Don’t waste time attempting to prevent the first visit to improve ED crowding
It’s been another trying flu season in the northern hemisphere—for patients and for emergency department (ED) providers. EDs that are crowded at the best of times come close to a tipping point, waits to be seen and for beds climb, and hospitals struggle to handle the load, sometimes coping by putting patients in hallways or lounges. Even well-written surge plans fall apart in the face of staff illness or unit outbreaks. The tension that can develop between staff and patients on the front line was described well recently by an emergency physician based in Ottawa, Ontario. Too often when trying to help the system cope, a hospital, health region, or government puts out a call for the public to stay away from crowded EDs unless absolutely necessary—but are such warnings ethical or effective?
My view on this issue is this: If a patient wants to come to the ED, they should; but if they don’t want to come, I don’t like them to be forced to do so. What I mean is that patients who feel they could safely be seen by their own primary care or specialist physician but were unable to access them ideally should have options other than the ED, but an anxious patient should always be welcomed. Another way I’ve expressed this to health system planners is: Let’s not waste time trying to prevent the patient’s first ED visit; let’s focus on preventing visits two through 10! If we get patients’ care right the first time, counsel them clearly, and arrange for proper follow-up, then ED volumes might drop as much or more than if we diverted the initial cases that someone (other than the patient!) feels could have been seen elsewhere.
In this month’s guest blog Dr. Paul Hannam, Chief of the ED at Michael Garron Hospital in Toronto, Ontario, looks carefully at the phenomenon of discouraging the public from using the ED and what the published evidence says about the underlying assumptions and effectiveness of this plan that is clearly doomed to fail.
—Dr. Howard Ovens, February 2018
Planning to Fail: Why Warning Patients to Stay Away from the ED Will Never Work
In February I received a message informing me that the influenza season was nearing its peak in my region, at least as measured by the surveillance systems in place in Southern Ontario in Canada. Regardless of whether the end is in sight, conditions in the ED have been challenging recently. Long lines of anxious people waiting to see a physician combined with tired-looking people in inpatient beds lining the hallway is a discouraging sight for anyone coming in to start a shift in a hospital, but it must be even more daunting for those seeking care. As the medical director in a community ED, I know that over the past few weeks we have broken several of our own records for the number and the acuity of the patients for whom we have provided care.
During or after such surges we and other care providers, administrators, and policy-makers are often left to reflect on the steadily mounting volume of patients coming to our EDs. Although flu season brings up these conversations, more and more people are seeking care in the ED year-round.[2,3] Many assume that low-acuity patients filling the ED are the cause of overcrowding even though we know this to be untrue. Well-intentioned drives to divert people away from the ED often focus on targeting the public with education campaigns, promoting telephone triage services such as Telehealth Ontario, and improving access to primary care even though these efforts have limited evidence of success in reducing ED visits.[5,6,7,8] Despite local and regional efforts, each year the pattern continues.
What’s going on? Is all this purely related to aging populations? Why are more and more people coming to the ED?
The 6 themes to classify patients’ motivations for visiting the ED
A review article published in 2017 may help answer these perplexing questions. The paper, which focused on studies from the United Kingdom and the United States and included cases from Canada, explores the motivations of patients and should remain a point of reference for both front-line providers and those involved in health care planning.
In the review article the authors identified six themes to classify patients’ motivations for visiting the ED, which I will explore further here:
1.Limited access to or confidence in primary care
Access to primary care is a frequent and important topic of discussion, but we often overlook the broader role of public trust in any health care profession. People are now more likely to seek health information from the Internet  in addition to advice from a physician, and trust in one type of provider is influenced by who else is available. This affects decision making about when and where to seek care. For those involved in planning, having a nearby clinic open after regular office hours may not affect ED visits for a given community if patients’ underlying priorities or preferences are not better served in the clinic setting. Demographic, cultural, and socio-economic factors influence this trust. For example, one study found that younger people were more likely to trust the services provided in the ED as opposed to those in a primary care setting. Marginalized populations such as immigrant communities also show a similar preference for care in the ED.[13,14]
2.The patient’s perceived urgency of their condition
Given how difficult it is to predict which patients require hospital admission solely on the presenting complaint in the ED , it should be no surprise that self-triage is difficult for the patient. The experience of illness and the perception of risk are inherently subjective, and we know that fear is a key driver of visits to the ED. Previous research has shown that people who perceive an urgent problem are not willing to wait more than one day for assessment , and as anxiety increases they will gravitate toward a setting in which their needs are met more quickly. These influences are dynamic and high-profile events will have a major effect on public perception and decision making.
