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Potentially avoidable emergency department attendance: interview study of patients' reasons for attendance
  1. S Agarwal1,
  2. J Banerjee2,3,
  3. R Baker1,
  4. S Conroy4,
  5. R Hsu5,6,
  6. A Rashid6,
  7. J Camosso-Stefinovic1,
  8. P Sinfield1,
  9. M Habiba4
  1. 1Department of Health Services, NIHR CLAHRC for LNR, University of Leicester, Leicester, UK
  2. 2Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
  3. 3NHS Leicester Leicestershire and Rutland, Leicester, UK
  4. 4Cancer Studies, University of Leicester and Associate Medical Director, Leicestershire County and Rutland PCT, Leicester, UK
  5. 5Department of Medical and Social Care Education, University of Leicester, Leicester, UK
  6. 6Leicestershire County and Rutland PCT, Leicester, UK
  1. Correspondence to Shona Agarwal, NIHR CLAHRC for LNR, Department of Health Sciences, University of Leicester, 22-28 Princess Rd West, Leicester LE1 6TP, UK; sa144{at}le.ac.uk

Abstract

Objectives To explore the reasons for attendance at the emergency department (ED) by patients who could have been managed in an alternative service and the rate of acute admissions to one acute hospital.

Design Interview study.

Setting One acute hospital (University Hospitals of Leicester) in the East Midlands.

Participants 23 patients and/or their carers.

Methods A purposive sample of patients attending the ED and the linked urgent care centre was identified and recruited. Patients in the sample were approached by a clinician and a researcher and invited to take part in an interview. Patients of different ethnicities and from different age groups, arriving at the ED via different referral routes (self-referral, emergency ambulance, GP referral, out-of-hours services) and attending at different times of the day and night were included. The interviews were recorded and transcribed with the individuals' permission and analysed using the framework analysis approach.

Results Patients' anxiety or concern about the presenting problem, the range of services available to the ED and the perceived efficacy of these services, patients' perceptions of access to alternative services including general practice and lack of alternative pathways were factors that influenced the decision to use the ED.

Conclusions Access to general practice, anxiety about the presenting problem, awareness and perceptions of the efficacy of the services available in the ED and lack of alternative pathways are important predictors of attendance rates.

  • Admission avoidance
  • emergency care systems
  • emergency departments
  • primary care
  • general
  • fractures and dislocations
  • systems
  • accidental falls
  • acute medicine-other
  • paediatrics
  • paediatric emergency medicine
  • cost effectiveness
  • education
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Introduction

Total attendances to emergency departments (EDs) in England have risen from 14.3 million in 2000/1 to 20.5 million in 2009/10.1 Potential explanations for the rise in admission rates include the changing provision of primary care out-of-hours services and changing patterns of illness in the population.2 The continuing rise in the numbers of older people with long-term conditions and consequent disability also contributes to the continuing annual increase in attendance rates.

In analyses of ED attendance rates, increasing socioeconomic deprivation, increasing patient age, smaller practice list size and lower reported satisfaction with practice telephone access were associated with higher use of the ED.3 However, with increasing distance of the patient's general practice from the hospital, the ED attendance rates fell. The rate of emergency hospital admissions also increased with increasing socioeconomic deprivation, patient age and closer proximity to the hospital, but decreased if patients reported greater satisfaction with being able to get an appointment with a particular general practitioner (GP).4 Higher continuity of care with a GP is associated with a lower risk of admission for all age groups.5 Although factors such as perceived difficulties with access to general practice and distance from the hospital appear to influence peoples' decisions to attend an ED,6 the precise reasons and circumstances leading to attendance are not clear from quantitative studies.

In a study of attendees at EDs in Wales, 44% of 321 patients considered their GP inaccessible, reporting that waiting for a GP appointment would take too long or was less convenient than attending the ED, or that the practice was closed.7 In a study of 200 patients admitted to hospital in Bristol, attendance at an ED was more common when help was sought by a bystander, and most patients attended the ED because of perceived severity or urgency of their condition.8 However, a study of EDs in New South Wales, Australia showed that the perceptions of health professionals of the reasons why patients attend EDs may not reflect the reasons given by patients themselves.9 While most patients gave the urgency of their problem as the reason for attending the ED, health professionals identified—in addition to convenience—the desire for a second opinion. However, these studies did not involve detailed qualitative interviews of patients.

