences over time and between hospital trusts were small and partly explained by demographics. In contrast, individual patients' frequent attendance was unstable between years. CONCLUSIONS ED attendance patterns are stable at the level of the system, but unstable at the level of individual frequent attenders. Attendances follow a power law distribution typical of complex systems. Interventions to address ED frequent attendance need to consider the whole system and not just the individual frequent attenders.
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Affiliation(s)
- Christopher Burton
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Tony Stone
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Phillip Oliver
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Jon M Dickson
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Jen Lewis
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Truter P, Edgar D, Mountain D, Bulsara C. An emergency department optimized protocol for qualitative research to investigate care seeking by patients with non-urgent conditions. Nurs Open 2021; 8:628-635. [PMID: 33570278 PMCID: PMC7877135 DOI: 10.1002/nop2.667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 11/11/2022] Open
Abstract
AIM To describe a tailored qualitative research methodology for exploring the complex interaction of factors driving non-urgent care seeking in the emergency department. DESIGN Qualitative descriptive design with a literature informed semi-structured interview and analysis structure. Triangulation with the State-Trait Anxiety Inventory allows expedited exploration of biopsychosocial factors. Consolidated criteria for reporting qualitative research requirements integrated. METHODS With a short 10- to 15-min interview and a low-inference analysis process, this methodology offers a structured way to explore the "go to ED" decision, to understand the patient perspective on their healthcare needs and feed into the development of suitable local services that meet patient healthcare needs. RESULTS This methodology offers a structured way for clinician-researchers to explore the factors that influence patients seeking care in the emergency departments for non-urgent conditions that are specific to their local health service environment. The described methodology is accessible to novice qualitative researchers and includes the semi-structured interview, coding and analysis frameworks.
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Affiliation(s)
- Piers Truter
- School of PhysiotherapyUniversity of Notre Dame AustraliaFremantleWAAustralia
- Emergency DepartmentFiona Stanley HospitalMurdochWAAustralia
- SJOG Midland Public and Private HospitalMidlandWAAustralia
| | - Dale Edgar
- School of PhysiotherapyUniversity of Notre Dame AustraliaFremantleWAAustralia
- Fiona Wood FoundationPerthWAAustralia
| | - David Mountain
- Emergency DepartmentSir Charles Gairdner HospitalNedlandsWAAustralia
- University of Western AustraliaNedlandsWAAustralia
| | - Caroline Bulsara
- School of Nursing and MidwiferyUniversity of Notre Dame AustraliaFremantleWAAustralia
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11
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Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study. Br J Gen Pract 2020; 71:e22-e30. [PMID: 33257462 PMCID: PMC7716877 DOI: 10.3399/bjgp20x713885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/20/2020] [Indexed: 11/21/2022] Open
Abstract
Background Non-urgent emergency department (ED) attendances are common among children. Primary care management may not only be more clinically appropriate, but may also improve patient experience and be more cost-effective. Aim To determine the impact on admissions, waiting times, antibiotic prescribing, and treatment costs of integrating a GP into a paediatric ED. Design and setting Retrospective cohort study explored non-urgent ED presentations in a paediatric ED in north-west England. Method From 1 October 2015 to 30 September 2017, a GP was situated in the ED from 2.00 pm until 10.00 pm, 7 days a week. All children triaged as ‘green’ using the Manchester Triage System (non-urgent) were considered to be ‘GP appropriate’. In cases of GP non-availability, children considered non-urgent were managed by ED staff. Clinical and operational outcomes, as well as the healthcare costs of children managed by GPs and ED staff across the same timeframe over a 2-year period were compared. Results Of 115 000 children attending the ED over the study period, a complete set of data were available for 13 099 categorised as ‘GP appropriate’; of these, 8404 (64.2%) were managed by GPs and 4695 (35.8%) by ED staff. Median duration of ED stay was 39 min (interquartile range [IQR] 16–108 min) in the GP group and 165 min (IQR 104–222 min) in the ED group (P<0.001). Children in the GP group were less likely to be admitted as inpatients (odds ratio [OR] 0.16; 95% confidence interval [CI] = 0.13 to 0.20) and less likely to wait >4 hours before being admitted or discharged (OR 0.11; 95% CI = 0.08 to 0.13), but were more likely to receive antibiotics (OR 1.42; 95% CI = 1.27 to 1.58). Treatment costs were 18.4% lower in the group managed by the GP (P<0.0001). Conclusion Given the rising demand for children’s emergency services, GP in ED care models may improve the management of non-urgent ED presentations. However, further research that incorporates causative study designs is required.
