Emergency Departments And Effects Of Non Urgent Cases

Emergency Departments And Effects Of Non Urgent Cases Emergency Departments (EDs) are under increasing pressure and increases in numbers of patients deemed inappropriate or some which could be seen by alternative providers are all a burden on the ED and the health service in general. Over recent years there has seen an increase of attendances at EDs of more than 20% with the majority being primary care cases. Recent changes to the GP contracts in 2003 have also had an impact on increases in attendance to EDs. There is a potential saving of in excess of  £120 million if patients attended the appropriate health service provider either GPs, walk in centres or by self treating and asking a pharmacist. Patient education and good promotion of the Choose Well campaign could reduce these numbers and therefore do away with the need to have to potentially turn away non-urgent cases. Introduction EDs are under increasing pressure to deliver high quality care due to rising attendances. Over the period from 2007-2010 there has been an overall increase in attendance at EDs of England of 20.9%. There was an increase of 10.7% in attendance between the period 07/08 to 08/09 (12,318,051 attendances in 07/08 and 13,794,072 in 08/09) 11.4% increase between 08/09 and 09/10 (15,569736 attendances in the period 09/10). There have been numerous attempts to try and stem the rise in ED attendances including offering patients guidance, making them aware of the consequences and informing them of the alternative health services available. A GP ED Triage Pilot conducted by Sheffield Teaching Hospitals NHS Foundation Trust and Sheffield General Practitioner Collaborative in March 20101 which was conducted to ensure patients were seen in the most appropriate location and by the most appropriate health care professional found that cases deemed to be actual primary care cases amounted to 19%. From this study it could be said that approximately 20% of attendees could potentially have been seen by a general practitioner in primary care rather than attending the ED but this is very small sample and many more studies would need to be carried out looking at different departments to be able to draw a more definitive conclusion. Applying 20% would therefore estimate that for the year 2009/10 in England approximately 3 million attendees were candidates for primary care. The estimated cost of seeing these patient in the ED based on the cost of  £56 for treating a minor ailment and  £75 for a standard (average cost  £65.50) totals  £196.5 million. Doctors consultations in primary care settings are the most cost effective part of the medical component of the NHS at  £15- £30 (averaging  £22.50), GP consultations cost less than out-patients appointments, ED and ambulance calls (ambulance calls costing  £255 per patient). Therefore the cost of treating the 3 million potential primary care/GP patients in the GP setting would total  £67.5million which would save the NHS a potential  £129 million.2 These values are only for normal working hours. Most non-urgent cases actually occur out of hours which would actually increase this amount even further with even more potential savings. The above costings are currently being changed to new Health Care Resource (HRG) code costings which are slightly less which could reflect lower savings than those calculated.3,4 The choose well campaign North West estimated the national cost to the NHS of treating minor illnesses is  £2 billion a year.5 The new system will have 11 different HRG groups, opposed to the current three Groups. The new HRG codes mean you must code both investigations and treatments, as opposed to investigations alone6 (appendix 1). This review hopes to come to an understanding why these patients use the emergency department rather than GP surgeries, barriers to other forms of care and access to GP surgeries and therefore answering the question whether emergency departments should be able to turn away non-urgent cases. Other points which will be taken into account are the ethical dilemmas associated with potentially turning patients away and the potential repercussions of doing so. Method and literature review A search was performed using Lancaster Universitys metalib data base which searched Scopus, Springerlink, Science Direct and Ovid Medline and Pub Med data bases. After accounting for duplicates and reviewing titles and abstracts, papers were selected for review. Search criteria included the terms, non-urgent, emergency department, primary care. The date was initially limited to 1996 2010 but on further searches earlier articles were allowed in order to search for historical articles. The search was also limited to humans and English language. The Department of Health website and the Primary Care Foundation website were also used to find current legislation and data. Database Limits Results OVID Medline emergency department, non-urgent primary care year-1996-2010 humans, English 25 Pub Med 12 Springerlink 19 Science Direct 72 Why patients attend the emergency department There is no formal definition of what is deemed an appropriate attendee to the emergency department due to peoples own impressions of what they believe to be an emergency. This leads to inappropriate attenders who could have legitimately seen their own GP. The types of patient who attend inappropriately and their decisions to do so are complex and involve social, psychological and medical factors.7 Urgency is also a term