In this study we explored the reasons for attendance at the ED and the emergency admission rate to one acute hospital (University Hospitals of Leicester) in the East Midlands. A description of health services available in Leicestershire is given in table 1.

Table 1

Health services available to the public in Leicestershire

Methods

The study took place at the University Hospitals of Leicester NHS Trust (UHL), the major provider of unscheduled hospital services (ED attendances and emergency admissions) in Leicestershire. In the 12 months from August 2008 to July 2009 there were 145 000 ED attendances, 72% occurring between 09:00 and 21:00 h. Over 95% of those attending the UHL ED have a GP in either Leicester City PCT or Leicestershire County and Rutland PCT. In addition to the primary care out-of-hours service, there are alternative services for patients with minor problems including two walk-in centres in Leicester, an urgent care centre (UCC) based at the Leicester Royal Infirmary and a walk-in centre in the town of Loughborough, 12.6 miles from UHL.

We identified and recruited a purposive sample of patients attending the ED and the adjoining UCC. Patients in the ED were recruited by the researcher based on the initial assessment by an experienced consultant in emergency medicine with extensive knowledge of local service provision who was asked to identify patients suitable to be cared for in an alternative urgent care provider service including primary care. This type of purposive non-probability judgemental sampling, taking account of the patient's presenting problem and also the alternative local services available, was chosen to demonstrate that this trait was present in the study population—that is, patients were attending the ED with urgent care needs that could be managed in other urgent care environments locally. The subsequent purpose of the study was to explore the reason for such an attendance. Several patients were recruited from the UCC situated alongside the ED. The ED and the UCC had set up a diversion scheme of patients 3 weeks prior to the commencement of this study. Patients who walked into the ED reception were streamed into the UCC, prior to being booked in, by a senior nurse or emergency care practitioner based on their experience and a set of criteria agreed between the services. This cohort therefore represented patients typical of those attending most EDs. If patients attended the ED with a carer, we interviewed the carer as well.

We aimed to include patients of different ethnicities and from different age groups, arriving at the ED via different referral routes (self-referral, emergency ambulance, GP referral, out-of-hours service, NHS direct) and attending at different times of the day or night. Semi-structured qualitative interviews were undertaken with consenting patients and their carers. A patient interview topic guide was developed from a literature review, the quantitative analyses we had undertaken3 ,4 and discussion among the research team. Patients were asked about their reasons for attending—that is, their initial presenting condition, their route to attendance (who was contacted and what happened next), whether they had considered or tried to see their GP prior to attending the ED, and the alternative services available to them in addition to the ED. The topic guide was extended as interviews progressed to explore additional topics/questions that emerged.

The interviews were recorded and transcribed, and analysed using the framework analysis approach.10 This approach develops a hierarchical thematic framework that is used to classify and organise data according to key themes, concepts and emergent categories. It was used to explore, compare and contrast key themes arising from the interview data, using the elements of the interview topic guide as a starting point. Analysis was undertaken by two authors (SA and RB) who compared and contrasted themes and issues between interviews. We sought to understand the reasons for the decision to attend the ED and to identify factors that could have led to avoidance of ED attendance when appropriate.

Results

Twenty-three interviews were conducted with patients and/or their carers, four of whom had attended the ED and been transferred to the UCC. The characteristics of the patients are shown in table 2. Three patients had attended the ED after 22:00 h. Three patients presented with chest pain, seven with abdominal symptoms, two with back pain, two with dizziness, two had collapsed or fainted and two had a fall. Other symptoms reported included a headache, cellulitis, palpitations, overdose and depression. These presentations are representative of the common presenting complaints to the ED at UHL.

Table 2

Characteristics of included patients (n=23)

Four main themes emerged from the interviews that are pertinent to patients' decisions to attend the ED: (1) anxiety about their health and the reassurance arising from familiarity with knowledge of the emergency service; (2) issues surrounding access to general practice; (3) perceptions of the efficacy of the service; and (4) lack of alternative approaches to care.

