Emergency Department Health Care Providers Research Articles

Older adults experience of transition to the community from the emergency department: a qualitative evidence synthesis

AimOlder adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults’ risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults’ experiences of transition to the community from the ED.MethodsSix databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990).FindingsTen studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult’s ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance.Discussion/ conclusionKey areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults’ changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life.

Validation of Employee Job Performance (EJP) Scale in an Arab Working Environment: The Case of Healthcare Providers in Emergency Departments in Jordan

Job performance is an essential contributing factor to hospital success because it appraises healthcare providers’ (HCPs) job performance. Achieving the purpose of measuring HCP’s job performance in the emergency department requires a valid, reliable, satisfying psychometric properties scale. This study aims to verify the validity and reliability of the employee job performance (EJP) scale developed by Na-Nan et al. (2018) . Two steps were followed to verify the validity and reliability of the EJP scale, namely, instrument validation and statistical testing, including exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). A survey questionnaire was distributed to the HCPs in two phases to collect the data in the period of April–July 2020. The findings failed to replicate the Na-Nan et al. (2018) EJP scale. Two items were dropped from the scale based on the content validity ratio results. The EFA yielded 11 items and two dimensions, and CFA yielded 9 items and two dimensions. The two dimensions name job quality (five items) and job time (five items). The goodness of fit of the model was defined as satisfactory with a value of Chi-square/ df 2.63 and RMSEA < 0.08, TLI, GFI and CFI ≥ 0.90. The results of this study failed to replicate Na-Nan et al. (2018) findings. The final results indicated a two dimensions scale consisting of job quality and job time construct. In general, the two dimensions EJP scales meet the goodness of fit, and the results confirm the reliability and validity of the two dimensions EJP scale.

49 Older adults’ experience of transition to the community from the Emergency Department: a qualitative evidence synthesis

Abstract Background Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes on discharge. Interventions to reduce older adults’ risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions, it is important to determine how older adults experience the transition from the ED to the community. This study systematically reviewed and synthesised qualitative studies reporting older adults’ experiences of transition to the community from the ED. Methods A systematic literature search of six databases was completed in March 2022 and updated in March 2023. Nine studies were included following full text review representing the experiences of over 490 older adults from five countries. Findings from included studies were synthesised as a meta-ethnography. Results Older adults often reported un-resolved symptoms on discharge (theme 1) which negatively affected transition home and return to daily life. Unresolved symptoms were also a major driver of ED re-attendance shortly after discharge (theme 2). Although older adults wanted a planned discharge home with organised transport (theme 4) however, this was not often achieved. Fragmented care at the point of transition home (theme 3) was a reoccurrence experience for older adults alongside inadequate healthcare provider communication/instructions on ED discharge (theme 5). Conclusion Study findings identified key areas for consideration in service development and intervention development for older adult’s care when transitioning from the ED to the community. ED healthcare providers should consider adapting their communication to meet the needs of older adults. Healthcare providers need to explicitly address expectations about symptom resolution during discharge planning as a collaborative process with older adults. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication from providers and desire to return to daily life.

Evaluating barriers and facilitators to healthcare providers’ use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework

Objective Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. Methods The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. Results Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. Conclusions Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Evaluation and management of acute epistaxis in the emergency department

Acute epistaxis, or nosebleed, is a common presentation in the emergency department (ED) that requires a systematic evaluation and prompt management. The assessment involves considering the severity of bleeding, identifying underlying causes, and implementing appropriate interventions. Modifiable risk factors, such as medication review, nasal hygiene, avoidance of nasal trauma, and humidification, should be addressed to prevent recurrence. Referral to specialists is necessary for cases of recurrent or severe bleeding, suspected underlying causes, or inadequate response to initial management. Collaboration between ED healthcare providers and specialists ensures comprehensive evaluation, specialized interventions, and long-term management. Regular follow-up appointments and patient education are essential for monitoring progress, adjusting treatment, and preventing complications. By employing a comprehensive approach, healthcare providers aim to alleviate distress, achieve hemostasis, identify underlying etiologies, and optimize patient outcomes in the ED.

