Adequate emergency department resource usage

Abstract Introduction: More than 80% of patients who visited Emergency Department (ED) was not urgent in Taiwan in 2019. It causes insufficient medical services and a latent fiscal threat to the Nation Health Insurance (NHI). This study adopted simulation-based educating modules to explore the effect in teaching competence among primary and middle school teachers for efficient AEDRU (adequate emergency department resource usage) education in the future. Method: The subjects were 414 elementary and junior high school teachers in Taiwan. 214 participants attended the simulation-based workshop as the simulation-based group, whereas 200 participants took an online self-learning module as the self-learning group. The workshop was created by an expert panel for decreasing the unnecessary usage amount of ED medial resources. The materials are lecture, board games, miniature ED modules, and simulation-based scenarios. A teaching competence questionnaire including ED knowledge, teaching attitude, teaching skills, and teaching self-efficacy was conducted among participants before and after the intervention. Data were analyzed via McNemar, paired t test and the generalized estimating equations (GEE). Results: The study showed that teachers who participated in the simulation-based workshop had improved more in teaching competence than those who received the online self-learning module. In addition, there were significant differences between the pre-test and post-test among the two groups in teaching competence. Conclusion: The simulation-based workshop is effective and it should be spread out. When students know how to use ED medical resources properly, they could affect their families. It can help the ED service to be used properly and benefits the finance of the NHI. The health care cost will be managed while also improving health.


Introduction
Taiwanese citizens or any person working in Taiwan that possesses a National Health Insurance card, has the privilege to access the National Health Insurance program (NHI). It is well known for its cost-effective and comprehensive coverage for quality medical treatment for the Taiwan population and its legal aliens. Over 99% of residents have attended in this system in 2019. [1] However, the quality and medical services have aggravated the abuse of the precious hospital resources. According to government publication, each Taiwanese used medical resources at an Outpatient (OPD) and Emergency Department (ED) an average of 17.3 times in 2019. [1] Moreover, there were 7.12 million the Taiwanese residences who visited the ED once or more in 2018. [2] The overflowing of emergency stations could crowd out not only patients with critical conditions but also build up distrust of the medical system by the general population. [3,4] In fact, there were <2 out of 10 persons who really need immediate medical treatment. [2] Patient dissatisfaction, unintended infections, and risks to patient safety with crowded EDs are a great challenge to healthcare workers. [5][6][7][8][9] This vicious cycle of unnecessary ED visits has also accumulated into an uncontrollable raise in health insurance. It cost 3.9% of the GDP (Gross Domestic Product) in 2020 in Taiwan, [1] and it has become an important topic to manage health care costs while balancing the coverage of health insurance, where properly early education is one of the most effective ways in reversing the abuse of the valuable ED system. Studies of promoting adequate ED resource usage (AEDRU) have been conducted extensively and several health policies have been developed accordingly. [10][11][12] Most of the studies focused on public health and insurance policies, the improvement of the health care system, and media advertisement resolutions [13][14][15][16] ; but the importance of school education from the perspective of a professional health promotion educator (instead of merely from a health policy perspective) with concepts of AEDRU is uncharted. Since the challenge of NHI cannot be solved by discipline alone, the interdisciplinary cooperation between school education and medicine could be a way forward. Despite individual preliminary knowledge of NHI and ED (i.e., personal experience, information from social news and official propaganda in schools), emergency response and AEDRU are essential topics for elementary and junior high school teachers to incorporate into classroom curriculum. In this way, this study will focus on evaluating the measure in promoting the Education modules for schoolteachers in passing on the AEDRU.
The simulation-based education module has been applied in medical education for years. [17][18][19] It provides effective learning environments for healthcare workers. With vivid teaching materials and scenarios, participants experience important concepts and practice skills without stress. As simulation-based module applied in surgery, clinical skills, disaster prevention, radiologists, technologists, and nurses training program, [17][18][19][20][21] but it was less seldom used in the lecture of the school teachers. Hence, the miniatures of medical facilities, simulation-based scenarios in ED, and simulation-based AEDRU board games were used in this study. Online education is an alternative solution, especially during the pandemic period. For example, students have been learning from home via online education during COVID-19. In this way, we also designed an onlinelearning educational module to provide comparison of the effectiveness between the two different modules. The participants were mainly first through ninth grade schoolteachers.
To study the effectiveness of AEDRU education, we selected two observation groups: one was lectured through simulationbased workshops and the other was an online self-learning module. Teaching competence was evaluated through knowledge, attitude, skills, and self-efficacy in a questionnaire. The research objectives are: 1. to assess the effects of the simulation-based learning module in AEDUR teaching competence among schoolteachers; 2. to assess the effects of the online self-learning module in AEDUR teaching competence among schoolteachers; and 3. to discover the effect on the teaching competence between two educational modules.
In addition, we provided the simulation-based material to school teachers as a reference for teaching method in the future. With better understanding of AEDRU, the non-essential visits to the ED from patients can be avoided and lessen the waste of precious NHI resources.

