Rural emergency department use by CTAS IV and V patients

EM Advances

CJEM 2008;10(3):209-214

Abstract

Résumé

Introduction

It is well known that many emergency department (ED) visits are considered less- or nonurgent (level IV or V as classified by the Canadian Triage and Acuity Scale [CTAS]).1-3 The reasons for these visits have been the focus of several studies, as many health care personnel consider such ED use inappropriate. They believe that less- or nonurgent problems should be treated in other health care settings, such as walk-in clinics or family physician (FP) offices.4-11 Many reasons have been suggested for less- or nonurgent ED use, including convenience,12,13 not having an FP12 and a lack of awareness of other treatment options.14 Boushy and Dubinsky discounted the notion of convenience by demonstrating that less- or nonurgent ED use can prove frustrating for patients because many of these visits are associated with lengthy wait times or negative interactions with ED staff. The latter often believe they are providing care that should be sought elsewhere.14

A study conducted by Field and Lantz in 200615 identified various reasons why CTAS IV and V patients use a tertiary care ED. Some of the most common reasons included: 1) patients felt they required a specific service offered by the ED; 2) they believed their condition was urgent; or 3) they were referred to the ED by a community member. The same authors also found that having or not having an FP bore no relation to rates of ED use by CTAS level IV and V patients. Our study undertook to determine if the reasons CTAS IV and V patients presenting to a low-volume rural ED are similar to those identified in an urban tertiary care setting.

Methods

Design and setting

Based on the model used by Field and Lantz,15 our cross-sectional patient survey was conducted over a 2-week period (24 h/d) in December 2006 at the South Huron Hospital ED in Exeter, Ontario. This 24-hour emergency care provider with a local population of 4000 treats approximately 10 000 patients per year. Our survey was approved by the South Huron Hospital Medical Advisory Committee.

Subjects

Using the Canadian Emergency Department Triage and Acuity Scale (CTAS),3,16,17 we defined less-urgent patients as CTAS level IV and nonurgent patients as CTAS level V (Box 1). All arriving patients were seen by a CTAS-certified triage nurse and assigned a CTAS acuity level (Box 1). Those who were triaged into these acuity levels were asked to participate in the study and they were given a cover letter that described the nature of the study, requested their involvement in the study and informed them that their participation was voluntary and confidential. For those who did not wish to participate, "void" was written on their survey when it was returned uncompleted.

Data collection and analysis

Each participant was given a questionnaire with 9 questions (Appendix 1). Survey results were tabulated and the data analyzed using Microsoft Excel (Microsoft Corporation, Redmond, Washington).

Results

During the 2-week study period, 141 patients were eligible for the study. Of them, 137 (97.2%) completed the survey and were all grouped together as less- or nonurgent for the purpose of analysis.

The majority of patients were from the local area and had an FP (Table 1). More than one-third of the respondents had already seen a physician for their problem (53 patients, 38.7%). Just over one-half of all patients (51.1%) had had their nonacute medical problem for more than 48 hours before presenting to the ED. Forty-two patients (30.7%) stated that they were referred to the ED for care (Table 1). When this latter group was further analyzed, 32 out of 46 of respondents indicated that a health care worker had recommended the ED visit (Table 2). The sum of patients for this subanalysis exceeds the study denominator because some patients cited more than 1 reason.

Many patients came to the ED because they did not have immediate access to primary care (Table 3). More than 20% of respondents reported that they presented to the ED because their own FP office was closed. Another 16.8% stated that they could not wait for an appointment with their own FP, while 24.8% stated that they went to the ED because the alternative site (i.e., a walk-in clinic) was closed. Only 4.4% listed not having an FP as the reason for their visit. Many (38.7%) felt that they needed treatment as soon as possible, while another 32.8% felt an ED-specific service, such as radiography, suturing, IV medication or casting, was required (Table 4).

Discussion

We found that there are many reasons why patients present to an ED with less- or nonurgent medical problems. This is consistent with previous literature.4-11,15 Previous investigators have suggested that a shortage of FPs could be partly responsible for ED use by this group of patients.18 Contrary to this belief, the vast majority of patients in our study had an FP (89.1%), which was similar to the results reported by Boushet and Dubinsky a decade ago.14 Furthermore, only 4.4% claimed to be using the ED because they did not have an FP. This agrees with the recent urban Canadian study published by Field and Lantz in 2006.15 Having an FP does not seem to prevent less- or nonurgent ED visits in this setting; moreover, not having one did not seem to contribute further to ED use, although here the numbers are too small to be certain.

Lack of access to primary care has often been suggested as a contributor to ED use.4,8,9,12,13,15 This was demonstrated in our study with patients presenting because their FP's office was closed (21.9%), because they could not wait for an appointment (16.8%) or because the walk-in clinic was closed (24.8%). Suggesting that diversion of these less- or nonurgent patients away from the ED if primary care access was available may not be without risk.1,19 In addition, these patients do not contribute to overcrowding and use only a small proportion of ED resources.2,12,19,20 Providing primary care to this group in an ED may be more cost effective than opening an additional health care facility. Such a facility would also require additional personnel, personnel who are lacking in most small Canadian communities.

Many of our patients reported being referred to our rural ED for care. Burnett and Grover21 reported 40% of patients were referred to their urban ED. In their study, the majority of those who referred these less- or nonurgent patients were health care professionals. This was confirmed in our study. More education may be needed to prevent less- or nonurgent patients from being directed to the ED when other options exist in the community.

Previous studies have demonstrated that patients' perceived urgency led to less- or nonurgent ED visits.4,21-23 Our study supports this finding. In this sense, patients used the ED appropriately. A patient's perception of urgency has been shown to vary greatly from that of a physician's.8,9,11,24 More than one-half of the study patients reported having their medical problem for more than 48 hours. Furthermore, 38.7% of patients had already seen a physician for their less- or nonurgent medical problem. These results may indicate patient dissatisfaction with their usual source of primary care, a suggestion that was previously raised by Sarver and colleagues.18 It is also possible that some patients are using the ED to obtain a second opinion.

Many patients presented to the ED with less- or nonurgent problems because they believed they required a specific service provided by the ED. The most common of these services was radiographs, which was the same reason cited by a number of other researchers.1,13,22 However, radiographs are offered by our local walk-in clinic, which is open 364 days a year. The walk-in clinic also offers casting, suturing and dressing changes. This finding may suggest that the public is unfamiliar with the walk-in clinic and the services it offers, or that they find the convenience of the ED's 24-hour-a-day availability more attractive than clinic hours. Even if public education made them aware of these alternate resources, there is little evidence that such sources of care will reduce the number of less- or nonurgent patients visiting the ED.13,19

Limitations

This study is limited by its relatively small sample size, single site location and brief seasonal sampling period. Moreover, the location is unique because it has a walk-in clinic in a rural setting. Further research should explore the reasons for choosing the ED for less- or nonurgent problems when alternate sources of primary care are open and available.

Conclusion

In this low-volume rural setting, the main reasons for many less- or nonurgent patients to present to the ED included the fact that they had an FP but had difficulty accessing timely care, that they were referred to the ED or that they perceived they needed specialized care.

The recent primary care reform movement has put together teams of health care providers. Goals of these teams include improving access to primary care and increasing the number of services available. A further study should be conducted to determine if the number of less- or nonurgent ED patients decreases as a result of this paradigm shift in the delivery of primary care.

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