Anxiety and familiarity

Most patients or their carers reported anxiety or concern about the presenting problem. Because he collapsed at home this morning and I rang 999 because I was concerned and didn't know what to do. (Carer of patient 16, male, aged 60) I made the decision to phone for a paramedic who came out, which I thought was the best thing, I wouldn't bother them unless I was worried. (Son of patient 4, male, aged 80)

Some patients had contacted NHS Direct and did have regular contact with their GP but, despite this, they had become anxious about the presenting problem and believed it needed dealing with quickly. I had to call my son to come and arrange something for me. I was going to call the GP or ambulance but he said no ambulance is the best, because if you need to be taken they will take you straight away. (Patient 10, male, aged 64)

Familiarity with the ED and the services available to them was important to patients and carers who were worried and, in some cases, it was the carer who took the initiative to seek help. Everybody knows about hospital, 999 or go to GP. (Patient 10, male, aged 64) This was the best place I thought to phone. (Patient 11, male, aged 69) Absolutely the best place to be. (Patient 17, female, aged 35)

Furthermore, the patients we interviewed did not report having any plans agreed with their usual providers on what to do if an acute problem arose. Patients did not express concern about using the ED unnecessarily; they viewed their use of the ED as legitimate and justified. There was a general acceptance that, when anxiety about an illness reached a level of urgency, the ED was the natural service to attend.

Access to general practice

Several patients had tried to get an appointment with their GP but had been unable to. Being distressed or concerned about their problem, they had chosen to attend the ED. I called the GP to get an appointment but couldn't get in so I didn't know what else to do or where else to go. I turned up at the emergency department and they diverted me to the urgent care centre (Patient 23, male, aged 63)

In some cases access was a problem because the practice was closed in the afternoon. Yes, I tried to get in to see the GP this morning but couldn't get in. Usually they are quite good but I guess it was Thursday and the surgery is only open for half a day, they get quite busy. (Patient 22, female, aged 65) Yeah, I tried to see the GP this morning, it's only open on Wednesday mornings and I couldn't get an appointment, not even an emergency one. (Patient 21, female, aged 29)

Access could also be a problem out-of-hours. The emergency number that the answering machine gave me redirected me back to the surgery, and it just kept looping me around so my ex-husband, I think he just panicked and called an ambulance. (Patient 18, female, aged 41) Regarding this time of the morning, they are not even open, it's hard getting an appointment with the GP. (Patient 1, male, aged 46)

The timeliness of an appointment at the general practice also led patients to choose the option of the emergency department. For NHS Direct, I did the online survey, which said ring them up and then they said try your doctor to see if you can get in within 1 or 2 h. Rang them up and they said 15:30 was the earliest they could get me in at 9:00 this morning, so that was 6½ h, so they said to come down here. (Patient 3, male, aged 25)

The relative ease of getting to the ED was important for some patients, for example the proximity to the patient's place of work or difficulty of walking to the general practice. I was feeling a lot nervous, I was on my way to work so I thought that I would just pull in, just in case anything else goes wrong. (Patient 1, male, aged 46)

Perceptions of efficacy of the service

In some cases patients or their carers regarded the ED as having the required range of services. For example, in some cases patients with chronic conditions had been under the management of the hospital outpatient clinics and saw attending the ED as the quickest way to obtain help once a new problem occurred. Even when an alternative hospital close to the patient's home might have been more appropriate for dealing with the presenting problem, they preferred to attend the hospital that cared for their other problems. They were thinking of sending me somewhere in the Rugby area but, no, I want the Leicester Royal, well they have got all my records here, I attend the Diabetic Clinic, I attend the Opthalmology Clinic. (Patient 15, female, aged 85)

Attending the ED was also seen as an opportunity to be thoroughly investigated in situations when ongoing care with a GP did not seem to be leading to improvement. I just thought that if I came straight here they might be able to do something with tests or exams, if I went to the doctors, I don't know if he would just put me on a different course of medication, see how it goes, I could be in pain again. I just feel that there is something more than what the doctor was saying it was, so I felt that after going there twice, I think I needed to come here, yeah I felt that was the better option. (Patient 20, female, aged 35)

Lack of alternative pathways

Patients had often received some help from services in the community prior to attending the ED, but this help was regarded as inadequate or unable to fully cope with the perceived complexity of the problem. In some cases they had telephoned or been to see the GP and been advised to go to the ED. The GP rang through as well, because she had had all these medical conditions, obviously the risk is there, so it's best that we were told that we ring the emergency departments, yeah that's what the GP said to come here. (Patient 6, female, aged 75) On the Friday I had pain on my hand and slightly on the chest and dizziness. I had been to the doctor this morning and the GP told me to come here. (Patient 7, female aged 55)