which is difficult to define and to measure. Studies have been carried out which have measured urgency but there is such wide variation on what is deemed urgent the results are subjective. Due to this subjective nature when defining urgent it is important to be consistent and have appropriate and qualified medical professionals determining the urgency of a situation using set criteria. In an early study Lavenhar et al described an urgent problem as one that requires medical attention within a few hours.8 This definition is used in this review. It has also been found, what medical professionals deem as non-urgent is often not perceived the same in the patient and the urgency of the situation should be based on the presenting signs and symptoms and not the eventual final diagnosis.9 Patients have been seen to attend the ED for many reasons including, the following: They deemed their condition/illness to be appropriate for the ED They believed the GP would refer them anyway The GP surgery was too far to travel to The GP surgery was closed A friend or family member felt it appropriate For those patients who deemed their attendance to be appropriate for their illness or condition it would be very difficult to convince them otherwise and such patients generally attend the ED for reassurance that there condition is not serious and is not going to get any worse. Such patients also have high anxiety, and a sense of urgency and self diagnose yet have no formal medical knowledge.9-12 Those who believed that their GP would have referred them anyway thought they would cut out the middle man. The patients found to do this in a study carried out by Palmer et al deemed their condition to be bad enough and that their GP would refer them, and attending their GP prior to attending the ED would just be a waste of time13 this study also found that pain was a major factor patients took into consideration when deciding on where to attend. Pain itself being subjective and open to individual interpretation. Those that found the GP surgery to be too far to travel were patients who generally lived in rural areas where the distance to both GP and ED were significantly far away and patients therefore decided they may as well attend the ED rather than the GP to save time in the event that the GP would just refer them anyway. Those patients for whom the GP surgery was closed mainly attended out of hours or at weekends. These patients generally thought their condition was urgent and couldnt wait until the surgery reopened.11,12 For attendees who were advised by friends and family to attend the ED did so purely on this advice and the majority of which would not have done so without this advice. This included people advised by colleagues, first aiders and schools where responsibility for the patient was in someone elses hands and the person advising did so in order to protect themselves.12,13 Another major factor to consider when looking at why patients attend the ED is the decision making capabilities of the patients themselves. This would include social, psychosocial and medical factors. Padgett and Brodsky14 proposed a three stage model which outlined how the stages of decision making interacted between the three different stages within the model. The three factors were predisposing, enabling and need. The decision making stages being recognising the problem, deciding to seek treatment and the decision on where to get the treatment. Predisposing factors which are part of stage one included the age, sex, race, level of education, family and social support available. The enabling factors, stage 2 were the income of the patient, usual source of care, proximity of the source of care and the perceived accessibility of this care source and the factors contributing to the need, stage three, were symptom recognition, evaluation of need, level of distress and psychiatric co-morbidity. Padgett and Brodskys three stage model14 Barriers to Care The above predisposing factors are also forms of barriers to care and are dealt with by patients in many different ways. Patient education would be a major tool for breaking down such barriers.11 This is the aim of a local and national campaign called Choose Well. This is a campaign that is supported by the NHS and its staff and aims to ensure people who need advice and treatment for common complaints, get fast and expert care.5 The North West has seen an increase of 177,000 patients in the ED over the last two years and hoped the Choose Well campaign would reduce this over the winter of 2010/11. The North West NHS estimated that 1 in 4 ED attendances were due to patients who could have self treated or could have been seen by other health professionals elsewhere. Offering guidance in both GP surgeries and EDs would give patients the information for themselves to determine the urgency of their condition. This information could include what definitely should be seen at the ED and what definitely shouldnt. Where this is a good idea and has the potential to work well however it could potentially cause patients with urgent problems to believe that they are non-urgent therefore putting them at risk of harm. On the other hand it could also cause some patients to deem themselves urgent and attend the ED when they were initially happy to attend their GP practice adding to the non-urgent caseload. The Choose Well campaign briefly describes the types of conditions that should attend the ED as an emergency and gives contact numbers for patients to ring in order to get