Who uses emergency departments inappropriately and when - a national cross-sectional study using a monitoring data system

Philip Mchale,Mark A Bellis,Karen Hughes,Ulf Demnitz,Sacha Wyke,Sara Wood

doi:10.1186/1741-7015-11-258

Abstract

BackgroundIncreasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide. A potentially avoidable pressure is inappropriate attendances (IA); typically low urgency, self-referred patients better managed by other services. This study examines demographics and temporal trends associated with IA to help inform measures to address them.MethodsUsing a national ED dataset, a cross-sectional examination of ED attendances in England from April 2011 to March 2012 (n = 15,056,095) was conducted. IA were defined as patients who were self-referred; were not attending a follow-up; received no investigation and either no treatment or ‘guidance/advice only’; and were discharged with either no follow-up or follow-up with primary care. Small, nationally representative areas were used to assign each attendance to a residential measure of deprivation. Multivariate analysis was used to predict relationships between IA, demographics (age, gender, deprivation) and temporal factors (day, month, hour, bank holiday, Christmas period).ResultsOverall, 11.7% of attendances were categorized as inappropriate. IA peaked in early childhood (adjusted odds ratio (AOR) = 1.53 for both one and two year olds), and was elevated throughout late-teens and young adulthood, with odds reducing steadily from age 27 (reference category, age 40). Both IA and appropriate attendances (AA) were most frequent in the most deprived populations. However, relative to AA, those living in the least deprived areas had the highest odds of IA (AOR = 0.89 in most deprived quintile). Odds of IA were also higher for males (AOR = 0.95 in females). Both AA and IA were highest on Mondays, whilst weekends, bank holidays and the period between 8 am and 4 pm saw more IA relative to AA.ConclusionsPrevention of IA would be best targeted at parents of young children and at older youths/young adults, and during weekends and bank holidays. Service provision focusing on access to primary care and EDs serving the most deprived communities would have the most benefit. Improvements in coverage and data quality of the national ED dataset, and the addition of an appropriateness field, would make this dataset an effective monitoring tool to evaluate interventions addressing this issue.

Highlights

Increasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide
Of the 15,056,095 attendances included in the analysis (86.2% of all recorded attendances), 88.3% (13,294,819) were categorized as AA and 11.7% (1,761,276) as inappropriate attendances (IA)
The clear relationship between IA and age indicates that prevention would be best targeted at parents of young children and at young adults

Summary

Introduction

Increasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide. A potentially avoidable pressure is inappropriate attendances (IA); typically low urgency, self-referred patients better managed by other services. Across the globe, pressures and crowding are resulting in increasingly strained and inefficient ED services, leading to increased waiting times and treatment delays, impaired access, financial losses for providers, and ethical consequences [1,2]. A potentially avoidable part of increased pressures on ED services is ‘inappropriate’ attendances (IA); patients who self-refer with low urgency problems that are unlikely to require admission and are more suitable for other services, such as primary care, telephone advice helplines or pharmacy [3]. Between 24% and 40% of all ED attendances are thought to be inappropriate [4] Such IA can hinder the ability of EDs to treat attendees in a timely and safe manner. Whilst low complexity patients may have a minimal effect on waiting times for more urgent attenders [5], non-urgent cases may prohibit access for real emergency cases [6] and have a negative impact on staff attitudes [7]

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