Inappropriate Attendance Research Articles

Patient's Perspective for their Non-Urgent Presentations to the Emergency Department in Najran City

Aim of Study: To explore patients’ perspectives regarding the reasons why some less urgent, or non-urgent patients prefer to attend emergency departments (EDs) instead of using other more appropriate healthcare services. Methods: This study followed a quantitative cross-sectional design. The study obtained and analyzed emergency attendance data from King Khalid Hospital, Najran City. A study questionnaire was designed by the researcher to interview 400 ED patients, who inappropriately attended the ED, to identify the reasons for their inappropriate attendance to the ED. Data collection was performed during the period of two months (November-December, 2022) to explore the proportions of different attendances that were deemed inappropriate according to the hospital’s followed triage system. The interviews were conducted with the non-urgent and less urgent patients during their waiting times. Results: The age of 18.3% of patients were <30 years old, while 28.5% were 30-39 years old. More than half of the participants’ visits were non-urgent, while 43.25% were less-urgent, 55.3% of patients visited the ED before due to similar complaints, and 46% visited a primary health care center before their ED visits. The main reasons for visiting the ED instead of the primary healthcare center (PHCC) were to save time (49.3%) and to get an earlier appointment (48%). Patients’ triage levels differed significantly according to their age groups (p<0.001), nationality (p=0.022), educational level (p=0.022), marital status (p=0.002), ED visits due to similar complaints (p<0.001), and previously visiting the PHCC for the current health problem (p=0.002). Triage levels also differed significantly according to some reasons for choosing to go to the ED instead of the PHCC, especially to get an earlier appointment (p=0.044), preferring the healthcare services provided by the ED (p=0.005), having a nearby ED (p=0.001), or being at the hospital at that time (p=0.002). Conclusions: There is a clear relationship between inappropriate ED visits and certain associated factors, indicating that prevention would be best targeted to certain categories, such as Saudi, younger, and educated patients. The main reasons for inappropriate ED visits are to save time and to avoid getting a late appointment. Recommendations: This study emphasized the importance of implementing proper health education and redirecting patients with inappropriate ED visits. Conducting a detailed analysis of the shortages in the utilization of primary healthcare resources is a pressing necessity. Further nationwide studies on patients’ perspective for non-urgent ED presentations are largely needed. Key Words: Emergency Department, Triage, Quantitative Research, Najran City, Saudi Arabia

Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy.

Frequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs. The analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors. A total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p < 0.001). The FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.

A tale of excess: the curious case of the woman with 1447 emergency visits

IntroductionFrequent attenders to emergency services are challenging and costly. We report the case of a woman in her mid-twenties who stands out for a total of 1447 emergency visits.ObjectivesOur primary objective was to describe the emergency visits of our patient. Secondary objectives were to assess her use of other healthcare services and to calculate her health expenditure.MethodsThis is a clinical case report. We reviewed the patient’s electronic medical records for sociodemographic and clinical data. We obtained detailed information of psychiatric ED visits (length, most frequent times and days) regarding the second most-visited hospital. We assessed the efficacy of hospitalizations in reducing ED visits with a paired samples t Test, comparing the number of visits 30 days pre- and post-hospitalization. We estimated the health expenditure using the regional public health system prices, including three direct costs: emergency visits, hospitalizations and ambulance transportation. We obtained written informed consent from the patient’s legal guardian.ResultsA 26-year-old woman from Barcelona (Catalonia, Spain), diagnosed with mild intellectual disability, made 1447 emergency visits between 2009 and 2021 (figure 1). 946 visits (65%) took place in psychiatric emergency departments (EDs), whilst 353 (24%) in non-psychiatric EDs and 148 (10%) in urgent primary care. She attended 24 hospitals (ranking number one the closest to the patient’s home, with 387 visits) and seven primary care centers, distributed across 17 cities in Catalonia. Most visits were self-referred, being the main presenting problems anxiety and instrumental suicidal behaviour. Saturday was her favorite day for hospital visits (24,1%), while she seeked care on Tuesdays much less often (4.5%). She made 73.5% of consultations between 1pm and 6pm, with a median length per visit of 2.8 hours (range 0.33-20.9 hours). Regarding other therapeutic approaches, she attended day hospitals, psychiatric rehabilitation programs and family therapy, among others (figure 2), for which she showed low adherence and scarce benefit. She had ten acute hospitalizations, interventions that did not reduce ED visits (t=-0.9835, p=0.36). Health expenditure reached 410.035€.Image:Image 2:ConclusionsThe most common definition of frequent attendance is a patient who has five or more visits per year. Many times, but not always, repeat visits are also inappropriate. The case we report is a grotesque example of both frequent and inappropriate attendance, which has been resistant to all kinds of interventions and has quality-of-care, financial and ethical implications. As of today, it is still a pending case. Maybe it is worth considering residential treatment?Disclosure of InterestNone Declared

