Provision for clinic patients in the ED produces more nonemergency visits

doi:10.1016/S0735-6757(99)90006-2

The American Journal of Emergency Medicine

Volume 17, Issue 1, January 1999, Pages 18-20

https://doi.org/10.1016/S0735-6757(99)90006-2 Get rights and content

Abstract

This study sought to evaluate how the addition of a general practitioner (GP) surgery influences the utilization of an emergency department (ED). An intervention trial with historical control was conducted in a Swedish university hospital ED. A GP surgery was established in the ED by the addition of GP physicians without the addition of other personnel (nurses, secretaries, aids). The number of persons evaluated and managed by the GP physicians and ED physicians were quantified preintervention (April 1992 to October 1993) and postintervention (April 1994 to October 1995). Further information was obtained by questionnaires distributed to all physicians and patients during three sample study weeks: 1 week before intervention and 6 and 18 months after the intervention. Patient volume, percentages of inappropriate visits, and types of services were recorded. The addition of GP physicians increased the number of visits to the ED by 27% (4,694 per month to 5,952 per month). The percentage of patients managed in the ED who had nonurgent complaints (primary health care needs) increased with the intervention from 22% (95% confidence interval [CI] 19%, 25%) to 33% (95% CI 30%, 37%). The increased demand on the ED of patients with nonurgent complaints increased the average waiting time for patients with urgent or emergent complaints from 35 minutes to 40 minutes (14%). The introduction of GPs to an ED increased the number and proportion of patients presenting to the ED with nonurgent complaints.

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Cited by (20)

ED patients: How nonurgent are they? Systematic review of the emergency medicine literature
2011, American Journal of Emergency Medicine
Citation Excerpt :
This review found no specific universal definition of nonurgent ED visits. Among the 2 definitions found, the most frequent was based on the concept of “delay of care” (11 articles): the delay of care ranged between 3 and 72 hours [11,24-26,31,32,39,44,49,52,54]. Five articles were based on the duration of symptoms before ED consultation [27,29,36,40,42]; for example, Buesching et al [29] define as nonurgent a patient who presented in ED more than 72 hours after an injury.
Nonurgent visits to emergency departments (ED) are a controversial issue; they have been negatively associated with crowding and costs. We have conducted a critical review of the literature regarding methods for categorizing ED visits into urgent or nonurgent and analyzed the proportions of nonurgent ED visits. We found 51 methods of categorization. Seventeen categorizations conducted prospectively in triage areas were based on somatic complaint and/or vital sign collection. Categorizations conducted retrospectively (n = 34) were based on the diagnosis, the results of tests obtained during the ED visit, and hospital admission. The proportions of nonurgent ED visits varied considerably: 4.8% to 90%, with a median of 32 %. Comparisons of methods of categorization in the same population showed variability in levels of agreement. Our review has highlighted the lack of reliability and reproducibility
Papanicolaou screening in an urgent care setting
2005, American Journal of Obstetrics and Gynecology
Citation Excerpt :
It is noteworthy that 151 patients presented with the complaint of vaginal bleeding, whereas only 7 (4.64%) were interpreted as “obscured by blood” and not satisfactory. There are many patients, when seen in an urgent care clinic, who believe that when a pelvic examination is performed, this is identical to “having a Pap smear.”6-10 When a system has a tracking system in place and the follow-up can be handled, this may be an opportunity to screen patients for CIN.
This study was undertaken to determine the efficacy of Papanicolaou (Pap) screening in an urgent care setting, and to compare the rates of cervical intraepithelial neoplasia (CIN), and follow-up in patients with and without established primary care.
All patients presenting with a complaint warranting pelvic examination between December 2000 and September 2001 underwent Pap screening. All patients were scheduled an appointment or follow-up visit when an abnormal Pap test was found. Charts were reviewed for cytologic interpretation, age, chief complaint, ethnicity, history of prior Pap smear in the institution, total visit history (includes urgent care and primary care clinics). SAS 8.1 was used for statistical analysis with the use of the Fisher exact test.
A total of 673 Pap smears were performed. Of those, 660 were analyzed and 13 were discarded because of inadequate slides. The mean age was 29.6 years; the ethnic distribution was 0.2% Native American, 1.2% Asian, 17% black, 62.4% Hispanic, 18.2% white, and 1.1% other. In the study population, only 40.6% of the patients had a prior Pap screen and 59.4% had not. There were 318 (48.2%) patients who had accessed care only through the urgent care clinic, and 342 (51.8%) patients who had established some kind of primary care in the past. The overall follow-up rate was 56% for any abnormal Pap smear, regardless of visit history.
Patients accessing medical care through an urgent care clinic exclusively had identical rates of CIN and follow-up when compared with patients with established care. Therefore, when a system exists to centrally process and triage cervical cytology, it is efficacious to screen for CIN in an urgent care setting.
A comparison of wait times and patients leaving without being seen when licensed nurses versus unlicensed assistive personnel perform triage
2004, Journal of Emergency Nursing
In today's health care environment, nurses are sometimes substituted with unlicensed assistive personnel (UAP), despite the lack of research into the possible negative effects. This study compared the wait time and the number of patients who left without being seen (LWBS) between triage systems that use nurses (including licensed practical nurses, nurses with an associate's degree, and nurses with a baccalaureate degree) versus UAP.
This study was a comparative descriptive retrospective chart review. The sample consisted of 2 parts: Part 1 involved charts for every fifth patient presenting to the emergency department during the second shift in April 1997 (N = 323) and April 1998 (N = 281). Part 2 included the monthly number of patients who LWBS between January 1997 and April 1998. Data were collected from department-generated reports with use of investigator-designed forms. Specific time increments were calculated and compared between triage systems via 2-tailed t tests. The number of patients who LWBS was analyzed for trends.
Wait time decreased by 73 minutes and the number of patients who LWBS decreased by 85% when nurses performed triage.
Results of this study show that a triage system using nurses provided more services during triage and were associated with less wait time after triage and a decreased likelihood of patients LWBS compared with the triage system using UAP.
The impact of general practitioners working in or alongside emergency departments: A rapid realist review
2019, BMJ Open
Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%–43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are ‘free to care for the sickest patients’. However, the research evidence to support this initiative is weak.
Rapid realist literature review.
Emergency departments.
Articles describing general practitioners working in or alongside emergency departments.
To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system.
Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes.
Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research.
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Realist analysis of whether emergency departments with primary care services generate ‘provider-induced demand’
2022, BMC Emergency Medicine
If you build it, will they come? Realist analysis of whether Emergency Departments with primary care services generate ‘provider-induced demand’
2022, Research Square

View all citing articles on Scopus

^☆: Supported by The County Council of Stockholm, Sweden.

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Original contributionProvision for clinic patients in the ED produces more nonemergency visits☆

Abstract

Ann Emerg Med

Am J Emerg Med

High consumers of health care in emergency units: How to improve their quality of care

Qual Assur Health Care

The use of the accident and emergency department

Arch Emerg Med

Delivery of primary care in hospital and community settings in Australia

Qual Assur Health Care

Management of minor medical problems and trauma: General practice or hospital?

J R Soc Med

Primary care in the accident and emergency department: I. Prospective identification of patients

BMJ

Introducing a community health center at Mosgiel, New Zealand: Effects on use of the hospital accident and emergency department

Med Care

Original contribution
Provision for clinic patients in the ED produces more nonemergency visits☆