Study design and participants
This study adopted a quasi-experimental design and purposive sampling. The participants were elementary and junior high school teachers. The study information was published in a Facebook group, official electronic document, and the notice board of the education departments in different counties and cities in Taiwan. There were 456 participants who volunteered to conduct the study and chose which delivery system they preferred. Excluding the persons who did not complete the questionnaires, 214 teachers chose the workshop as the simulation-based group, whereas 200 teachers took the online self-learning module as the self-learning group. The missing value was 42. The proportions of participants in elementary school (43.5%) and in junior high school (56.5%) were nearly equivalent in both groups.

Simulation-based learning module development and implementation
An expert panel developed a simulation-based learning module which consisted of five professors in health promotion. Six primary and junior school teachers familiar to health promotion education also played a critical role. Finally, four emergency medicine clinical doctors and one ED administrator were also invited to identify and to explain important concepts of ED clinical practices. The panel discussion consolidated the topics within the curriculum of the simulation-based learning module.
Based on teacher empowerment concepts, the simulationbased learning module included a lecture of synergistic integration of the clinical ED principles, board games, medical facility miniatures, and simulation-based scenarios. The process of this module is: first, participants interacted with medical facilities miniatures, and acted out simulation-based scenarios with Q&A in small group activities. Second, the clinical experts explained important concepts within an ED with recent social events and news from public media to help teachers realize the health policy behind reasonable usage of ED resources. Third, the Health Education professors showed these concepts with AEDRU simulation-based board games in small group activities. Last, schoolteachers were encouraged to be more reflective when participating in board games to verify major principles in ED and synthesize information from the simulation-based scenarios that might help them to create curricular activity in schools. Professors also challenged and extended the voluntary teachers' conceptual understanding and teaching skills by discussing possible educational events in schools during health promotion. At the end of the simulation-based learning module, professors led postsimulation reflection to reinforce key concepts that can stimulate teachers' future educational activity in schools. The duration of the workshop was four hours, and it was implemented three times in northern, central, and southern Taiwan.

Online self-learning module development and implementation
The online program offered all information of the workshop including slides and related videos. The link of the online program was offered in the Facebook group or email (if the participants requested). It was available two weeks after all the simulation-based workshops. In the Online module: first, the participants watched AEDRU related videos which covered several ED issues. Then, they watched the slides of ED concepts and the presentation video from the clinical experts on the workshop. Last, they were able to share about their learning experiences online. The flowchart for research design and intervention is shown in Figure 1.

Questionnaires
The questionnaire used in this study was self-reported with closeended questions. It was divided into ED knowledge (10 questions), teaching attitude (10 questions), teaching skills (7 questions), and teaching self-efficacy (10 questions) in AEDRU. These sections were named "teaching competence." The content is shown in Table 1. The questionnaire was given before and after the simulation-based health education module or online selflearning module to provide quantitative information.
In the ED knowledge section, each correct response was valued as one while incorrect or "don't know," responses were scored as 0. Participants were asked to report their subjective teaching attitude to express their opinions in AEDRU, based on a 5-point Likert scale (1 = strongly disagree; 2 = tend to disagree; 3 = neutral; 4 = tend to agree; 5 = strongly agree). The items of teaching skill, and self-efficacy of the participants were rated on a 5-point Likert scale (from 1 = not confident to 5 = very confident).
The questionnaire took ∼15 min to complete. It was reviewed for content validity and reliability by the panel experts, and pilot tested on 20 schoolteachers. The content validity is 0.8 and the Cronbach's a of each item are between 0.68 and 0.96 that shows good reliability. Hence, this questionnaire has been developed appropriately and rigorously.

Statistical analysis
SPSS version 22 (IBM Inc., New York) was used in data analysis among two groups. The ED knowledge section in each group between the pre-and post-test used McNemar to do data analysis because it was categorical and matched-pairs data. [22] The sum of ED knowledge, teaching attitude, teaching skill, teaching selfefficacy sections in each group between the pre-and post-test were analyzed via paired t test due to continuous and matchedpairs data. [23] Moreover, the difference in the pre-test results of the teaching competence was analyzed via independent t test. Because this study adopted purposive sampling, it might have considerable difference in the pre-test results. Thus, we used the generalized estimating equations (GEE) to analyze the differences of teaching competence between different educational modules. GEE is used to estimate the parameters of a generalized linear model with a possible correlation between outcomes. The main advantage of GEE resides in the unbiased estimation of population-averaged regression coefficients despite possible misspecification of the correlation structure. It is applied in repeated measurements, and the correlated responses can be discrete or continuous. [24] For measuring the difference in    Questions in the questionnaire.