further information on where is best for them to attend. This may be difficult for some patients; particularly the elderly as navigating around a website may be difficult or impossible and at a time when you are not well or believe to be in an emergency situation this could be valuable time needed for treatment. It does however offer valuable advice for minor injuries and illnesses known not to be life or limb threatening and could possibly eliminate the need for these patients to enter the health service at all reducing overall numbers and costs. Does Choose Well make a difference? The Choose Well campaign North West sent out a survey (appendix 1) to determine the number of people who had made alternative decisions to attending the ED and whether the messages from the campaign had reached the local people. The survey results are not yet available but Merseyside NHS was successful in increasing the level of awareness amongst the people of Merseyside of the range of NHS services available to them over the winter of 2008 with 94,547 people using NHS Walk in centres in Merseyside, a rise of 18% from the year before and there was a drop in AE attendance of 6.4%, compared to the previous winter yet they still had high attendances to the ED with up to half of these potentially of the type that could have been treated by more appropriate NHS services.15   Many patients do not realise that there are cost implications and differences in cost between EDs and GPs and believe that it makes no difference whether they visit as all they want is a diagnosis regardless of who gives it to them.16 Many do not visit their GPs because of the appointment systems in place, and they are often unable to make an appointment and are therefore more willing to wait around in the ED where they are guaranteed to be seen rather than wait for an appointment at their GP practice. It has also been noted that when patients were unable to see their regular GP and were offered an appointment to see an alternative the decision was made to attend the ED rather than see the alternative.17,18 The opening hours of primary care facilities also do not satisfy the needs of some patients, those who work during the day may not be able to take time off from their daily activities to attend appointments which are set at the discretion of the GP practice rather than at the discretion of the patient such as in the evening, during the night and at weekends. Repeat attendees of the ED are found to make up a large proportion of cases. In a report by NHS Manchester19 who had registered 230,000 attendances per year at its three main sites showed that 13% of these attendances were frequent attendees (patients who attended the ED four or more times in a six month period) with the average number of times a frequent attender being 5.7 times. The report also suggested that this was inappropriate use of the ED and that patients needs were not being met by primary care providers. They decided to increase performance by putting in place best practice which was to include devising computer software that would identify the frequent attenders and allow GPs to see who they where so that they can make contact with the patients and inform them about their inappropriate use of the ED. The patients were sent letters stating key messages on the use of the ED and an information leaflet. The pro-forma letter which read An AE department is often not the best p lace to receive care for non-urgent problems or those that will need ongoing treatment. They do not have your medical records which included information about other medical problems both past and present, investigations, regular medication, and any allergies to medication. Not having this information can compromise the treatment you receive. The enclosed leaflet contains information about services other than AE departments which are available to you. à ¢Ã¢â€š ¬Ã‚ ¦.AE departments should be used when the problem is an accident or requires emergency treatment. We would request that you contact the surgery first when you have a health problem that requires some advice and/or treatment.19 This intervention was found in one GP practice to reduce the number of repeat attenders by 20%19 even though studies have shown that this would be the number of frequent attenders that would over time stop attending anyway without any form of intervention.20,21 In order to validate the results found the intervention should be compared between surgeries with some surgeries having intervention and some not having the intervention. GP services within the ED There has been an increase in the number of primary care doctors in EDs or based closely to EDs over recent years. This has been found to decrease the numbers of non-urgent cases seeking ED treatment in favour of a GP and has also reduced the number of unnecessary admissions to hospital. This sort of initiative requires team work and close working partnerships with both EDs and GPs which at times has be proven to be tricky due to differences in culture and beliefs. The primary Care Foundation has carried out research commissioned by the Department of Health, the study, which was carried out in May 2009, looked at different models of primary care across England practising within and alongside EDs. The number of patients deemed to be primary care patients were identified. It found that around half of all EDs did in actual fact have some form of primary care presence working within the ED and that between 10% and 30% of attendees were classified