In other cases a paramedic or ambulance had been called and the assessment by these services led to transfer to the ED. So they sent for an ambulance as his blood pressure was very, very low, the doctor and the ambulance people thought it was better to come here, even if it's only for a few hours for them to keep their eye on him. (Patient 12, female, aged 82) I think somebody more qualified than me and that's why I called the paramedic out but, yes, I mean we could have called the doctor, he would have come out afterwards, but I couldn't leave him there laying. (Patient 4, male, aged 80)

Discussion

In this study we interviewed a sample of patients attending a single ED who had been identified by clinical staff as potentially suitable for management by another service. The findings indicated that perceptions of access to alternative services including general practice, patients' perceptions of the range of the services available in the ED and the perceived efficacy of these services, and lack of alternative pathways were factors that influenced the decision to use the ED. In addition, patients or carers were worried about the presenting illnesses and sought reassurance or confidence by turning to services of which they had prior knowledge. The findings indicate that steps to improve perceptions of access to and effectiveness of alternative services and the ability of these services to undertake more detailed assessments without delay might be strategies worth investigating to reduce the number of patients attending the ED.

There are a number of limitations to this study. It was undertaken in only one ED and the findings may not be generalisable to other centres as local provisions may vary. For example, the availability of different alternative providers in other localities would determine which patients could be managed elsewhere rather than in the ED. We interviewed a range of patients but did not include children or their parents, and there may be other groups of patients not included in our sample who had other reasons for using the ED. Furthermore, our sample only included patients whose ED clinician thought they might have been able to safely use an alternative source of care for the problem. Despite these qualifications, the study has identified a number of factors that help explain the decision by patients and carers to use the ED.

In other work we have shown associations between patients' perceptions of access to general practice and the use of the ED.4 Other research has also highlighted this association.7 The proportion of patients attending EDs who do so because of difficulty accessing general practice is not clear from this study, but the finding from the interviews tends to suggest that perceptions of poor access in general practice cause some patients to attend EDs. Intervention studies are required to confirm causation and the effectiveness of improved access in general practice on ED attendance rates.11

Our findings throw light on the decision making of patients and their carers and show that other services—including GPs and NHS Direct, paramedics and ambulance staff—are also involved in decision making. Consequently, the development of processes to assess patients more thoroughly in the community may have the potential to avoid transfer to the ED. Precisely how community services for patients with urgent problems can be restructured or interact more effectively and how they should be organised to deliver cost-effectiveness is unclear, but the potentially confusing network of services many patients encounter before attending the ED does suggest that better integration of services coupled with rapid assessment, standardised management plans and short-term observation at home might help to avoid some ED attendances.12

Attendance at an ED when anxiety about health reached a sufficient level and when the problems become urgent seemed generally accepted among the patients interviewed. However, patients did not have a pre-existing conception of what conditions are appropriate for the ED. It is possible that prior education or agreements with their GPs on what to do when faced with an acute problem might reduce reliance on the ED. This finding suggests that more might be done to educate patients and their carers—especially those with established health problems and those at risk of experiencing acute problems—on what service to call on if a problem arises and what problems are appropriate for EDs. Before interventions such as these are widely adopted, however, evaluation studies are required to determine their cost effectiveness.

Conclusion

The patients in this study indicated that their attendance at the ED was influenced by a perception of lack of access to general practice, their anxiety or concern about the presenting problem, their awareness of the range of services available in the ED and their perceived efficacy and the lack of alternative pathways. Steps to reduce attendance should focus on improving access to general practice. Educating patients on the appropriateness of ED attendance and accessing alternative services is of unproven benefit in most areas except chronic disease management.13 Reorganisation of primary care response to urgent care and its impact on patient attendance at EDs and hospital admission need to be studied to appreciate its clinical and cost effectiveness.

References

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Footnotes

  • Funding This study is part of a programme of research funded by the National Institute of Health Research (NIHR) which is being undertaken by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Leicestershire, Northamptonshire and Rutland (LNR). The views expressed in the paper do not necessarily reflect those of the Department of Health or the NIHR. The funder had no role in study design, collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication. All the researchers had access to the data.

  • Competing interests MH is an employee of Leicestershire County and Rutland Trust, and JB and MH are employees of University Hospitals of Leicester Trust that might have an interest in the submitted work in the previous 3 years.

  • Patient consent A patient and carer consent form was designed by the team and was used to obtain consent.

  • Ethics approval The study was a service evaluation. NHS ethics committee approval was not required, but we sought and obtained approval from the Medical Directorate Safety, Effectiveness and Audit Committee at UHL.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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