Items Content
Which description of ED resources is correct? (1)119 service is one of ED resources. (2)The functions of ED are receiving, sorting, assessing, stabilizing, and managing patients arriving at its door with different degrees of urgency and complexity. (3)All ED patients can get treatments in two hours. (4)ED means the express line of Outpatient Department(OPD). Q2 Which statement is wrong about the difference between OPD and ED? (1)OPD for elective appointments and ED for urgent situations. (2) OPD patients are served on an appointment schedule and ED patients are served on a triage system. (3)There are more resources in the ED than OPD. (4)The medical cost in ED is more than OPD. Q3 The activities in ED include (A)registering (B)clinical evaluation (C)triage (D)discharge or observation. Which sequence is appropriate?
According to the data in Jan. 2018 and Jan. 2019 from National Health Insurance Administration, the proportion of ED urgent cases is.
Which of these factors result in inappropriate usage of ED? (A)person medical right (B)less ED doctor (C)ED is 24/7 (D)people won't be refused using ED resources (E)affordable medical cost (1) Comprehending concepts related to ED resources is important. Q2 Positive attitude of AEDRU * is important.

Q3
Valid skills of AEDRU is important. Q4 To promote how to use ED resources appropriately at school is important Q5 It is important to implement the educational modules for AEDRU at school. Q6 It is important to have the educational materials for AEDRU at school. Q7 Educational website for AEDRU at school is important. Q8 It is important to promote AEDRU at school to increase students' knowledge.

Q9
It is important to promote AEDRU at school to improve students' positive attitude.

Q10
It is important to promote AEDRU at school to develop students' skills.

The effect on AEDRU teaching competence in each group among intervention
Teacher competence was divided into four sections: ED knowledge, teaching attitude, teaching skills and teaching selfefficacy. As shown in Table 2, the sum of scores of all sections in two groups are statistically significant between the pre-test and post-test via pair-t test. In the simulation-based group, the average accuracy in knowledge section was 85.19% in the posttest and it was 64.77% in the pre-test; the average score in attitude section was higher in the post-test (4.75) than it was in the pre-test (4.36); the average score in skills section was also higher in the post-test (4.31) than it was in the pre-test (3.65); and the average score in self-efficacy section was also higher in the post-test (4.16) than it was in the pre-test (3.42). There were similar outcomes in the self-learning group. The average accuracy in knowledge section, the average scores in attitude skills and selfefficacy sections were higher in the post-test than they were in the pre-test.
To examine the effect on each question in the knowledge section, the McNemar test was used to do data analysis because it Table 2 Comparison of each section in teaching competence by two groups among intervention. The attitude section was analyzed via pair-t test due to continuous and matched-pairs data. The simulation-based group got higher score in the post-test than in the pre-test in all of questions and there were significant differences between pre-test and post-test in all of questions. Although the self-learning group also got higher scores on the post-test than it did in the pre-test in all of questions, there were no significant differences between pretest and post-test in question A1, A2, A3 and A9.
The skills and self-efficacy sections was also analyzed via pair-t test. Both groups got higher score in the post-test than on the pretest in all of questions and there were significant differences between pre-test and post-test in all of questions.

The effect on the teaching competence between two groups
Before the intervention, the homogeneity of each section in the teaching competence among two groups was analyzed via independent t test. As shown in Table 3, there are statistically significant indicators in knowledge and attitude section but no significant evidence in the other two sections (skills and selfefficacy). Because this study had considerable differences in the pre-test results, we used the generalized estimating equations (GEE) to analyze the differences of teaching competence between different educational modules.
To examine the effect on the teaching competence, all of the sections were statistically significant (Table 4). "Time" (the reference time is pre-test), "Group" (the reference group is the self-learning group), and the interaction-"Time * Group" were the considering variances used to measure the difference in teaching competence between two groups among intervention. As shown in Table 4, "Time * Group" showed that there was a significant difference (P < .001) in ED knowledge and the accuracy of simulation-based group was improved by 0.056 Table 3 Comparison of each section in teaching competence by two groups before intervention via independent-t test.

