The reasons that patients present to the ED are varied and based on a host of factors including resources, education, efficiency and convenience. There is a commonly held belief that excessive ED use is found in high-risk populations.
One program offering extensive resources included a “Foster Grandmother” to assist at home, 40 hours per week of follow up clinic care and unlimited access to the physician assistant (PA) or nurse practitioner (NP), and free taxi service to a cohort of inner city high risk neonates factoring in either low birth weight of assisted ventilation requirement.1
These ED visits were tracked for a full year after many received instructions to help recognize early signs of illness. They reported ED visits for 52% of children with multiple visits found in one quarter. The moms remembered that fever is a worrisome sign in 75% of cases, but two-thirds could recall none of the other signs of illness and one-fifth could not offer any sign of illness on presentation to the ED.
The process variables were sub-optimal as well, with half of the visits involving parents not contacting their pediatric PA/NP prior to the visit, one-third of visits were for minor problems, 40% of visits were capable of clinic care, and the average interval of illness was 42 hours prior to presentation.
Clearly, focusing on this disappointing study alone, in which the families were provided maximal resources to avoid ED use, would have us conclude that an unremediable problem exists.
However, on a more positive note, the Emergency Medicine Patient’s Access To Healthcare (EMPATH) Study explored behavior in a more empowered population. Here, the mean patient age was 46 years, the group was 55% female, and 81% of those studied had health insurance.2
The rationale for presentation was medical necessity (95%) followed by convenience (87%), citing hours of operation, ease of travel, and availability of immediate medical attention and preference (89%) for ED use. Analysis found that financial reasons were cited less often in this population, specifically affordability (25%) and insurance limitations (15%).
The “preference of the ED” descriptor involves four factors: the environment and staffing of the ED, the availability of a wide range of services at a single site, the availability of diagnostic testing and the availability of specialty consultants (Figure 4).
Figure 4. Why the Affirmative Choice of the Emergency Department
Clearly, the ED can be viewed as an “affirmative choice” in some patient populations rather than just the “last resort” in less advantaged patient groups.
The patient intake process is often complicated by the referral of “elective” patients blending with the ED population. The mix between acute and elective patients proves especially difficult during high saturation times in the department due to triage inadequacies. Triage agreement can be notoriously poor. An evaluation of emergent (15%), urgent (44%) and routine (41%) patients finds substantial agreement in only 1 of 5 cases and the overall level of agreement (kappa=0.35) was poor.3
Therefore, the needle-in-the-haystack approach to finding the ‘sick’ patient in triage should be avoided. A multifaceted system is required in the sea of routine patient processing tasks. A helpful approach is to set reasonable patient expectations, explaining morning/early day accessibility versus afternoon or evening/late day lack of processing capability as well as the necessity of ‘calling ahead’ by office personnel to allow the ED staff time to budget accordingly.
These patients are typically referred by their physicians’ offices due to the convenience of STAT testing without the conventional laboratory wait time. This practice can interfere with the routine ED triage and the flow of more critically ill patients.
A more efficient approach would be to rotate these referred patients to a separate holding area or waiting area to await the results of noncritical testing. The referring physicians of those patients who warrant admission would be directed to the Direct Emergency Admission (DEA) pathway4 (Figure 5).
This pathway allows a nursing vital sign evaluation and floor transfer to a waiting bed, where the lab and x-ray personnel could also be alerted. The radiology department can be visited during the transfer process and laboratory specimens can be obtained on bed arrival.
The referral of patients from their doctor’s office—often due to lack of appointment availability—causes perhaps the most significant inequity encountered in the system. This problem manifests itself in two variants. The first involves the referring office’s clerical staff who may not have a vested interest in seeing additional patients. The compliant patients who have followed their doctor’s advice to “call the office, not just go to the emergency room (ER),” are then instructed to “go to the ER.”
The second variant has the same endpoint for the patient but emanates from the physician or midlevel provider—“since you have ‘blank’ condition or need ‘blank’ test you need to go to the ED, otherwise we could see you in the office.”
Here, a helpful approach is to suggest that practitioners use a recommended office emergency appointment availability allotment time. Another approach is the “open office” with the flex capacity to see all patients who desire to be seen. This approach may allocate anywhere from 5 to 10% of office appointment availability to this patient population which often present—especially in peak seasons related to infectious disease outbreaks or regarding routine health needs, such as school physicals and vaccinations.
An interesting paradox is that some office-based practitioners might muse that they could never see such an influx of patients with their current office staff, but recognize that we would then expect the ED staff to perform the same task, while having to take care of true emergencies as well.
The last issue is usually a physician-based decision as well, where patients are referred to the ER for “difficult procedures.” These tend to be interventions that are time consuming, work intensive or subject to skill attrition. These procedures include lumbar punctures, alleged child abuse evaluations, alleged sexual assault evaluations, gynecologic exams, or involuntary commitment procedures.
Figure 5. Direct Emergent Admission (DEA) Protocol
Here, it is helpful to maintain select procedural competence in physicians, requiring doctor-to-doctor referral, because these transfers utilize other procedural-based specialties, specifically radiology and anesthesia personnel for requested procedures such as lumbar puncture. Likewise, the office staff should be familiar with the procedural requirements of other public service agencies for certain forensic patient examinations, such as those required for an alleged sexual assault evaluation, for instance.
Obviously, these considerations are factored into the ED operating plan and are incorporated into the average daily patient evaluation plan. If peak use times are encountered in the ED, alternate suggested referral patterns are helpful to the primary care physicians (PCPs) to ensure that their patients are seen as well, utilizing hospital resources other than the emergency department to get these goals accomplished.
1. Hoffmann, C., Broyles, R.S., Tyson, J.E. “Emergency room visits despite the availability of primary care: A Study of High Risk Inner City Infants.” American Journal of the Medical Sciences 1997; 313(2): 99 – 103.
2. Ragin, D.F., Hwang U., Cydulka, R.K., Holson, D., Haley, L.L. Jr., Richards, C.F., Becker, B.M., Richardson, L.D. “Reasons for using the emergency department: results of the EMPATH Study.” Academy of Emergency Medicine 2005; 12: 1158 – 66.
3. Wuerz, R., Fernandes, C.M., Alarcon, J. “Inconsistency of emergency department triage. Emergency Department Operations Research Working Group.” Annals of Emergency Medicine 1998; 32(4): 431 – 5.
4. Emergency Consultants Inc.© Vukmir, R., O’Rourke, I. QualChart Information Systems Patient Management Program. Traverse City, MI. Revision 4.04; 2005 – 2006.