Non-Urgent Pediatric Presentations to the Emergency Department, Khamis Mushayt Maternity and Children Hospital, Saudi Arabia

Aim of Study: To explore parents’ perspectives regarding why parents (caregivers) prefer to escort their less urgent, or non-urgent sick children to the emergency departments (EDs) instead of using other more appropriate healthcare services. Methods: This study followed a quantitative cross-sectional design at Khamis Mushayt Maternity and Children’s Hospital (KMMCH). A study questionnaire was designed by the researchers to interview parents of 400 children who inappropriately attended the ED to identify the reasons for their inappropriate attendance at the ED. Data collection was performed during the period of January 2023 to explore the proportions of different attendances that were deemed inappropriate according to the hospital’s followed triage system. The interviews were conducted with parents/caregivers of non-urgent and less urgent children during their waiting times. Results: The age of 18.3% of parents was &lt;30 years, while 28.5% were 30-39 years old. More than half of the parents’ visits were non-urgent, while 43.25% were less-urgent, 55.3% of patients visited the ED before due to similar complaints, while 46% visited a primary health care center before their ED visits. The main reasons for visiting the ED instead of the primary healthcare centers (PHCCs) were to save time (49.3%) and to get an earlier appointment (48%). Patients’ triage levels differed significantly according to parents’ age groups (p&lt;0.001), nationality (p=0.022), educational level (p=0.022), ED visits for similar complaints (p&lt;0.001), and previously visiting the PHCC for the current health problem (p=0.002). Triage levels also differed significantly according to some reasons for choosing to go to the ED instead of the PHCC, especially to get an earlier appointment (p=0.044), preferring the healthcare services provided by the ED (p=0.005), having a nearby ED (p=0.001), or being at the hospital at that time (p=0.002). Conclusions: There is a clear relationship between inappropriate ED visits and certain associated factors, indicating that prevention would be best targeted to certain categories, such as Saudi, younger, and educated parents. The main reasons for inappropriate ED visits are to save time and to avoid getting a late appointment. Recommendations: This study emphasized the importance of implementing proper health education and redirection of patients with inappropriate ED visits. Conducting a detailed analysis of the shortages in the utilization of primary healthcare resources is a pressing necessity. Further nationwide research on patients’ perspective for non-urgent ED presentations is largely needed. Key Words: Emergency Department, Triage, Children, Non-urgent level, Less urgent level.

Factors reducing inappropriate attendances to emergency departments before and during the COVID-19 pandemic: A multicentre study

Inappropriate attendances (IAs) to emergency departments (ED) create an unnecessary strain on healthcare systems. With decreased ED attendance during the COVID-19 pandemic, this study postulates that there are less IAs compared to before the pandemic and identifies factors associated with IAs. We performed a retrospective review of 29,267 patient presentations to a healthcare cluster in Singapore from 7 April 2020 to 1 June 2020, and 36,370 patients within a corresponding period in 2019. This time frame coincided with local COVID-19 lockdown measures. IAs were defined as patient presentations with no investigations required, with patients eventually discharged from the ED. IAs in the 2020 period during the pandemic were compared with 2019. Multivariable logistic regression was performed to identify factors associated with IAs. There was a decrease in daily IAs in 2020 compared to 2019 (9.91±3.06 versus 24.96±5.92, P<0.001). IAs were more likely with self-referrals (adjusted odds ratio [aOR] 1.58, 95% confidence interval [CI] 1.50-1.66) and walk-ins (aOR 4.96, 95% CI 4.59-5.36), and those diagnosed with non-specific headache (aOR 2.08, 95% CI 1.85-2.34), or non-specific low back pain (aOR 1.28, 95% CI 1.15-1.42). IAs were less likely in 2020 compared to 2019 (aOR 0.67, 95% CI 0.65-0.71) and older patients (aOR 0.79 each 10 years, 95% CI 0.78-0.80). ED IAs decreased during COVID-19. The pandemic has provided a unique opportunity to examine factors associated with IAs.

Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial

ObjectivesThe primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF).DesignAppropriate ED attendance was defined by...