Section
Group N M SD df t P  Table 4 The effect on the teaching competence via GEE analysis. There was also a significant difference in teaching attitude (P < .001), teaching skills (P < .001) and teaching self-efficacy (P < .001). Hence, the score of the simulation-based group was increased by 0.26 more than that of the self-learning group after the intervention in teaching attitude. It was increased by 0.18 more in the teaching skills and by 0.25 more in the teaching self-efficacy. The score range in attitude, skills and self-efficacy was 1 to 5.

Item
In addition, all of GEE analysis graphics showed that the slope of the simulation-based group is bigger than the self-learning group. The detail was presented in Figure 2. Therefore, the participants in the simulation-based module improved more than those in the online self-learning module in teaching competence.

Discussion
As Dr Himmelstein and Dr Woolhandler indicated, 530,000 American families (67%) suffer bankruptcies each year that are linked to illness or medical bills. [25] People impoverished by the huge medical debt continue to issue great challenge to modern society. [26,27] Although NHI in Taiwan is more than insurance and provides healthcare within affordable payment, [28] the financial situation of NHI has become worse since 2004. [29] Inappropriate ED usage is one of the major challenges for NHI.
Education might provide possible solutions but there are few related studies in Taiwan or other countries. [30,31] Considering the willingness, availability, knowledge of health promotion, and teaching skills of health promotion educators, factors appear to be well suited to fulfill supportive roles of the promotion of AEDRU at schools. Knowledge, attitude, and practice (KAP) surveys have been widely used to gather information in many subjects such as medicine, [32] public health, [33] exercise science, [34] economy, [35] and ecology [36] for years. It provides objective measurement of health education activities in changing health-related behaviors. Therefore, it was applied to this study to provide objective assessment.
Several courses regarding medical issues have adopted simulation-based education to connect the real situations over the years. [37] The simulation-based learning module induces participants' learning from operation via exposure, sequence, feedback, and repetition. [37] It is able to help participants improve more in knowledge, attitude and skills than those within a traditional learning module. [38,39] Piryani et al developed a oneday simulation-based workshop for 17 health educators to evaluate the perceptions of participants on simulation-based education and a simulation-based workshop. They used a questionnaire for measurement. The results showed that the simulation-based education was not only able to improve the doctor-patient communication skills but also enhance the ability in care and medical issues. [38] Another study was focused on 1178 medical students to process simulation-based education. The results pointed out that simulation-based education could improve the reflective capacity and communication of students. [39] The simulation-based learning module in this study also presented the positive effectiveness among schoolteachers in AEDRU.
In this study, we received positive feedback that many teachers expressed greater willingness to continue this topic as part of the health promotion course in school. Teaching competence is all improved in the ED knowledge, teaching attitude, teaching skills and teaching self-efficacy. The cumulative self-efficacy and KAP scores were higher in the simulation-based group compared to the self-learning groups.
Teachers participated in board games with simulation-based scenarios which included important concepts from different professions. The board game designed as the teaching material could encourage the teacher to imagine what the teaching activity will be like, and to engage challenges they might have in class. Teachers who were involved in the simulation-based learning module could use the teaching materials during real-time classroom interactions to a greater degree than those who learned from the online self-learning module.
During the study period, teachers all showed positive attitudes towards AEDRU, and they all demonstrated positive teaching attitudes in practicing the board games and scenarios in schools. Compared with the online self-learning module, the simulation-   based learning module not only provides teachers medical clinical concepts, but also emphasizes group interaction and discussion. Teachers could clarify content knowledge with clinical medical experts and learn teaching skills through interaction and discussion in the workshops. In summary, teaching competence in AEDRU improved substantially after the intervention. The simulation-based learning module is also able to enhance teacher empowerment. Teachers were encouraged to form an online community for discussion of practices and to be collaborative and especially reflective in their professional health promotion activity. The sharing of the resources that the teachers themselves created is also essential in bolstering efforts in effective lesson planning.

Conclusions
The simulation-based learning module proves effective and it should be spread. When students know how to use ED medical resources properly, their families will also benefit. Health care cost will decrease while also improving health outcomes if used correctly.
Health education in elementary and junior high schools in appropriate use of ED medical resources is important. Teachers' perceptions of the knowledge, teaching attitude, teaching skills, and self-efficacy were critical for their adoption of utilizing ED access. Through hands on learning experiences, teachers were able to see many facets of the simulation-based health education module and build their own understanding of the characteristics of the curriculum innovation at schools.
Through using the board game, ED miniature, and simulationbased scenarios, we recognized the key factor that leads to the success of accessing ED use reasonably, is the teaching activity of the teachers. We look forward to the participants playing an important role in the process of diffusion of AEDRU. They will apply the materials from the simulation-based learning module in class activities, and develop similar but innovative education modules in AEDRU to solicit the students' interest and attention. The promotion by and feedback from teachers are critical in future series research.