Lessons learned from an evaluation of referrals to the emergency department

Shifra Unger,Evan Avraham Alpert,Roee Gorodetzer,Zvika Orr,Todd Zalut

doi:10.1186/s13584-020-00377-2

Shifra Unger, Evan Avraham Alpert + Show 3 more

Open Access

https://doi.org/10.1186/s13584-020-00377-2

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Abstract

BackgroundEmergency department (ED) crowding is an international phenomenon dependent on input, throughput, and output factors. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs.MethodsA retrospective cohort study was conducted of patients referred to an ED in Jerusalem by either their PCP or a group of UCCs with a full range of laboratory tests and basic imaging capabilities between January 2017 and December 2017. The data were analyzed to identify referrals involving diagnoses, specialist consultations, and examinations unavailable in the PCP’s office or UCC (e.g., ultrasound, CT, echocardiogram, or stress test); these referrals were considered necessary for completion of the patient work-up. If patients were evaluated by an ED physician and sent home after an examination or laboratory test available at least in the UCC, the referrals were considered potentially unnecessary.ResultsSignificantly more referrals were made by PCPs than UCCs (1712 vs. 280, p < 0.001). Significant differences were observed for orthopedics, general surgery, and obstetrics/gynecology referrals (p = 0.039, p < 0.001, p = 0.003). A higher percentage of patients referred by PCPs had potentially unnecessary visits compared to patients referred by UCCs (13.9% vs. 7.9%, p = 0.005).ConclusionA robust UCC system may help further reduce potentially unnecessary visits (including complex patients) to the ED.

Highlights

When patients arrive at a crowded emergency department (ED), they are likely to experience treatment delays, longer wait times, and increased medical errors, which may result in poorer health outcomes, including death [1,2,3,4]
This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physician (PCP) or urgent care centers (UCCs) can be identified, which could be used to reduce unnecessary inflow to the Emergency department (ED)
Most patients below the age of 18 were sent directly to the Shaare Zedek Medical Center (SZMC) pediatric ED, a small number of children were seen in the general ED for orthopedic problems

Summary

Introduction

When patients arrive at a crowded emergency department (ED), they are likely to experience treatment delays, longer wait times, and increased medical errors, which may result in poorer health outcomes, including death [1,2,3,4]. Inefficient work processes can lead to delays in treatment These include a lack of continuity of patient care due to shift changes, communication problems between the treating teams, and lack of access to important medical information. Extra-ED factors include delays caused by waiting for laboratory tests, imaging studies, and consultants. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs

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