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European Journal of Internal Medicine 24 (2013) e13e14

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Letters to the Editor

Reasons for inappropriate attendance of the Emergency Room in a large metropolitan hospital '
Keywords: Emergency Room Inappropriate attendance Overcrowding

Major changes in the health-care systems of western countries occurred in the last few years, owing to the increasing age of the population, need to balance with cost resource availability and development of new diagnostic tests. This has led to a signicant overcrowding of Emergency Rooms (ER) [1], resulting in a global impairment of this service, increasing waiting times for attendants and a heavy burden of physical and mental stress for ER operators. Many people attending the ER have non-urgent conditions, that should instead be dealt with by the family doctor or the specialist in non-urgent settings. The reasons leading to the inappropriate use of the ER have been only partially investigated [25]. To develop and adopt organizational countermeasures, it is necessary to understand those more in-depth reasons. Our goal was to investigate the inappropriate access to the ER of a major metropolitan teaching hospital, as a rst step towards the elaboration of alternative strategies to deal with non-urgent cases. This survey was conducted in the ER of the Maggiore Policlinico Hospital of Milan (Italy) by physicians and nurses of the Emergency Department. A questionnaire-based interview, prepared with the additional input from sociologists of the Bocconi Business University, was delivered by nurses to 583 people referring to the ER for nonurgent complaints over an 8-month period. According to the color codes assigned to ER patients, white codes and the majority of green codes are assigned to people affected by mild complaints, who should therefore be considered inappropriate users of the ER. However in this study it was decided that interviewers should not be cognizant of the complete medical records of the patients. Therefore a denition of appropriate and inappropriate uses of the ER was developed independently of the assigned code, but based on the time pattern of symptom onset according to the following criteria: - appropriate cases: those who attended the ER for a sudden health problem - inappropriate cases: those who attended the ER for a long-lasting problem - hybrid cases: those who attended the ER for a long-lasting problem that had suddenly re-emerged, or for a long-lasting problem that had worsened in the last few hours. The questionnaire interview was administered by nurses to cases according to the forementioned criteria. The questionnaire consisted of forty questions, with limited possibilities of double answers, with

We wish to thank Dr. G. Cavalca and Dr. S. Sabatinelli. The questionnaire in Italian language is available upon request.

a few control questions in order to verify the coherence of answers. The questions dealt with the demographic and socio-economic conditions of the interviewed cases, their reasons for attending the ER, degree of trust towards the ER and attitude towards other territorial medical services, particularly their family doctor. Data were analyzed by means of SPSS. Two-thirds (63.9%) of the interviewed patients were classied as green codes, and 36.1% as white codes. In terms of main demographic features, the most notable nding was that people with higher education level had more frequently an appropriate attendance to the ER (59.3% vs. 49.5% for people with lower education levels). Table 1 shows that the most frequent reasons for attending inappropriately the ER included the possibility to obtain all the necessary examinations at the same time and pragmatic reasons such as that the ER being the fastest or the nearest solution to tackle the actual complaints. Other reasons were the declared impossibility to wait for the scheduled visiting hours of the family physician and the advice given by pharmacists, relatives and friends to attend the ER. A minority of people mentioned an economic reason (ER chosen as the cheapest option). A relation between long-lasting complaints and need for a comprehensive and fast solution appeared evident. A relevant proportion of inappropriate attendances was by people with no family doctor (15.9%). This percentage reached 36.7% in the group of patients attending the ER to solve a long-lasting problem (the most evident cases of inappropriate access to the ER). 21.7% of patients with symptoms lasting three or more days answered that it was not possible to wait for the visiting hours of their family doctor: a reason very hard to be real, because it does imply that the doctor was not available for as long as three days. Only 11.3% of people declared dissatisfaction for the services provided by their family doctor (particularly for what concerns the inconvenience of their visiting hours). There was a higher degree of dissatisfaction among people with a higher education level, with less dissatisfaction in elderly people. More than 95% of the interviewed people declared a signicant condence in the ER of the hospital, with a higher level of condence among those who had already been in the ER. A specic question concerned the time interval between the decision to attend the ER and the moment people started to move to reach it. Assuming that a problem considered truly urgent leads the patient to take a rapid decision, inappropriate use of the ER was conrmed by nding that 34% of people waited for more than 2 h before moving to the ER, for various reasons listed in Table 2. ERs are, by denition, medical structures that should deal only with cases needing intensive and rapid interventions for acute clinical problems. Accordingly, the pertinence of the services that the ER offers to non-urgent cases is very limited, so that inappropriate attendants are often obliged to prolonged waiting times, thereby causing their own dissatisfaction and worsening of ER overcrowding [15]. Moreover, ER interventions lacks by denition continuity (follow-up procedures are not expected). On the other hand, people are often attracted by the clinical and diagnostic competences of the ER and the possibility to perform laboratory and instrumental investigations and specialist consulting while spending a relatively limited amount of time and money. In this study the reasons for inappropriate access were evaluated through a

