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Why do patients with minor or moderate conditions that could be managed in other settings attend the emergency department?
  1. Robert Penson,
  2. Patricia Coleman,
  3. Suzanne Mason,
  4. Jon Nicholl
  1. ScHARR, University of Sheffield, Medical Care Research Unit, Sheffield, UK
  1. Correspondence to Patricia Coleman, Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA, UK; p.coleman{at}sheffield.ac.uk

Abstract

Objectives To estimate the potential of alternative providers of care for minor health problems to reduce demands on emergency departments (EDs).

Methods Data were collected in a type 1 urban ED over a 2-month period in two stages: questionnaire to adult attendees presenting to the ED; and a notes review.

Results The usable response rate was 68% (n=261/384). The notes review confirmed that more than two-thirds of the presenting conditions could have been managed in settings other than the ED. The attendees' reasons on the questionnaire indicated a strong belief that the only provider able to deal with their concerns at that time was the ED. For some users, the ED was not the first contact with a healthcare provider for the same health problem. Few believed that they would be seen quicker in the ED or that the ED was more convenient. The most frequent reason for presenting to the ED was ‘being advised to attend by someone else’. The ‘adviser’ was more likely to be a health professional (doctor or nurse or NHS Direct) than to be ‘friends or family’.

Conclusions Although there appears to be considerable potential for minor conditions to be managed in settings other than the ED, our findings indicate that patients will continue to present these conditions to the ED. Patient perceptions of the urgency of their treatment need, and also the availability and capacity of alternative services may be offsetting their potential to substitute for the ED. Advice from other services may be contributing to demands on the ED.

  • Emergency services utilisation
  • patients health beliefs
  • help seeking behaviour
  • minor health conditions
  • appropriateness
  • emergency care systems
  • intermediate care
  • emergency departments
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Background

In the past 10 years, despite the growing availability of different models of urgent and immediate care in the UK, emergency department (ED) demands have continued to rise.1 Using various criteria, the proportion of relatively minor health problems seen in EDs that could be treated in other settings has been estimated previously to be between 10% and 62%.2 3 Since 1997 the configuration of immediate care services nationally has changed.4 ‘Walk-in’ health facilities5 and telephone advice services6 have been expanded. Newly extended clinical roles, for example nurse practitioners7 and emergency care practitioners,8 have increased patient choice and supplemented the healthcare workforce. In 2004, the new general practitioner (GP) contract introduced changes in primary care affecting the organisation and delivery of out of hours care.9 There have also been several initiatives to improve the quality of patient care in EDs, including the 4-hour standard.10 Given that some of the new services and changes to acute provision have been established for several years, we examined the reasons why patients continue to present minor health problems to the ED.

Objectives

By examining a ‘subjective’ measure of the reasons why patients present with minor health problems to the ED against ‘objective’ criteria of the suitability of the case to be managed in a setting other than the ED, this study estimated the likelihood that alternative providers of care for minor and moderate health problems could reduce demands on EDs in the future.

Methods

The two-stage methods repeated those developed previously.3 The study took place in a single type 1 urban ED during September and October 2006. The department sees approximately 96 000 adult attendees per annum. Just under two-thirds of these have been estimated previously to be low treatment priority.3 For the study period of 4 weeks, a sample of 384 attendees was estimated to be sufficient to enable the percentage of patients presenting conditions that were suitable to be managed by services other than the ED with 95% confidence ±5%, assuming that the true proportion is 10% (http://www.surveysystem.com/sscalc.htm). Data were collected by: (1) a patient questionnaire; and (2) a clinical notes review. A children's ED is located on another site, however the study ED will accept attendees from age 14 years. A minor injury unit (MIU) is located within the study ED. Patients are advised when registering at the ED reception that they can self-refer to the MIU before being triaged in the ED if they wish to do so. After assessment, patients preferring to be seen by the triage nurse are directed to either the minors or majors waiting area. Patients were recruited into the study by the researcher or the triage nurse who handed out a questionnaire to consenting patients to complete on arrival. The questionnaire asked patients to indicate their reasons for presenting to the ED. It also asked about their awareness of other local providers and perceptions of the suitability of those services to manage the presenting health problem. Data collection took place during four consecutive weeks in September and October 2006. The weeks were divided using a Latin-square two-dimensional grid into 32 predetermined time periods that rotated daily to cover the 24 hours. Completed questionnaires were collected by either the principal researcher (RP) or clinical staff in the ED. The notes review collected information directly from ED records about the presenting condition, investigations, treatment and disposal. All the notes reviews were undertaken by the researcher (RP).