Where’s the Marker? Perceptions of Whiteboards in the Emergency Department

BackgroundIn the emergency department, bedside whiteboards are used to help improve communication, teamwork, and collaboration among health care providers. In addition, previous studies have shown that whiteboards aid the patient with the identification of their health care providers, plan of care, expected length of stay, and overall patient satisfaction. PurposeThis evidence-based evaluation project assessed the perceptions of emergency department health care providers on their awareness of the effectiveness of bedside whiteboards, whether there are challenges with using them, and whether they are being updated and used consistently. MethodA survey was utilized to evaluate emergency department health care providers (nurses, patient care technicians, and attending providers) on their perceptions of bedside whiteboards in the patient rooms using a 10-question survey. OutcomesThe survey was sent via email to 135 emergency department health care providers, with 64 respondents. The survey results showed that 41.3% of the respondents agreed that bedside whiteboards promote patient satisfaction, 36.5% agreed that they promote patient safety, 53.1% agreed they take minimal completion time, and 50% felt they help keep patients informed about care. However, 85.9% of participants felt bedside whiteboards are not updated consistently, and 81.2% felt they are not updated consistently among all 3 shifts. In addition, 73.4% reported that they lack access to materials to update the whiteboards and 38.1% were neutral regarding whiteboards promoting patient safety. ImplicationsProper materials (markers and erasers) are integral to bedside whiteboard use. Continued staff education on the function of bedside whiteboards may improve proper whiteboard use.

Triage Competency and Its Associated Factors Among Healthcare Providers in Emergency Department in Kenya

Background: In developing world triage is underutilized and often an ineffective area of health system. In Kenya triage system is considered under developed and there is no National acceptable Accident and Emergency (A&E) triage system. Objective: The main objective of the study was to assess triage competency and its associated factors among healthcare providers in emergency department at selected hospitals in Kakamega County. Methods: This was a cross-sectional study design. Census sampling was used to select the General Practitioner hospitals. Systematic sampling was used to select study participants from the 11selected hospitals. The study participants were 183 health care providers including; doctors, clinical officers and nurses working within the selected hospitals in accident and emergency departments. Data was collected using an observation check list and structured questionnaire. Data was analyzed using statistical package of social science software version 24. Inferential statistics were used to test the strength of association. Results: The triage competency skills observed were; Rapid assessment; high level of skills observed at a mean of 88.9, patient categorization; the skills were moderate at a mean of 79.1, and Patient allocation skills which was moderate at a mean of 79.2. Conclusion: The hospital should organize unit base training on triaging, formulate guidelines triaging, avail resources needed and supervise triage area.

Assessment of Emergency Department Health Care Providers’ Readiness for Managing Intimate Partner Violence and Correlation With Perceived Cultural Competence

IntroductionIntimate partner violence is a public health problem, and emergency departments are often a victim’s only contact with health care providers. Despite this, recognition of intimate partner violence within emergency departments remains low owing, in part, to barriers experienced by providers. To better understand these barriers, this study examined relationships between readiness for managing intimate partner violence and cultural competence among emergency department health care providers. MethodsA cross-sectional, correlational study was conducted in 3 emergency departments. Eligible participants included registered nurses, physicians, physician assistants, nurse practitioners, and residents. Data were collected through an anonymous online self-report survey. Descriptive statistics and correlation analyses were conducted to answer study aims. ResultsOur sample included 67 respondents. More than one-third (38.8%) reported no previous intimate partner violence training. Those with previous training had higher readiness scores. Physicians were found to have higher intimate partner violence knowledge scores than registered nurses. Cultural competence scores were generally positive across domains. Aspects of intimate partner violence readiness were associated with culturally competent behaviors, communication, and practices. DiscussionOverall, participants were found to have low perceived readiness scores. Those with previous intimate partner violence training were found to have greater readiness in practice, suggesting that standardization of screening practices and intimate partner violence-related training should be the standard of care. Our data also suggest that perception of culturally competent behaviors and communication are learned skills that can increase screening rates within the emergency department.

Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis.

Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED. In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives. We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP. The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED.

Burnout Syndrome in Emergency Department Healthcare Providers In Aljouf Region

Background: Burnout refers to job dissatisfaction caused by work-related stress. The aim of this study was to explore the prevalence, risk factor, protective factors of burnout among emergency department healthcare providers in Al Jouf region hospitals. We aimed to investigate the psychological impact of burnout, how it weighs down on mental health and physical health, and ways to prevent it. Burnout syndrome is emotional exhaustion (EE), depersonalization (DP) and reduced personal accomplishment (PA) among individuals who work with people. Methodology: This study used a self-administered online questionnaire distributed through data collectors by sending the link to participants. A pilot study will be conduct on 10 subjects to estimate the time needed to fill the survey and test the logistics and its comprehensibility. A self-administered MBI-HSS was used to collect data on burnout in terms of emotional exhaustion, depersonalization and low personal accomplishment. Study period from March 2021– January 2022. Results: We found burnout to be multidimensional such that different variables were associated with one or more aspects of burnout. Majority of respondents felt emotionally drained from work a few times a week. Low personal accomplishment results are caused by factors such as age, marital status, smoking, psychological/ psychiatric disorders. The results showed that the highest mean and standard deviation for MBI-HSS subscale scores for risk burnout was found in emotional exhaustion. The majority of participants (71.28%) had high prevalence of high depersonalization. 84.43% of participants were not burnt out. Conclusion: Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment which arises in response to chronic stress in jobs where individuals work with people. Workers at the emergency department were more susceptible to burnout. Different factors are associated with burnout. Demographic factors of age, sex and marital status were significant in the study. Social and organizational solutions in preventing and alleviating this syndrome are recommended to address emotional exhaustion, depersonalization and low personal accomplishments.

Abstract 14095: Factors Influencing Timely Recognition and Treatment of Severe Hypertension in Pregnancy

Background: Severe hypertension is an obstetric emergency. Timely identification and management can reduce risk of serious events. Aims of our study were to 1)assess whether severe hypertension is being recognized and managed within the recommended time frame and 2)evaluate the factors that are associated with timely identification and treatment of severe maternal hypertension. Methods: A retrospective study of pregnant and postpartum women presenting with severe hypertension to tertiary care hospital between 1/1/19 to 12/1/19. Main outcome measures were ‘time to repeat blood pressure check(TTC)’ and ‘time interval between confirmation of severe hypertension and initiation of pharmacotherapy(TTT)’. We examined the association of the type of hospital unit, time of day of presentation and race/ethnicity with the outcome measures. Results: A total of 656 women were included in the study. Median time for repeat blood pressure check was 16 minutes. Only 46.2% of women had a repeat blood pressure check within 15 minutes. Median interval between confirmation of severe hypertension and initiation of therapy was 38.5 minutes. 63.3% of women were treated within the recommended time frame of 60 minutes. Both timely blood pressure re-check(15.6% vs 51.4%, p < 0.001) and initiation of treatment(38.5% vs 70.8%, p < 0.001) were significantly lower in the emergency department (ED). TTC(57.9% vs 31.4%, p < 0.001) and TTT(86.4% vs 42%, p < 0.001) were significantly better in the labor and delivery unit. Time of day(day 51.6% vs night 57.3%, p = 0.15) and race/ethnicity(black 57.1% vs non-black 51.6%, p = 0.16) were not associated with delay in repeat blood pressure check. However, black race(46.2% vs 28.6%, p = 0.018) was associated with delayed initiation of therapy compared to non-black patients. Conclusions: We found both the rates of timely identification and treatment of severe maternal hypertension in the ED were lower compared to other units. This points to need for continuous education of ED healthcare providers about timely recognition and management of severe maternal hypertension. We also found racial disparities in timely initiation of therapy, thus demonstrating the need for standardization of protocols.