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e14 Letters to the Editor Table 2 Time awaited before moving to ER and reasons for waiting. 12 h 23 h 4 or more hours N At work/studying 21% Unpostponable engagement 12% Sudden impediment 15% Could wait some more hours 10% Waited for health improvement 3% Transport problems 26% Difcult access to specialist ofces during receiving hours Others 50% Total 17% 52% 44% 52% 30% 15% 41% 77% 50% 41% 27% 44% 33% 60% 82% 33% 23% 42% 86 34 27 69 39 99 13 4 371

Table 1 Reasons for inappropriate access to the Emergency Room (multiple answers were possible). N of answers Possibility to carry out all necessary examinations Fastest solution for the complaint Closest solution Cheapest solution Suggested by a pharmacist Could not wait for family doctor visiting hours Suggested by relatives/friends Total 232 187 169 12 99 97 60 856 % answers 27% 22% 20% 1% 12% 11% 7% 100 % cases 41% 32% 30% 2% 18% 17% 10% 153

questionnaire administered by nurses to the people who attended the ER of a large metropolitan hospital, in which 86% of cases are classied as white or green codes. Inappropriate ER attendance resulted to be 12% among white codes, but this prevalence is lower than the real one, because it was obtained according to the study denition of inappropriate access, considering only the time of onset of the problem rather than its clinical relevance. The main reasons for attending the ER were related to convenience: facilities for a quick and complete clinical evaluation, possibility to do all the necessary exams and to be visited by competent specialists. A high condence in the ER does partially explain the inappropriate behavior, especially if associated to a difculty to reach the family doctor during their visiting hours, even though no real dissatisfaction for the services of the family doctor was declared. A high education level was associated with a more appropriate use of the ER, thus emphasizing the positive role of information campaigns with the aim to contribute to solve the problem. In conclusion, the decisional process that takes a person to the inappropriate attendance of the ER is complex and calls for a number of social, psychological, medical and organizational factors. The specic combination of these elements is probably unique for each ER and each patient and also depends on the local supply and organization of health care facilities. At least three possibilities are suggested to improve the inappropriate use of the ER: - the creation of ofces with multiple family doctors available 24 h daily, to give a real-time answer to health complaints of people in non-critical conditions; - the organization of family doctors ofces close to the ER where non-urgent cases should be addressed, with the possibility of an ER evaluation if necessary; - the development of an information campaign to emphasize why and when attendance to the ER is inappropriate, and the negative consequence of this for the community. Limitations of this survey are the denition of appropriate and inappropriate attendances to the ER, based upon the onset of the problems leading to the ER, without considering the clinical relevance of the problem and that probably led to a signicant under-estimation of inappropriate cases, and the limited number of patients included in

the study, even if representative of the overall proportion of white and green codes. Some characteristics of our hospital (i.e. the presence of specialists like earnosethroat 24/24 h) are not present in other hospitals, but they only partially explain the overcrowding and inappropriate attendance of the ER.

Conict of interest All authors declare that there is no actual or potential conict of interest, including any nancial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately inuence or be perceived to inuence their work.

[1] Davidson SM. Understanding the growth of emergency department utilization. Med Care 1978;16:12232. [2] Elshove-Bolk J, Mencl F, van Rijswijck BTF, Weiss IM, Simons MP, van Vugt AB. Emergency department patient characteristics: potential impact on emergency medicine residency programs in the Netherlands. Eur J Emerg Med 2006;13:3259. [3] Kooiman CG, Van De Wetering BJM, Van Der Mast RC. Clinical and demographic characteristics of emergency department patients in the Netherlands: a review of the literature and a preliminary study. Am J Emerg Med 1992;7:6328. [4] Murphy LAW. Inappropriate attenders at accident and emergency department I: denition, incidence and reasons for attendance. Fam Pract 1998;15:2332. [5] Padgett DK, Brodsky B. Psychosocial factors inuencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery. Soc Sci Med 1992;35:118997.

Fernando Porro Valter Monzani Christian Folli Division of Emergency Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy Corresponding author. Tel.: +39 0255033602; fax: +39 0255033600. E-mail address: Folli) 26 October 2012