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Hautz WE, Sauter TC, Hautz SC, Kämmer JE, Schauber SK, Birrenbach T, Exadaktylos AK, Stock S, Müller M. What determines diagnostic resource consumption in emergency medicine: patients, physicians or context? Emerg Med J 2020; 37:546-551. [PMID: 32647026 PMCID: PMC7497575 DOI: 10.1136/emermed-2019-209022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVES A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients' health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption. METHODS Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression. RESULTS In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians' ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and-less surprising-on patients' acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients' chronic health status or the context seems to have a measurable impact (all p>0.05). CONCLUSIONS Diagnostic resource consumption in the ED is heavily affected by physicians' situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.
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Affiliation(s)
- Wolf E Hautz
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland.,Center for Educational Measurement, University of Oslo, Oslo, Norway
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland.,Medical Skills Lab, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephanie C Hautz
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland
| | - Juliane E Kämmer
- Center for Adaptive Rationality, Max-Planck-Institut fur Bildungsforschung, Berlin, Germany.,Institute of Health and Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan K Schauber
- Center for Educational Measurement, University of Oslo, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland
| | | | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, Cologne, University Hospital of Cologne, Cologne
| | - Martin Müller
- Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland .,Institute of Health Economics and Clinical Epidemiology, Cologne, University Hospital of Cologne, Cologne
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El-Masri M, Bornais J, Omar A, Crawley J. Predictors of Nonurgent Emergency Visits at a Midsize Community-Based Hospital System: Secondary Analysis of Administrative Health Care Data. J Emerg Nurs 2020; 46:478-487. [DOI: 10.1016/j.jen.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 12/01/2022]
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14
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Whitehouse DP. Streaming patients from emergency to primary care: to what degree do patients self-triage? BMJ 2020; 369:m1402. [PMID: 32265197 DOI: 10.1136/bmj.m1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- D P Whitehouse
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Colineaux H, Pelissier F, Pourcel L, Lang T, Kelly-Irving M, Azema O, Charpentier S, Lamy S. Why are people increasingly attending the emergency department? A study of the French healthcare system. Emerg Med J 2019; 36:548-553. [DOI: 10.1136/emermed-2018-208333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 06/12/2019] [Accepted: 06/20/2019] [Indexed: 11/04/2022]
Abstract
ObjectiveIt is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types.MethodsThis observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients’ condition during ED visit was determined through the ‘Clinical Classification of Emergency’ score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures.ResultsThe 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes.DiscussionIt appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.
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Gordon-Shaag A, Zimmerman DR, Shneor E. The epidemiology and treatment of conjunctivitis at Urgent Care Centres in Israel. Clin Ophthalmol 2019; 13:771-779. [PMID: 31118555 PMCID: PMC6504553 DOI: 10.2147/opth.s202362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/04/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose: Conjunctivitis is the most common ocular condition diagnosed at emergency departments (ED) in the USA, although it is generally not an emergent condition. Treatment of conjunctivitis at Urgent Care Centres (UCC) could offer lower cost than ED. This study describes the demographics and outcomes of a cohort presenting with conjunctivitis to a nationwide UCC system. Methods: This retrospective study included 17 branches of UCC. Electronic Medical Record data (November 2015–October 2016) of patients diagnosed with conjunctivitis or ocular disorder were retrieved. Data included gender, age, diagnosis, treatment, discharge status and temperature. Patients without conjunctivitis, presenting to UCC during this period served as the control. Results were compared to all ED patients in Israel (from a public report). Descriptive statistics, Chi-square and Z-proportion test were used. Results: Altogether, 602,074 patients presented to UCC, of which 5,045 (0.84%, 95% CI 0.74–0.94%) were diagnosed with conjunctivitis. Conjunctivitis was more prevalent among young males (0–14, p<0.001) and older females. The conjunctivitis cohort at UCC was significantly younger than the ED cohort (p<0.01). UCC treated and released home 96.7% (95% CI 96.2–97.2%) of cases. This is significantly higher than the treatment rate for the entire UCC cohort (93.2%, CI 93.2–93.3%, p<0.05). Treatment in most cases (82.0%, 95% CI 80.9–83.0%) involved the prescription of ocular antibiotic. Conclusion: Similar to previous studies at ED, conjunctivitis patients are primarily young males. Most patients were treated with antibiotics at UCC and released home. This suggests that UCC may be a good venue for treatment of conjunctivitis.