Designing a Sensory Kit to Improve the Environment for Children with Autism Spectrum Disorder in the Pediatric Emergency Department.

Children with autism spectrum disorder (ASD) have more frequent use of healthcare services, including visits to the emergency department (ED). Medical care for children with ASD can be adversely affected by the highly stimulating environment of the ED. In this study, we gained insights from stakeholders with lived experience (parents of children with ASD, children with ASD, and ED healthcare providers) to create and implement a sensory equipment kit. The kit was evaluated and iteratively improved based on observations of children using the sensory equipment, satisfaction surveys from their parents, and interviews with healthcare providers in the ED. Findings from this study can be used to guide other EDs in creating their own ASD sensory kit.

Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns.

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

Investigation of usability problems of electronic medical record systems in the emergency department.

Despite the benefits of using electronic medical record (EMR) systems, existing studies show that many healthcare providers are uncertain regarding their usability. The usability issues of these systems decrease their efficiency, discourage clinicians, and cause dissatisfaction among patients, which may result in safety risks and harm. The aim of this study was to collect and analyze EMR system usability problems from actual users. Practical user interface guidelines were presented based on the medical practices of these users. Employing an online questionnaire with a seven-point Likert scale, usability issues of EMR systems were collected from 200 emergency department healthcare providers (103 physicians (medical doctors) and 97 nurses) from South Korea. The most common usability problem among the physicians and nurses was generating in-patient selection. This pertained to the difficulty in finding the required information on-screen because of poor visibility and a lack of distinctiveness. The major problems of EMR systems and their causes were identified. It is recommended that intensive visual enhancement of EMR system interfaces should be implemented to support user tasks. By providing a better understanding of the current usability problems among medical practitioners, the results of this study can be useful for developing EMR systems with increased effectiveness and efficiency.

Perceptions, challenges and experiences of frontline healthcare providers in Emergency Departments regarding Workplace Violence during the COVID-19 pandemic: A protocol for an exploratory qualitative study from an LMIC

IntroductionWorkplace violence (WPV) against Healthcare Workers (HCWs) has emerged as a global issue. Emergency Department (ED) HCWs as front liners are more vulnerable to it due to the nature of...

SARS-CoV-2 mRNA vaccine induces robust specific and cross-reactive IgG and unequal neutralizing antibodies in naive and previously infected people

Understanding vaccine-mediated protection against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is critical to overcoming the global coronavirus disease 2019 (COVID-19) pandemic. We investigate mRNA-vaccine-induced antibody responses against the reference strain, seven variants, and seasonal coronaviruses in 168 healthy individuals at three time points: before vaccination, after the first dose, and after the second dose. Following complete vaccination, both naive and previously infected individuals developed comparably robust SARS-CoV-2 spike antibodies and variable levels of cross-reactive antibodies to seasonal coronaviruses. However, the strength and frequency of SARS-CoV-2 neutralizing antibodies in naive individuals were lower than in previously infected individuals. After the first vaccine dose, one-third of previously infected individuals lacked neutralizing antibodies; this was improved to one-fifth after the second dose. In all individuals, neutralizing antibody responses against the Alpha and Delta variants were weaker than against the reference strain. Our findings support future tailored vaccination strategies against emerging SARS-CoV-2 variants as mRNA-vaccine-induced neutralizing antibodies are highly variable among individuals.

