What number of visits to the Emergency Department are inappropriate?
13 Dec 2013
At least 11% of visits to accident and emergency departments in England between April 2011 and March 2012 were inappropriate, according to a study published in the open access journal BMC Medicine. With growing strain on emergency departments (EDs), researchers found that inappropriate visits were more common in deprived areas, amongst young adults and toddlers, and during bank holidays and weekends.
This is the largest ever study to investigate attendance to EDs, which looked into a total of 15,053,095 attendances in England. The researchers classified these as inappropriate and appropriate attendances. For the purpose of this study, inappropriate attendance was classified as an attendance that is self-referred, received no investigation and no treatment, and was discharged without any follow up or referral to primary care.
Figures recently released by the Health and Social Care Information Centre show that attendances to EDs have grown by 11% in the last 4 years. The rise in the people going to A&E could not only have a significant effect on the quality of care that patients receive but also place a financial strain on the NHS. The authors of the BMC Medicine article estimated the number of inappropriate attendances (1,721,276) between 1 April 2011 and 31 March 2012 cost nearly £100 million.
When investigating ED attendances it was found that both inappropriate and appropriate attendances were higher in deprived areas. The authors suggest that this is most likely due to the poorer health and greater risk of injury experienced in deprived areas. One way of overcoming the pressures put on EDs by inappropriate attendances would by the provision of additional primary care facilities in areas of deprivation.
When investigating inappropriate attendances it was found that there was a strong correlation to age. Most inappropriate attendances were for young children under the age of two and for young adults in their late teens and late twenties. For young children, it is thought that parents bring their children to A&E through concern and the belief that this is the most appropriate place to receive care for their child out-of-hours. The researchers were keen to point out that parents of young children shouldn’t be put off seeking medical help out-of-hours. The high number of inappropriate attendances seen in late teens and twenties is thought to be due to the lack of knowledge about health services available. Another factor is being unable to access primary care as they are still registered with their childhood GP after leaving home.
Measures should be taken to address the high number of attendances in these two age groups. The parents of young children should be educated about when it is appropriate to seek care at the ED and provided with details of other local health services available out-of-hours. School leavers and university students should be informed about appropriate attendance to the ED and encouraged to register with a local GP.
Timing was also found to have an effect on attendance to the ED, with inappropriate attendances more likely to occur on weekends or bank holidays. The authors believe that this probably due to lack of access to primary care services during these times and a reluctance to take time off work during the week to access these services. The lowest number of inappropriate visits occured during May, December and the Christmas period. These figures can be used to manage resources in EDs but also when to target campaigns about when to attend the ED.
The authors acknowledge the limitations of their study. They have defined inappropriate attendance based on criteria which differs from that of other studies and could potentially misallocate some attendances as it does not include inappropriate attendances from referral by primary care or the ambulance service. The data analysed does not contain additional information on why a patient attended A&E, such as their view of services available and their own views on appropriate attendance.
Lead author of the study, Philip McHale from Liverpool John Moores University, says: “Increased odds of attendance on weekends and bank holidays, in deprived areas and younger age groups, suggests that reduced access to primary care is an important factor in inappropriate attendances. The methods used here could form the basis of a monitoring system to evaluate the effectiveness of any interventions implemented to reduce inappropriate attendances.”
- ENDS -
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Notes to Editor
1. Who uses emergency departments inappropriately and when? A national cross sectional study using a monitoring data system
Philip McHale, Sara Wood, Karen Hughes, Mark A Bellis, Ulf Demnitz and Sacha Wyke
BMC Medicine 2013, 11:258 doi: 10.1186/1741-7015-11-258
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