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Affiliation(s)
- Ariela Gordon-Shaag
- Department of Optometry, Hadassah Academic College, Jerusalem 9101001, Israel
| | | | - Einat Shneor
- Department of Optometry, Hadassah Academic College, Jerusalem 9101001, Israel
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Whyatt D, Tuson M, Haynes E, Mountain D, Nagree Y, Vickery AW. Burden of primary care‐type emergency department presentations using clinical assessment by general practitioners: A cross‐sectional study. Emerg Med Australas 2019; 31:780-786. [DOI: 10.1111/1742-6723.13255] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/20/2018] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
- David Whyatt
- Division of General Practice, Medical School, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - Matthew Tuson
- Division of General Practice, Medical School, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - Emma Haynes
- Division of General Practice, Medical School, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - David Mountain
- Division of Emergency Medicine, Medical School, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - Yusuf Nagree
- Division of Emergency Medicine, Medical School, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - Alistair W Vickery
- Division of General Practice, Medical School, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
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Lawton R, Robinson O, Harrison R, Mason S, Conner M, Wilson B. Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England. BMJ Qual Saf 2019; 28:382-388. [PMID: 30728187 PMCID: PMC6560462 DOI: 10.1136/bmjqs-2018-008390] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/03/2022]
Abstract
Background Risk aversion among junior doctors that manifests as greater intervention (ordering of tests, diagnostic procedures and so on) has been proposed as one of the possible causes for increased pressure in emergency departments (EDs). Here we tested the prediction that doctors with more experience would be more tolerant of uncertainty and therefore less risk-averse in decision making. Methods In this cross-sectional, vignette-based study, doctors working in three EDs were asked to complete a questionnaire measuring experience (length of service in EDs), reactions to uncertainty (Gerrity et al, 1995) and risk aversion (responses about the appropriateness of patient management decisions). Results Data from 90 doctors were analysed. Doctors had worked in the ED for between 5 weeks and 21 years. We found a large association between experience and risk aversion so that more experienced clinicians made less risk-averse decisions (r=0.47, p<0.001). We also found a large association between experience and reactions to uncertainty (r=−0.50, p<0.001), with more experienced doctors being much more at ease with uncertainty. Mediation analyses indicated that tolerance of uncertainty partially mediated the relationship between experience and lower risk aversion, explaining about a quarter of the effect. Conclusion While we might be tempted to conclude from this research that experience and the ability to tolerate uncertainty lead to positive outcomes for patients (less risk-averse management strategies and higher levels of safety netting), what we are unable to conclude from this design is that these less risk-averse strategies improve patient safety.
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Affiliation(s)
- Rebecca Lawton
- Institute of Psychological Sciences, University of Leeds, Leeds, UK .,Quality and Safety Research, Bradford Institute for Health Research, Bradford, UK
| | | | | | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mark Conner
- School of Psychology, University of Leeds, Leeds, UK
| | - Brad Wilson
- Accident and Emergency, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Rees N, Porter A, Rapport F, Hughes S, John A. Paramedics' perceptions of the care they provide to people who self-harm: A qualitative study using evolved grounded theory methodology. PLoS One 2018; 13:e0205813. [PMID: 30332480 PMCID: PMC6192640 DOI: 10.1371/journal.pone.0205813] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 10/02/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Self-harm (SH) accounts for over 5% of the workload of emergency ambulance services, and therefore Paramedics are often the first health professional in contact with people who SH. The authors of this paper have reported elsewhere the significant gaps in our understandings which exist surrounding this early care interaction, and some of the challenges paramedics and opportunities in paramedic care for people who SH. This study aimed to explore paramedics' perceptions of caring for those who SH using Evolved Grounded Theory Methodology. METHODS This study took place between 2014-2016 in one UK ambulance service covering a population of three million people. Semi structured interviews were conducted, purposively sampling paramedics until saturation was reached. Interviews were recorded, transcribed verbatim, and coded through open, axial, and selective levels of coding, identifying the Basic Social Process (BSP) and developing a Grounded Theory. A second researcher (SH) independently reviewed early results, which were also member-checked with participants. RESULTS Eleven paramedics were interviewed. The following six categories emerged: Context; Judgements and values; Isolation and system failure; Managing risk; Competence at the boundary of mental and physical health needs; Professional, legal and ethical tensions. The BSP Decision making in a context of risk was identified. The final Grounded Theory that emerged was one of 'Wicked Complexity of paramedic care for people who SH, which includes usual factors such as tiredness and frequent callers, heightened factors including lack of support and pathways, and factors specific to SH such assessing mental health and suicide risk. CONCLUSIONS This study builds on a very small body of literature to have explored paramedic care for people who SH and has found that this care interaction provides uniquely complex challenges. The multiple influences within the categories defined in this study need considering conjointly when making improvements to care.
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Affiliation(s)
- Nigel Rees
- Pre Hospital Emergency Research Unit (PERU), Institute of Life Sciences, Swansea University, Swansea, Wales, United Kingdom
| | - Alison Porter
- Institute of Life Sciences, Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Sarah Hughes
- Abertawe Bro Morgannwg University Health Board, Princess of Wales Hospital, Bridgend, Wales, United Kingdom
| | - Ann John
- Farr Institute, Swansea University Medical School, Swansea, Wales, United Kingdom
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