The integration of advanced practice nurses in emergency departments

The saturation of emergency departments due to inappropriate attendance by patients is becoming increasingly commonplace. It often leads to the discontent of users, due to long waiting times, and stretches the hospital staff physically, mentally and psychologically. Innovative organisation models have been developed abroad. They draw on the skills of advanced practice nurses in emergency departments. The impact of these models has been assessed very positively in numerous studies. They improve the quality and safety of care as well as the satisfaction of users.

Distance to the Pediatric Emergency Department and Nonurgent Visits in Friuli Venezia Giulia, Italy.

Our objective was to assess how the distance from home to the closest pediatric emergency department (ED) affects nonurgent emergency room visits among the child population of the Northeastern Italian region of Friuli Venezia Giulia. The study was based on the administrative databases of the Regional Health Information System of Friuli Venezia Giulia. For the year 2014, we abstracted the records of all white-triage-tag visits of children younger than 16 years from the databases of the 3 regional pediatric EDs located in the 3 main cities. Those records were individually linked to the regional population's georeferenced address database through an anonymous univocal identifier. For each child younger than 16 years living within 20 km from an ED, we calculated the linear distance between the ED and home address. Distances were grouped into 7 circular distance bands: less than 2, 2 to 4, 4 to 6, 6 to 8, 8 to 10, 10 to 15, and 15 to 20 km. Within each band, we calculated the rate of ED visits during the year. In 2014, there were 12,055 white-triage-tag visits accounting for 24.7% of all visits in the regional pediatric EDs. Although the overall rate of ED visits was different among the EDs, it decreased significantly with increasing distance to the ED, with a 6-fold difference between the innermost and the outermost bands. In Friuli Venezia Giulia, short distance is a prompter for inappropriate pediatric ED attendance. Further research is needed in this region to understand the parental standpoint to implement strategies promoting uniform behaviors within the regional boundaries.

8 Different approaches needed to manage ED demand among different age-groups

Background/objectivesA variety of interventions have been proposed to manage rising demand for Emergency and Urgent Care, described by an NHS England review as unsustainable in the long term. However it...

Is health systems integration being advanced through Local Health District planning?

Objective Delivering genuine integrated health care is one of three strategic directions in the New South Wales (NSW) Government State Health Plan: Towards 2021. This study investigated the current key health service plan of each NSW Local Health District (LHD) to evaluate the extent and nature of health systems integration strategies that are currently planned. Methods A scoping review was conducted to identify common key principles and practices for successful health systems integration to enable the development of an appraisal tool to content assess LHD strategic health service plans. Results The strategies that are planned for health systems integration across LHDs focus most often on improvements in coordination, health care access and care delivery for complex at-risk patients across the care continuum by both state- and commonwealth-funded systems, providers and agencies. The most common reasons given for integrated activities were to reduce avoidable hospitalisation, avoid inappropriate emergency department attendance and improve patient care. Conclusions Despite the importance of health systems integration and finding that all NSW LHDs have made some commitment towards integration in their current strategic health plans, this analysis suggests that health systems integration is in relatively early development across NSW. What is known about the topic? Effective approaches to managing complex chronic diseases have been found to involve health systems integration, which necessitates sound communication and connection between healthcare providers across community and hospital settings. Planning based on current health systems integration knowledge to ensure the efficient use of scarce resources is a responsibility of all health systems. What does this paper add? Appropriate planning and implementation of health systems integration is becoming an increasingly important expectation and requirement of effective health systems. The present study is the first of its kind to assess the planned activity in health systems integration in the NSW public health system. NSW health districts play a central role in health systems integration; each health service plan outlines the strategic directions for the development and delivery of all state-funded services across each district for the coming years, equating to hundreds of millions of dollars in health sector funding. The inclusion of effective health systems integration strategies allows Local Health Districts to lay the foundation for quality patient outcomes and long-term financial sustainability despite projected increases in demand for health services. What are the implications for practice? Establishing robust ongoing mechanisms for effective health systems integration is now a necessary part of health planning. The present study identifies several key areas and strategies that are wide in scope and indicative of efforts towards health systems integration, which may support Local Health Districts and other organisations in systematic planning and implementation.

Maternal near miss and maternal deaths in Mozambique: a cross-sectional, region-wide study of 635 consecutive cases assisted in health facilities of Maputo province.