One example of how current events affect health care decision making followed the tragic death in 2009 of 13-year-old Evan Frustaglio from Toronto, Ontario, due to complications related to H1N1 influenza. Despite usual efforts encouraging flu vaccination in advance of the flu season that year, media coverage of Evan’s death led to a sudden massive surge in public demand for the vaccine. The result was record-setting line-ups at clinics, vaccine shortages, and widespread anger over disparities in access for “preferred” groups.
3.Convenience in terms of opening hours and access to appointments
Accessing appropriate testing or services can be just as difficult for doctors as it is for patients, particularly in the outpatient setting. Examples include provider-centric procedures for testing or referrals to other specialists, the downloading of responsibility for scheduling and system navigation to the patient, and modes of communication that do not match community needs. These barriers to access can make it challenging or even impossible for the front-line provider to fully meet patient expectations during a single encounter. Depending on the reason for the visit or the time of day, it may be entirely logical for both the provider and the patient to recommend care in the ED, where there is better access to testing and more immediate referrals to other specialists.
The logistical realities of providing care in an outpatient setting are often overlooked in policy discussions regarding access to primary care. Blaming primary care providers for not providing after-hours care misses the point. A more constructive approach might be to examine the barriers primary care providers face—i.e., if a doctor is not able to access testing or other essential services after hours, it may not make sense for them to see patients at that time.
4.Views of family, friends, or health care professionals
Many studies have demonstrated the powerful influence of family, friends, and health care providers on the patient’s decision to seek care in the ED. In one Canadian study the majority of patients sought medical advice prior to presenting to the ED. Of the patients who called a physician’s office, 67 per cent received advice to attend the ED. Similarly, a 2004 Cochrane review of telephone triage systems (a Canadian example being Telehealth Ontario) did not demonstrate a decrease in ED usage, with one study reporting a non-significant increase.
5.The patient’s belief that their condition required the resources and facilities offered by a particular health care provider
The experience of care is framed in a much larger context of social influences and may be only partly related to the actions of a specific provider. If a patient feels strongly that their presentation is serious enough to require a certain set of resources/testing/facilities, they may be less likely to accept the same recommendations from a provider in another setting. Whether or not we as providers or policy-makers consider these opinions to be valid, we need to recognize them and work with them.
6.Individual patient factors
Individual patient factors such as unstable housing situations are known to affect access to care and overall health outcomes. The formal and informal barriers to accessing scheduled outpatient care are vast, but can be as simple as the costs associated with transportation to and from an appointment. We know that low socio-economic status has been shown to increase the rate of ED use in Canada , and that ED closures are more likely to affect marginalized populations. We need to ensure we understand each of the communities we serve if we hope to match health care services to their needs.
The 4 goals of patients: Understanding the cause and expected trajectory of their symptoms, reassurance, symptom relief and having a plan to manage their symptoms
Care providers and volunteers in the ED know that attempting to convince an anxious person waiting for care that they could have received care in another setting, regardless of the situation, is a losing battle. It’s also not helpful. As we are taught early in medical school and as reinforced in practice, we find that things go more smoothly when we listen to and validate the emotions of the patient. A more formal version of this conclusion was reached in a 2017 Canadian study that found patients in the ED share four basic goals, namely “understanding the cause and expected trajectory of their symptoms; reassurance; symptom relief; and having a plan to manage their symptoms.” These expectations relate to the motivations for seeking care in the first place, and remain fundamental to understanding patient behaviours.
These patient-level priorities should apply at the system level, as well. Rather than judging people for accessing resources, a more effective approach would be to accept the emotions and priorities of people looking for help and work on factors to address them. Simplistic solutions to redirecting patients away from emergency departments such as more public education have shown themselves to be ineffective and assume that the patient is the problem. As suggested in an opinion piece by a Canadian health care columnist, “What flu season does, more than anything else, is remind us that our health system is too often contemptuous of patients.” At the policy level, a patient-centred approach needs to focus on maintaining public trust, ensuring timely access to care, and minimizing the barriers faced by front-line providers.
In my view, the six themes presented above should influence both how we plan and provide care. A more detailed discussion belongs in another paper, but here are some of my own conclusions:
- The health-seeking behaviours of the patient in front of us may be entirely logical to that person and their circumstances even if they don’t fit a pre-conceived model of “appropriateness.”
- Blaming the patient for seeking care in an ED without providing an alternative that addresses their needs is unlikely to help in the short or long term. It certainly will not decrease future visits to the ED.
- The advice we offer as physicians or other front-line providers is interpreted in a much broader context. These other influences are powerful and dynamic. Our own expertise is only as valuable as the trust we maintain.
