Reasons why patients with primary health care problems access a secondary hospital emergency centre

Abstract

Emergency centres (ECs) provide emergency care to people with acute trauma and illness who require the services and expertise available at a hospital.1 However, the presenting complaints at an EC overlap considerably with those encountered at primary healthcare (PHC) level.2 Studies suggest that one-third to two-thirds of patients attend ECs with problems that could have been managed at a PHC level. 2-5The South African Triage Score (SATS) (previously known as the Cape Triage Score) 6-7 is routinely used at George Provincial Hospital to triage patients presenting to the EC to determine their acuity level and prioritise them accordingly. The five categories are red (immediate care), orange (very urgent care), yellow (urgent care), green (routine care) and blue (dead).A retrospective descriptive study at George Hospital in May 2010 to determine the after-hours case mix and workload 8 demonstrated that 65% of patients who presented to the EC after-hours were triaged green. This demonstrated that many low-acuity patients are seen in the EC. From the perspective of service delivery this 'inappropriate' attendance is problematic, as it competes for the attention of EC staff and potentially compromises the quality of care for more serious cases needing urgent treatment. A need was identified to determine the patient-specific reasons for presenting to a secondary hospital EC with PHC problems. MethodsGeorge Hospital is a secondary (level 2) provincial hospital in the Western Cape province of South Africa, providing healthcare to the population of the Eden and Central Karoo districts. The population numbers about 512 000, of whom about 140 000 live in George. 9 The health needs of the George community are served by 10 PHC clinics, a few mobile clinics, private practitioners, the private Mediclinic and George Hospital. There is no district hospital in the George subdistrict, and the PHC clinics offer no after-hours services. Everyone requiring healthcare after-hours, over weekends and on public holidays must therefore access the EC at George Hospital or use the private sector.The study was conducted between 5 March and 5 April 2012. A validated questionnaire 10 was refined to our setting after conducting a pilot study which included 30 patients.Convenience sampling was used. The SATS was used to identify all patients triaged as green. A questionnaire was then placed in the patient's folder by the nurse practitioner who did the triaging. The doctor who subsequently saw the patient obtained informed written consent from the patient. The duration of the presenting complaint, the referral source and whether the referral was appropriate were obtained. An inappropriate referral was considered to be a patient who was not admitted, did not need a procedure or special investigation, or was not referred to a specialty. The patient was then asked to select his or her two or three main reasons for attending the EC from a list of 17 options.Data were captured and analysed using Microsoft Excel 2003 software. Data were mainly descripti...

Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis

“…Only 13 of the 23 cross‐sectional studies reported a sample size justification or power description or provided variance and effect estimates. It was not possible to calculate the response rate for one study, due to insufficient detail given 18. However, for the 22 studies that did provide this information, the mean response rate was 77% and the range was 45% to 99%.…”

“…Three studies did not provide sufficient information about ethical or research approvals and two studies lacked information about the considerations of the relationship between the research and the patient. Some studies used multiple methods incorporating a range of qualitative methods across whole populations, while others employed simpler designs with less comprehensive samples, for example, multisite studies using focus groups and interviews39 and multisite surveys24 compared to single‐site qualitative studies 18…”

“…Anticipated waiting times for appointments and PCPs (including GPs) being busy were key factors,40, 41, 42 with one study reporting that 44% of patients found their GP “inaccessible to their needs.” This was also linked to patient perceptions around accessibility and availability of appointments at times of day that were convenient to patients,43 limited PCP opening hours,44 with a small proportion of patients reporting that they were unable to obtain a PCP appointment 38. Lack of primary health service available after hours was raised by one study 18. Another factor was lack of awareness of other services, with one study reporting that seven of 30 patients who attended ED had no knowledge of alternative primary care options 38.…”

“…Published literature suggests that some of the increase in demand is attributable to people with primary care problems who use emergency and urgent care services to access care,18 and some studies suggest that large proportions of patients (10%–60%) can be managed using lower‐acuity‐care services 19. However, this is not the only reason and factors contributing to increased demand for emergency and urgent care are often complex and multifactorial.…”

“…Other studies have reported that patients bypass their primary care physician (PCP; also known as a general practitioner [GP]) and instead go directly to urgent or emergency care,22 particularly for out‐of‐hours care and in urban centers 23. Factors such as perceived superior treatment at hospitals,18 lack of access to other care,24 a belief that the problem was serious enough to warrant emergency treatment,24 and lack of awareness of other services19 have all been reported as potential reasons why people choose emergency and urgent care and thus may all impact on why demand for these services is continually increasing. The aim of this study was to systematically review the related literature and, using narrative synthesis, to identify the factors behind patient decisions to access urgent and emergency care, including why patients access emergency and urgent care and how and why they choose which service to access.…”