Classification of patients' reasons for attending the ED

We used the same ‘subjective’ measure of the likelihood that in similar circumstances a patient would present to a provider other than the ED developed in a previous study.3 In that study each reason on the questionnaire was assigned independently by three members of a panel (consisting of two non-clinical researchers and an emergency medicine registrar), into ‘strong’, ‘medium’ and ‘weak’, according to whether the individual panel member felt the reason was likely to affect future health-seeking behaviour. If all three members of the panel agreed on the rating for a particular reason, this was adopted. Differences between members of the panel were resolved through group discussion. The ‘strength of reason’ ratings were analysed to estimate the likelihood that the patient would present with similar health problems to the ED in the future. If a patient included a ‘strong’ reason for presenting to the ED (ie, a low likelihood of changing consulting behaviour in the future), this took precedence over any other reasons that patient may have included.

Objective classification of the suitability of the presenting problem to be treated by a provider other than the ED

Using the diagnoses and process data recorded in the ED notes, we applied algorithms to the information collected for each case to assess whether it could have been managed in a primary care setting, or nurse-led service such as a walk-in centre (WIC), NHS Direct or self-care. The algorithms for GP care, minor injury, WIC and self-care were developed in previous studies3 11 (box 1).

Box 1

Objective criteria for identifying potential care pathway for conditions presented to an emergency department (ED)

  • Suitable for treatment in general practice

    • Self-referred

    • Registered with a GP

    • Not an accident except at home

    • No treatment other than a prescription, or a dressing, sling, bandage, or steri-strip, or advice

    • No investigations

    • Discharged home or to GP

  • Suitable for treatment in a minor injury unit remote from ED

    • Self-referred

    • Comparison of the description of the health problem given by the patient shortly after their arrival in the ED, and the nurse practitioner protocols in use at a minor injury unit on a different Trust site in the city

    • Not referred to other hospital services on the day of attendance

    • Availability of the minor injury unit service (08:00–20:00 h×7 days/week) at time of registration

  • Suitable for treatment in a walk-in centre remote from ED

    • Self-referred

    • No treatment other than a prescription in line with nurse practitioner protocols, or a dressing, sling, bandage, or steri-strip, or advice

    • No hospital-based investigation services (eg, x-ray, CT scan, etc)

    • Not referred to other hospital services on the day of attendance

    • Availability of the walk-in service (07:00–22:00×7 days/week) at time of registration

  • Suitable for advice from NHS Direct to self-care

    • Self-referred

    • Access to a telephone at home if the health problem occurred in the home

    • No investigations or prescription of medicine

    • No treatment other than advice

    • No known barriers (language or health problems) prohibiting use of the telephone

    • Discharged home

  • Suitable for treatment in an ED setting

    • ‘Default’ of not meeting the criteria for inclusion elsewhere

Analyses

We compared the results of the objective classification of the health problem to be managed in settings other than the ED with the subjective measure of the likelihood that, in similar circumstances, the patient would present to the ED. The sample of responses were weighted so that age, gender, location seen, and period reflected that of the population of moderate or minor attendees at the study site. Statistical analyses were performed using Excel and SPSS V.12.0. Validity was tested using the Pearson χ2 and Student t test when appropriate.

Ethical approval

The study was approved by the Doncaster NHS Research Ethics Committee. A condition of the approval was that participants had to sign separate consent forms for each part of the study—that is, the self-completed questionnaire and the review of the ED notes for that visit.

Results

Achieved samples

A total of 291 attendees were recruited initially into the study; 285 completed or partly completed questionnaires (74% of the target of 384) were returned. Table 1 shows the basic demographic characteristics of the 261/285 (68%) responders who provided sufficient usable information. For these, 232 sets of notes were retrieved for review.

Table 1

Demographic profile of sample

Awareness of other services

Depending on whether the other service was NHS Direct, GP out-of-hours or a WIC, between 30% and 50% of responders reported that they did not know either that the service existed or that it was available.

Previous consulting behaviour for the same health problem

For a significant proportion of responders (n=86/285, 30%), the ED was not the first contact or attempted contact with health services for the same health problem. Of those patients who reported seeking or attempting to seek advice before presenting to the ED (n=86/285, 30%), most (n=37/86, 43%) sought advice from primary care clinicians including GPs or nurse-led facilities. NHS Direct was given as the source by 15 (17%). Some participants reported seeking advice previously from as many as five providers. Seeking advice from friends and family was cited by 14.5% of responders.

Objective measures of appropriateness

Just under one-third of the achieved sample presented with health problems that required the services available only in an ED (30.4%). The health problems of over two-thirds (69.6%) did not require the resources of a type 1 ED. Overall, on a strict application of the ‘Sheffield algorithm’11 (box 1), 29.2% of presenting conditions were suitable to be treated by a GP.