- Communities are showing us how they view and want to receive health care. Effective solutions at the policy level need to incorporate patients’ motivations for seeking care and the needs of the community being served.
As front-line staff in the ED we are on the sharp end of any mismatch between health care supply and demand. This is emotionally as well as professionally draining, and we feel a deep-seated need to advocate on behalf of our patients and ensure that those in power genuinely understand the magnitude of the situation. Instead of discouraging patients from coming to our EDs, staff and ED leaders should acknowledge that these visits may be the most appropriate option for care and help educate policy-makers about these realities so we can work toward effective solutions.
—Dr. Paul Hannam is Chief and Medical Director of the Department of Emergency Medicine at Michael Garron Hospital in Toronto, Ontario.
Dr. Hannam and Dr. Ovens have no conflicts of interest to declare.
- Lougheed T. Lougheed: ER patients, we know how long you’ve been waiting. Ottawa Citizen. 2018 Feb 17. http://ottawacitizen.com/opinion/columnists/lougheed-er-patients-we-know-how-long-youve-been-waiting. Accessed 2018 Feb 19.
- Health Quality Ontario. Under Pressure: Emergency department performance in Ontario. Toronto, ON: Queen’s Printer for Ontario; 2016.
- Tang N, et al. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010;304:664-670.
- 4. Schull M, et al. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49(3):257-264.
- Morgan S, et al. Nonemergency department interventions to reduce ED utilization: a systematic review. Acad Emerg Med. 2013; 20(10):969-85.
- Nagree Y, et al. Telephone triage is not the answer to ED overcrowding. Emerg Med Austral. 2012;24(2):123-126.
- Lake R, et al. The quality, safety and governance of telephone triage and advice services – an overview of evidence from systematic reviews. BMC Health Serv Res. 2017;17:614.
- Blanch V. Campaign to reduce wait times at Moncton ER not working. CBC News. 2018 Feb 5.
- Coster J, et al. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137-1149.
- Hesse B, et al. Trust and sources of health Information: The impact of the Internet and its implications for health care providers: findings from the first health information national trends survey. Arch Int Med. 2005;165:2618-2624.
- Cuffee Y, et al. Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. Am J Public Health. 2013;103(11):e55-62.
- Benger J, et al. Why are we here? A study of patient actions prior to emergency hospital admission. Emerg Med J. 2008;25(7):424-427.
- Tozer A, et al. Socioeconomic status of Emergency Department users in Ontario, 2003-2009. CJEM. 2014;16(3):220-225.
- Norrendum M, et al. Motivation and relevance of emergency room visits among immigrants and patients of Danish origin. Eur J Public Health. 2007;17(5):497-502.
- Raven M, et al. Comparison of presenting complaint vs. discharge diagnosis for identifying “nonemergency” emergency department visits. JAMA. 2013;309(11):1145-1153.
- Rising K, et al. “I’m Just a Patient”: Fear and uncertainty as drivers of emergency department use in patients with chronic disease. Ann Emerg Med. 2016;68(5):536-543.
- Love M, et al. Commitment to a regular physician: how long will patients wait to see their own physician for acute illness? J Fam Pract. 1999;48(3):202-207.
- Friscolanti M, et al. The flu shot screw up. Maclean’s. 2009 Nov 16.
- Krebs L, et al. Low-acuity presentations to the emergency department in Canada: exploring the alternative attempts to avoid presentation. Emerg Med J. 2017;34(4):249-255.
- Bunn F, et al. Telephone consultation and triage: effects on health care use and patient satisfaction. Cochrane Database Syst Rev. 2004;(4):CD004180.
- Callaham M. The prudent layperson’s complicated and uncertain road to urgent care. Ann Emerg Med. 2017;70(6):871-874.
- Ross N et al. The Contribution of Neighbourhood Material and Social Deprivation to Survival: A 22-Year Follow-up of More than 500,000 Canadians. Int J Environ Res Public Health. 2013;10(4):1378-1391.
- Hsia R, et al. Factors associated with closures of emergency departments in the United States. JAMA. 2011;305(19):1978–1985.
- Centor R. To be a great physician you must understand the whole story. Med Gen Med. 2007;9(1):59.
- Vaillaincourt S, et al. Patients’ perspectives on outcomes of care after discharge from the emergency department: A qualitative study. Ann Emerg Med. 2017;70(5):648-658.
- Picard A. What’s really to blame for ER congestion? The Globe and Mail. 2015 Jan 6, updated 2017 Jan 1. Available at: https://www.theglobeandmail.com/opinion/dont-blame-the-flu-for-er-congestion/article22309794/.