as primary care candidates.22 Discussion Ethical dilemma of turning patients away The four principles of ethics developed by Beauchamp and Childress23 must be taken into account when coming to a decision as to whether to turn patients away from the ED. The 4 principles approach takes into account that whatever our personal beliefs, philosophy, moral theory or life stance the care of patients is the most important factor. It could be said that turning patients away from the ED was going against the ethics of the health service in that it is considered freely accessible to all at any time. The Four Ethical Principles Autonomy Patients must be respected and must not be deceived and must be given adequate information. If patients are turned away then they are not given all the required information regarding their condition. Even though they would be advised to see their GP they may not do so. Beneficence and non-maleficence It may be seen as causing the patient harm by turning them away, they may suffer further pain or psychological trauma by not being seen. Justice Justice or fairness may be breached if patients are turned away. The health service is free at the point of entry and patients that are turned away may feel as if they are being denied care or treatment, even though they would be offered it at their GP practice for some this may not be possible or an option therefore denying them any form of care at all. Conclusion From the articles and documents reviewed it can be seen that non-urgent attendees at the ED are a drain on public funds and a time of economic instability and when there is a keen focus on service cuts and delivering value for money. In spite of the evidence and from reviewing articles I feel that it could potentially be detrimental to the health and well being of patients if they were to be turned away from the ED for non-urgent or minor conditions that could be seen in general practice. Turning them away could make them stop seeking medical treatment and could make them lose faith in the health service altogether. I believe that more patient education and greater access to GPs and primary care health professionals is what is required in order to reduce the numbers and therefore the cost of treating such patients. It is not the duty of the treating professional to determine the perceived severity of illness or injury a patient attends with but to offer them the care and support they need in order for them to continue their lives as they would like to. It is however the duty of health professionals to educate their patients and offer support on how they should deal with such illnesses and injuries so as not to have to attend or re-attend the ED. This could come in the form of information leaflets or just by talking to the patients and finding out their reasons for attending the ED rather than GPs and how things can be put in to place and organised for future patients to overcome the barriers to other forms of care. In 2003/4 there was a change in the GP contracts, following this there was an increase in ED attendances. The new contracts made changes to the after-hours access to GPs and allowed GPs to opt out of this area of care, this then resulted in the increase of after-hours presentations to the ED of GP cases.24 So in order to increase access there would need to be more GPs not opting out of the after-hours work or changing the contracts to omit the option to opt out of such. Even though there are provisions such as walk in centres and out-of-hours services people attend the ED, this could be due to the unfamiliarity of such places and lack of knowledge of the facilities available. More patient education and promotion of such centres would be required to ensure they are made aware to everyone in the event of requiring such services. Also the integration of primary and secondary care could help improve services for everyone by bringing GPs into the EDs and from a closer working partnership. Appendix 1 HRG code HRG name Band AE tariff ( £) VB01Z Any investigation with category 5 treatment 1 183 VB02Z Category 3 investigation with category 4 treatment 1 183 VB03Z Category 3 investigation with category 1-3 treatment 2 133 VB04Z Category 2 investigation with category 4 treatment 2 133 VB05Z Category 2 investigation with category 3 treatment 2 133 VB06Z Category 1 investigation with category 3-4 treatment 3 78 VB07Z Category 2 investigation with category 2 treatment 4 110 VB08Z Category 2 investigation with category 1 treatment 4 110 VB09Z Category 1 investigation with category 1-2 treatment 3 78 VB10Z Dental Care 5 52 VB11Z No investigation with no significant treatment 5 52 HRG codes and tariffs6 Appendix 2 North West Choose Well Survey If you or a family member had a minor illness or injury (for example a sore throat, backache, cough or cold), which is the first NHS service you would use for advice and treatment? (Please select one answer) Y/N Y/N Pharmacy Minor Injuries Unit GP/Doctor Look for advice on the internet Phone NHS Direct or look on their website Dial 999 NHS Walk-in Centre Go to AE Urgent Care Centre None of the above, I would look after myself Other, please state below If your first choice service was unavailable, which other NHS service would you contact next? (Please select one answer) Y/N Y/N Pharmacy Minor Injuries Unit GP/Doctor Look for advice on the internet Phone NHS Direct or look on their website Dial 999 NHS Walk-in Centre Go to AE Urgent Care Centre None of the above, I would look after myself Other, please