Development and Validation of A New Islamic Work Ethics Scale for Healthcare Providers in Emergency Departments (EDIWES)

Purpose: Research on work ethics has acquired considerable scholars’ attention. Research on employees’ religion-oriented ethics, particularly Islamic Work Ethics (IWE), has remained relatively narrow in healthcare settings. This study aims to develop and validate a scale to measure Healthcare Providers (HCPs) IWE in Emergency Departments (EDs). Design/methodology/approach: This study was conducted on HCPs who work at EDs in Jordan. The scale goes through a series of validation processes, including content validity, face validity, and construct validity. This study employed exploratory factor analysis for construct validity and Cronbach’s alpha for reliability analysis. Findings: Exploratory factor analysis yielded 17 strong explanatory items on a three-dimension scale, namely obligation of HCP to their patients, obligation of supervisors to their subordinates and obligation of HCP to their colleagues. Conclusion: The findings of this study provide a valid and reliable scale that had a satisfactory psychometric property for measuring Healthcare Providers’ IWE in EDs.

210 Assessment of Emergency Department Health Care Providers’ Readiness for Intimate Partner Violence Screening and Correlation With Cultural Competence

Intimate partner violence (IPV) is a serious public health issue and emergency departments (ED) are often a victim’s only contact with healthcare providers (HCPs). The ED also increasingly serves as a primary source of care for racial/ethnic minorities and other historically marginalized groups because of rising healthcare costs and declining access to care. The need for culturally competent providers, resources, and messaging when addressing IPV cannot be overstated. To inform more inclusive IPV screening strategies, this study explored the intersectionality of IPV readiness and cultural competence among ED HCPs.

Heat Emergencies: Perceptions and Practices of Community Members and Emergency Department Healthcare Providers in Karachi, Pakistan: A Qualitative Study

Heat waves are the second leading cause of weather-related morbidity and mortality affecting millions of individuals globally, every year. The aim of this study was to understand the perceptions and practices of community residents and healthcare professionals with respect to identification and treatment of heat emergencies. A qualitative study was conducted using focus group discussions and in-depth interviews, with the residents of an urban squatter settlement, community health workers, and physicians and nurses working in the emergency departments of three local hospitals in Karachi. Data was analyzed using content analysis. The themes that emerged were (1) perceptions of the community on heat emergencies; (2) recognition and early treatment at home; (3) access and quality of care in the hospital; (4) recognition and treatment at the health facility; (5) facility level plan; (6) training. Community members were able to recognize dehydration as a heat emergency. Males, elderly, and school-going children were considered at high risk for heat emergencies. The timely treatment of heat emergencies was widely linked with availability of financial resources. Limited availability of water, electricity, and open public spaces were identified as risk factors for heat emergencies. Home based remedies were reported as the preferred practice for treatment by community members. Both community members and healthcare professionals were cognizant of recognizing heat related emergencies.

I'm here because I was told to come: a study of cancer patients' reasons for attending the emergency department.

Patients with cancer are seen frequently in emergency departments (EDs). It has been proposed that many of these visits are preventable, but the patient perspective has not been well-studied. We conducted structured interviews with a convenience sample of patients who presented to a single ED with a cancer-related complaint. We asked standardized questions regarding patient predisposing characteristics, enabling factors (e.g., access to support), and perceived need for care. We compared the reported perceived need with the evaluated need by ED healthcare providers. Themes were identified using descriptive content analysis. Forty-five patients completed interviews, of whom 30 (67%) were admitted to hospital. The most frequent reasons for seeking ED care were pain (includes abdominal) (33%), fever (11%), and weakness (11%). The majority (77%) did not make the decision to go to the ED alone: healthcare providers (40%, most commonly oncologists) and caregivers (36%) were the reported decision-makers in these cases. The majority (73%) felt their ED visit was not preventable. Themes of an alternative oncological setting for tests, improved community services, and both earlier medication management and referral to specialist care were identified from patients who reported their visit was avoidable. Congruence between (patient) perceived need and evaluated need was high (96%). The minority of patients made the decision to seek ED care by themselves. While the majority did not believe emergency care was avoidable, those who did had cogent suggestions to that end. Patient's assessments of their own need had high agreement with ED providers' evaluations.