Elsevier

Health Policy

Volume 66, Issue 2, November 2003, Pages 159-168
Health Policy

How to minimize inappropriate utilization of Accident and Emergency Departments: improve the validity of classifying the general practice cases amongst the A&E attendees

https://doi.org/10.1016/S0168-8510(03)00023-XGet rights and content

Abstract

Studies have found that one-third to two-thirds of all patients attending Accident and Emergency (A&E) Departments could be managed appropriately by general practitioners (GPs). There is also evidence that referral to GPs can be acceptable to patients. The question of primary concern is screening non-urgent cases with high degrees of sensitivity (S), specificity (SP), and positive predictive value (PPV). This paper reports the findings of the validity (S, SP and PPV) of nurses and patients in triaging A&E visitors. A cross sectional study was conducted over a 1 year period and subjects were randomly selected from four A&E Departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. S, SP and PPVs were computed for both non-weighted and weighted conditions. The gold standard for defining the true urgency status of each selected patient was based on a review of the patient's record 3–21 days (or longer if necessary) following the A&E visit. The record review in each A&E was blinded and done independently by a panel of two (and if disagreement existed, three) senior emergency physicians who did not practice in the same hospital. The greatest weights would be for incorrect decisions with greatest impact on patients’ well being. The most accurate unweighted nurses’ triage classification had an average sensitivity of 87.8%, specificity of 83.9%, and a PPV of 70.1%. When weighted, the average sensitivity reduced to 75%, specificity to 65.7%, and PPV to 54%. The most accurate unweighted patients’ self-triage classification yielded a sensitivity of 62.5%, specificity of 69.2%, and a PPV of 58.1%, and correspondingly reduced to 43.3, 49.2 and 38.6% if weights were applied. Validity of the derived patients’ self-classifications was too inaccurate for practical use. Hong Kong's current use of a five-point urgency scale by nurses would be further refined for identifying non-urgent visitors. If a mechanism was put in place for additional screening on visitors with a borderline semi-urgent or non-urgent status, the nurses could safely reassign non-urgent patients to GP care. If implemented, a significant impact on hospital costs could be realized.

Section snippets

Background

Accident and Emergency (A&E) Departments are designed to handle cases of acute emergency. However, these departments have become frequently used venues for delivering primary care. Within Hong Kong this phenomenon is particularly acute and the continuing inappropriate attendance of non-urgent patients is considered a serious problem in terms of inefficient utilization of resources and reduced efficiency in the care of true emergent cases.

Studies have found that one-third to two-thirds of all

Sampling frame

The study was designed as a prospective investigation of a representative sample of visitors to four A&E Departments located across the four principle geographic regions of Hong Kong. A stratified, two-stage (randomly selection of visitation periods followed by random selection of patients within each selected period) sampling frame was used. Based on past utilization data, visitation periods were broken into 24 h blocks for each day of the year and then stratified according to peak (>+1 S.D.)

Results

A total of 2410 subjects were included in the validity analyses. The level of disagreement between the paired expert record reviewers (for determining the gold standard of urgency) was 5%. For these, the third reviewer always resulted in an agreement with one of the inconsistent paired reviewers, and also the principal investigator and project co-ordinator. For both nurses and patients, S, SP and PPV were derived for all practical collapsed options from their five-point urgency ratings.

The

Discussion

Although the selection of hospitals in this study was not random, the samples obtained from them were, and matched well with the age and sex distributions of the A&E population of visitors for the whole territory of Hong Kong [13]. As the study sampled a 1 year time period accounting for both high and low utilization periods, and as the four departments handled about 35% of all A&E visits annually in Hong Kong, we concluded that the results had some degree of generalisability to Hong Kong's A&E

Conclusion

The current operating system in Hong Kong for classifying urgency status into five levels by nurses can be used to derive a reasonably valid triage, even if weighting for incorrect decisions is taken into consideration. Provided a mechanism exists for additional screening for some borderline cases (such as semi-urgent and urgent 2 cases), a safe system appears possible for screening out non-urgent patients from A&E (i.e. referring them to the care by GPs).

In Hong Kong, over half of the A&E

Acknowledgements

The authors would like to thank you the staff of the A&E Departments of United Christian Hospital, Pamela Youde Nethersole Eastern Hospital, Yan Chai Hospital and Tun Mun Hospital for their kind co-operation and assistance in data collection. We also wish to thank Health Services Research Fund for the research grant in this study.

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    Present address: Department of Health Science, The Hong Kong Polytechnic University, Hong Kong.

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