BackgroundLife-threatening events during pregnancy are currently used as a measure to assess quality of obstetric care. The aim of this study is to assess prevalence of near miss cases and maternal deaths, to elucidate the causes and to analyze avoidable factors based upon the three-delays approach in southern Mozambique.MethodsNear miss cases comprised five categories: eclampsia, severe hemorrhage, severe sepsis, uterine rupture and severe malaria. Pregnant women surviving the event were interviewed during a 5-month period within five health facilities offering comprehensive emergency obstetric care in Maputo City and Province. Family members gave additional information and were interviewed in case of the patient’s death.ResultsOut of 27,916 live births, 564 near miss cases and 71 maternal deaths were identified, giving a total maternal near miss ratio of 20/1,000 live births and maternal mortality ratio of 254/100,000 live births, respectively. Near miss fatality rate was 11.2%. Among near miss cases hemorrhage accounted for the most common event (58.0%), followed by eclampsia (35.5%); HIV seroprevalence was 22.3%. Inappropriate attendance in antenatal care services (21.1%), late or wrong diagnosis (12.6%), inadequate management immediately after delivery (9.6%), no monitoring of blood pressure and other vital signs (9.2%) were the most prevalent factors contributing to the severe morbidity under study. Third delay was identified in 69.7% of the interviews. In more than one fourth of near miss cases treatment was not started immediately. Lack of blood derivates and unavailable operating room were reported in 42.0% and 35.0%, respectively.ConclusionsNear miss cases were frequent and related to delays in reaching and receiving adequate care. First and third type of delay contributed significantly to the number of maternal near miss cases and deaths. Maternal health policies need to be concerned not only with averting the loss of life, but also with ameliorating care of severe maternal complications at all levels including primary care. Sexual and reproductive health services for adolescents should be prioritized to prevent adverse outcomes.

WHEN UNPLANNED ACUTE HOSPITAL ATTENDANCE IS APPROPRIATE: DEVELOPING A PATHWAY TO FACILITATE URGENT HOSPITAL REVIEW OF PATIENTS ATTENDING A SPECIALIST PALLIATIVE CARE DAY UNIT

BackgroundSpecialist palliative care services are increasingly accessed by people in the early stages of a life-limiting illness, when functional status may be good and treatment aimed at prolonging life. Whilst...

Assessment of the Content and Utilization of Antenatal Care Services in a Rural Community in Cameroon: A Cross-Sectional Study

Background: Pregnant women receive antenatal care (ANC) to ensure favorable pregnancy outcomes. Despite the high ANC coverage rate registered nationally in Cameroon; rural women, women with no formal education and those in the most deprived quintile still face difficulties in having access to quality ANC. The impact of the aforementioned factors on ANC use in the Muea Health Area (MHA) is unknown. The objective of this study was to determine the proportion of women attending ANC and the factors influencing ANC attendance in the MHA. Materials and Methods: This was a community based, analytical, cross sectional survey that involved pregnant women and women with children less than two years old who gave an informed consent or assent. Data were collected using a semi structured questionnaire. EPI info Version 7 and Stat Pac for Windows version 12? 1998-2011 (Stat Pac Inc, Bloomington, USA) were used for data analysis. Associations were considered statistically significant for p values less than 0.05. Results: Two hundred and twenty women were interviewed. The mean age was 25 years (SD 5.28). Ninety-nine percent of women had at least one ANC visit meanwhile 84.8% had at least four ANC visits. Only 27.2% of women booked for ANC in the first trimester. Rural (Maumu) residence was associated with inappropriate ANC attendance (attending less than four times) (χ2 = 18.5; p = 0.001). Semi urban women (87%; 95% C.I. = 85.10% - 89.0%) were more likely to attend four or more sessions than rural (Maumu) women (60.7%; 95% C.I. = 44.2% - 77.3%) (p = 0.001). Participant’s educational level was a significant predictor of early booking for ANC (χ2 = 26.8; p = 0.0002). Semi urban wom- en (79.1%; 95% C.I. = 76.0% - 82.2%) were significantly more likely to have a vaginal examination done than rural (Maumu) women (42.1%; 95% C.I. = 17.5% - 68.2%) (p = 0.0001). Women who met a doctor during ANC (84.0%; 95% C.I. = 80.8% - 87.0%) were more likely to have a vaginal examination done than women who only met a nurse or a midwife during ANC (65.0%; 95% C.I. = 57.7% - 71.4%) (p = 0.002). One third of women did not have a vaginal examination performed during ANC. 45.83% and 47.6% neither did a stool test nor received an insecticide treated net (ITN) respectively. Conclusion: Women in the MHA start their antenatal care late, so they should be encouraged to book early for antenatal surveillance. Furthermore, efforts should be made to increase the access of these women to quality ANC services and to adequately trained ANC providers.