state below If you are a parent or carer for children under 16 years of age, please complete questions 3 4. Otherwise go straight to question 5. Which age group are your children in? Y/N Y/N 0 4 years 10 13 years 5 9 years 14 16 years If your children had a minor illness or injury (for example a temperature, a sore throat, cough or cold, a small cut or a sprain), which is the first NHS service you would use for advice and treatment? (Please select one) Y/N Y/N Pharmacy Minor Injuries Unit GP/Doctor Look for advice on the internet Phone NHS Direct or look on their website Dial 999 NHS Walk-in Centre Go to AE Urgent Care Centre None of the above, I would look after myself Other, please state below 5. If you have selected AE or 999 in answer to questions 1, 2 or 4 above, please answer this question. Otherwise go straight to question 6. If you have selected AE or 999 in answer to questions 1, 2 or 4 above, can you tell us why you would make this choice? (Select as many as apply) Y/N Y/N You will receive the best quality care and advice You know that you are guaranteed to be treated You will be seen quicker than any other service The AE is closest to where you live You do not know where else to go In the past your GP sent you to your AE or told you to call 999 You would have chosen a GP, but are not registered with one In the past you were told to go to AE or to call 999 by another health service, e.g. pharmacy/NHS Direct You would have chosen a GP, but it is difficult to get an appointment Other, please state below Which of the following services do you currently use your local pharmacist store for? (Select as many as apply) Y/N Y/N Picking up a prescription Advice if your child has a high temperature Advice and treatment for a headache Advice and treatment for backache and other aches pains Advice and treatment for an upset stomach Advice and treatment for a urine infection Advice and treatment for treating coughs, colds flu Contraceptive advice Other, please state below Did you know that your local pharmacist store provides a confidential consultation area? Yes/No Did you know that your local pharmacist can offer you confidential advice and treatment without an appointment? Yes/No Would you consider using your local pharmacist for any of the following? (Select as many as apply) Y/N Y/N Contraceptive advice Advice if your child has a high temperature Advice and treatment for a headache Advice and treatment for backache and other aches pains Advice and treatment for an upset stomach Advice and treatment for a urine infection Advice and treatment for treating coughs, colds flu Other, please state below Do you know where to find information about late night and weekend opening hours for your local pharmacist? Yes/No Choose Well is an NHS campaign that aims to help people in the North West to understand which NHS service to use if they need fast and effective treatment for minor illnesses and ailments; and how to use 999 and AE services appropriately. Have you heard of the Choose Well campaign? Yes/No If yes go to Q 12; if no go to Q 13 Where have you seen or heard about the Choose Well campaign? (Select as many as apply) Y/N Y/N Local newspaper Local news websites PCT website Community radio Local radio Life Channel (GP TV) Bus advert Leaflet Signs on ambulances Other posters Word of mouth (someone mentioned it to you) Other, please state below Have you heard any of the following messages? Tick as many as appropriate. The number of people using AE and 999 services is continuing to rise One out of every four people who go to AE could have either treated themselves at home, or used another local NHS service You can get three free text messages, with details of your three nearest pharmacies by texting pharmacy to 64746 Your local pharmacy provides expert, convenient advice and treatment for minor ailments AE and 999 services are for life-threatening and serious conditions such as heart-attacks, strokes, breathing problems and serious accidents Get the right NHS treatment As a result of seeing these messages, if you or a member of your family has a minor illness or ailment are you less likely or more likely to use the following services (please select as appropriate). Less Likely More Likely Your local pharmacy Your local GP NHS Walk-in Centre or similar service Minor Injuries Unit Urgent Care Centre NHS Direct NHS Choices Website AE 999 To help us to get our campaign right, it would be really helpful if you could give us some information about yourself. Which age group do you fall in to? Y/N Y/N Y/N 16 19 40 49 70 79 20 29 50 59 80 89 30 39 60 69 90+ Gender please delete as appropriate Male Female Please could you tell us the first part of your postcode e.g. M22 or SK6 Ethnicity Please can you select the group that best describes your ethnic background White Y/N Y/N English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Traveller Other, please give details Mixed/Multiple Ethnic Groups Y/N Y/N White and Black Caribbean White and Asian White and Black African Other, please give details Asian/Asian British Y/N Y/N Indian Bangladeshi Pakistani Chinese Other, please give details Black/African/Caribbean/Black British Y/N Y/N African Caribbean Other, please give details Other Ethnic Y/N Y/N Arab Other, please give details Thank you for your time we really appreciate your help. If you are willing to help us to develop this project further, please fill in your contact details below Name Address Tel. No. Email address Taken directly from the Choose Well questionnaire5