Patients' reasons for attending the ED

The proportion of participants considered to have given a ‘strong’ reason for presenting to the ED (ie, a reason judged to have a low likelihood of behaviour change) was 82%. Fifty-seven (22.2%) reported presenting to the ED because they suspected they had a fracture, and 84 (32%) believed they needed a radiograph. The proportions who included in their reasons that ‘they would be seen quicker at the ED’ (5.5%) or who reported that ‘the ED was easier to get to than other services’ (6.5%), was low. The most frequent reason given by patients for attending the ED was ‘being advised to attend by someone else’. The reported source of the advice was more likely to be from a health professional or other person or agency in authority than from ‘friends or family’. Just over a third of responders (35%) expressed a wish ‘to see a doctor as soon as possible’. Almost 10% were seeking a ‘second opinion’. A reason cited by 16% of responders was that ‘my GP was unavailable’ (table 2).

Table 2

Classification of reason for attending the emergency department (ED)

Discussion

Using objective criteria, potentially over two-thirds of minor or moderate health problems presenting to this type 1 urban ED could have been managed effectively by other providers in alternative settings or self-care. Our data suggest that attendees are not presenting to the ED because it is more convenient than other services or because they expect to be seen quicker. The proportion of attendees reporting that they consulted or tried to consult at least one other healthcare provider before attending the ED (and reports that [their] ‘…GP was not available’ or ‘I wanted to see a doctor as soon as possible’ or ‘I wanted a second opinion’), indicates that availability or the perceived availability of primary care services for immediate care may be contributing to demands for ED services. Reports that the main source of advice before presenting to the ED was from NHS Direct or another health professional (GP or nurse) may be offsetting the potential for other services to substitute for the ED.

The proportion in our sample who reported seeking a radiograph among their reasons for attending the ED indicates that the ability of providers of urgent care that do not have on-site access to diagnostic facilities, such as x-ray or the capacity to interpret them, to reduce ED attendances, may be limited.

The proportion of 30% of our sample reportedly seeking help elsewhere before attending the ED (some from as many as five providers) suggests the need for closer integration or co-location of urgent care providers within a wider system of care.12

Strengths and weaknesses of methods

The achieved sample of 285 questionnaires fell short of the target of 384. This was due to initial lapses in the recruitment process due to changes in triage staff rotas, resulting in fewer invitations being made rather than refusals by patients to take part. However, a usable response rate of 68% (n=261/384) is reasonable. The difference between the numbers of usable questionnaires (n=261) and the fewer numbers of notes reviewed (n=232) arose because some participants did not sign the consent to their notes being reviewed. We have no way of knowing whether this was an oversight or objection by patients to their notes being reviewed. Although this is a small study conducted in one ED and the findings may not be transferable, there is no reason to assume that the study ED and the configuration of alternative emergency and urgent care provision locally is atypical of type 1 urban EDs elsewhere. Within time limits (2–3 months recall period), patient self reports of consulting behaviour have been found to be reliable.13 14 Our achieved sample was weighted to represent the population with minor and moderate conditions presenting to this ED. All ambulatory ED patients enter and leave by the same door, but some patients are informed at reception that they can self-refer to the minor injury service before being triaged in the ED if they wish to do so. Patients who have attended this ED previously and are familiar with the MIU option may be encouraged to present to the ED knowing that once there they will be offered the option of the MIU with the resources of the ED in the immediate proximity. Our study was undertaken in 2006 which predates the urgent care centres15 or GP-led health centres16 that became available in many areas of the UK from 2008. Although we are confident that our findings are reasonably robust, it would be interesting to repeat our study in more Trust areas with a larger patient sample to examine whether our results are generalisable to other sites over time.

Comparability with other studies

We found no consistent link between patients' perceptions of the suitability of their health problem to be presented to services other than the ED, and an ‘objective’ view informed by reviewing the care processes and disposal decisions recorded in the ED notes. Most patients in our sample were judged to have a ‘strong reason’ for believing that the ED was the only appropriate provider for their health problem. Our findings confirm those of previous studies that health professionals and patients judge the severity and urgency of a condition differently.3 Our estimate that two-thirds of the minor and moderate conditions could be treated in settings other than the ED is higher than the 55% reported in a previous study conducted in the same ED in 1997 using the same methods.3 Our estimate that 29% of presentations were suitable for GP care is also higher (29% vs 10%). The finding that in 2006 a higher proportion of cases suitable for primary care was presenting to the ED than reported previously, confirms the findings of a recently published study covering the same period.17

The reported lack of awareness of nurse-led services such as a WIC or NHS Direct in our sample has been found previously.3 This may seem unusual given that a new service is usually accompanied by publicity and these particular services have been established for several years.7 It may be that for many people, seeking care urgently is a rare event and other than GP in-hours and the ED, information about the location of newer services and their opening times may not be retained routinely.

Conclusion

Although there is considerable potential for alternative services to manage minor and moderate health problems and these facilities are available locally, with the patterns of reasons indicated in our study, patients will continue to present minor or moderate health problems to the ED.

References

View Abstract

Footnotes

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Doncaster NHS ethics committee.

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

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