Inappropriate attendance is top threat to A&amp;E, poll shows

Inappropriate attendance is top threat to A&amp;E, poll shows

Healthcare providers attitudes and perceptions of ‘inappropriate attendance’ in the Emergency Department

Emergency Departments (EDs) worldwide are facing a crisis from overcrowding and a common perception exists that inappropriate use of the ED is a major contributing factor. Patients, who attend the ED with non-urgent problems, could be dealt with by a General Practitioner; such patients use time and resources that would otherwise be used for patients with more appropriate needs. Study aimTo explore attitudes and perceptions of healthcare providers regarding ‘inappropriate attendance’ in the ED. Study designUsing a survey questionnaire, this descriptive quantitative study included ED nurses, doctors and paramedics from three regional hospitals in the Republic of Ireland. ResultsA total of 163 surveys were returned (59% response rate). There was an overwhelming agreement among respondents that inappropriate attendance in Irish ED exists and poses a considerable challenge for healthcare providers. Results suggest differences of opinion on what represents inappropriate ED use.Potential solutions to address the issue of inappropriate ED attendance include General Practitioners and Advanced Nurse Practitioners practicing within the ED setting; education and greater public awareness and faster access to a specialist opinion in the Out Patient Department.

Use of GPs

I READ Daniel Jones’s article, how GPs can help reduce inappropriate attendance, in the July edition of emergency Nurse with interest. Dr Jones reports on some useful qualitative research but has missed an opportunity to discuss important aspects of an initiative that places GPs in emergency departments (EDs).

How GPs can help reduce inappropriate attendance

York District Hospital emergency department (ED) piloted a scheme in which GPs work alongside ED staff. By seeing and treating minor cases, the GPs allowed ED staff more time to care for acutely ill patients, thereby reducing waiting times and the rate of inappropriate attendance, and improving patient flow. This article discusses the scheme and a qualitative review of how staff perceived it. Findings from the review suggest that the introduction of GPs to EDs can improve the healthcare experience for staff and patients.

Effect of patients seeing a general practitioner in accident and emergency on their subsequent reattendance: cohort study

General practitioners working in an accident and emergency department manage non-emergency patients safely and use fewer resources than do usual accident and emergency staff.1 2 In our previous study we...

Public knowledge of dental registration and management of common dental problems.

The government has recently changed its policy on dental registration. There is now a requirement to attend a dentist within 15 months of the previous appointment or dental registration will lapse. The authors of this article undertook a survey of the patients attending for dental treatment at the accident and emergency department of their hospital to ascertain whether inappropriate attendance was due to ignorance about general dental services. Of the 501 respondents 14% had not seen their general dental practitioner within the last 15 months and were therefore no longer registered--only 21% realized that they had to keep regular appointments or dental registration would lapse. A proportion (30%) had tried to contact the dentist outside normal working hours; 27% of these were unhappy with the outcome. Telephone calls were unanswered in 38% of those expressing dissatisfaction and 45% subsequently attended hospital for treatment.

Utilización inadecuada de un servicio de urgencias hospitalario. Una evaluación con criterios explícitos

Several studies have shown a growth in the number of visits to accident and emergency (A&E) hospital departments with a high proportion of inappropriate utilization. Methods to identify improper use based on implicit criteria limit the comparisons between hospitals. The aim of this study is to know the proportion of inappropriate attendance's in an A&E department and their associated factors, using a method with objective criteria. An instrument based on diagnosis-independent explicit criteria was used to identify inappropriate visits in a random sample of 1845 14-year-old greater patients attended to A&E medical services, and the factors associated with improper demand were analysed. The proportion of inappropriate attendance's was of the 26,8% (495/1. 845). The unadjusted analysis show that the smaller age, absence of comorbidity, spontaneous visit and some diagnostic groups (diseases of the skin, muscle-skeletal, mental, and bad defined symptoms) were associated to a greater proportion of improper use. Upon adjusting the variables through logistics regression, the age, associated pathology, the spontaneous attendance's and diagnostic groups, maintained the association with improper use, but other variables as woman gender, and night hours were also associated to inappropriate utilization. At least the fourth part of the attendance's in the A&E medical services do not require urgent attention. Inappropriate utilization is associated to characteristic of the patient and the attended process.