Inappropriate utilization of emergency department services in Universiti Sains Malaysia hospital.

Abstract

Inappropriate utilization of Emergency Departments (ED) services may result in compromised management of patients requiring true emergency treatment. Significant attendance of non-emergency cases in ED was found in several countries. A cross-sectional study was conducted in Universiti Sains Malaysia Hospital (HUSM) to determine the proportion of the inappropriate cases and the utilization pattern by time (over 24 hours and within a week) and by diagnoses. A sample of 350 cases was randomly selected from ED-HUSM register of the year 2000. A decision flowchart, which was adopted from 4 guidelines, was applied to classify appropriate and inappropriate cases. There were 55% inappropriate cases in this study. The inappropriate cases increased considerably in early morning, late evening, during the weekend and early part of the week. Most common diagnoses of inappropriate cases were upper respiratory tract infections, mild acute gastroenteritis and urinary tract infections. Considerable attendance of inappropriate cases calls for interventions.

Full text

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26 Med J Malaysia Vol 59 No 1 March 2004
Introduction
Hospital Emergency Department (ED) serves a vital role
in the health care system and as the interface between
hospital services and the community1. As Hospitals ED
mostly provide 24-hour services2, it becomes easily
accessible to the public. However, some patients
attending ED have problems which can be treated in the
primary care services in the community3. These patients
and their conditions have been described as
inappropriate for ED services4.
Studies have reported inappropriate utilization of ED
services between 6.7% and 89%5. In 1992, the National
Hospital Ambulatory Medical Care Survey (USA)
identified 55.4% of the ED visits as non-urgent6.
In Malaysia, 38.3% of ED attendees were non-urgent
cases in Hospital Universiti Kebangsaan Malaysia
(HUKM) in 19987, and 35% in Hospital Kuala Lumpur
(HKL) in 20018. In both settings, it was reported as an
increasing trend.
The implication of inappropriate utilization of ED
services is enormous. Resources intended for the care of
the critically ill and injured patients may be diverted to
those not actually needing emergency care9. It may also
lead to inefficiency in delivering ED services9.
The purpose of this study was to determine the extent
and pattern of inappropriate utilization in ED of Hospital
Universiti Sains Malaysia (ED-HUSM).
Inappropriate Utilization of Emergency Department
Services in Universiti Sains Malaysia Hospital
ORIGINAL ARTICLE
This article was accepted: 29 May 2003
Corresponding Author: Lin Naing, School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
H G Selasawati, MD*, L Naing, MMedStat**, W A Wan Aasim, MMed (Anest)***, T Winn, DrPH*, B N
Rusli, PhD****
*Department of Community Medicine, School of Medical Sciences, **School of Dental Sciences, Universiti Sains Malaysia, ***Emergency
Department, Hospital Universiti Sains Malaysia, ****Deputy Dean (Research & Postgraduate Education), Deputy Dean Office, School of
Dental Sciences, Universiti Sains Malaysia
Summary
Inappropriate utilization of Emergency Departments (ED) services may result in compromised management of
patients requiring true emergency treatment. Significant attendance of non-emergency cases in ED was found in
several countries. A cross-sectional study was conducted in Universiti Sains Malaysia Hospital (HUSM) to determine
the proportion of the inappropriate cases and the utilization pattern by time (over 24 hours and within a week) and
by diagnoses. A sample of 350 cases was randomly selected from ED-HUSM register of the year 2000. A decision
flowchart, which was adopted from 4 guidelines, was applied to classify appropriate and inappropriate cases. There
were 55% inappropriate cases in this study. The inappropriate cases increased considerably in early morning, late
evening, during the weekend and early part of the week. Most common diagnoses of inappropriate cases were upper
respiratory tract infections, mild acute gastroenteritis and urinary tract infections. Considerable attendance of
inappropriate cases calls for interventions.
Key Words: Emergency department, Inappropriate utilization, University hospital

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Inappropriate Utilization of Emergency Department Services in Universiti Sains Malaysia Hospital
Med J Malaysia Vol 59 No 1 March 2004 27
Materials and Methods
A retrospective review of hospital registration and
patients' record from 1st January to 31st December 2000
was conducted to determine the proportion, pattern and
common diagnoses of inappropriate cases of ED in
HUSM. The study population were cases from ED-
HUSM, numbering 33,126 cases10. All cases except
referral cases were included in the sampling frame. By
using systematic random sampling, a sample of 350 was
selected. The above sample size was calculated for the
expected proportion of 30% inappropriate utilization of
ED, with a precision of 5% at 95% confidence level.
The classification of appropriateness of ED utilization
into appropriate and inappropriate was based on a
decision flow chart. This flow chart was developed
based on four guidelines the triage guidelines from
HKL8, HUKM, American College of Emergency Physician
(ACEP)11, and the explicit ED criteria of Davis Medical
Centre, University of California9. The initial drafted
decision flow chart was reviewed by ED experts such as
the ED head departments of HKL and Hospital Kota
Bharu (HKB). In order to classify each and every case
into appropriate or inappropriate, the 6 steps described
in Table I were applied. If a case was noted to be
appropriate in any step, (example, in step 1, arriving by
ambulance), the subsequent steps were omitted.
Basically, the inappropriateness is classified after
exhaustively ruling out
appropriateness in all 6 steps.
all possibilities of
A pilot study was conducted in May 2001 on 80 cases at
ED-HUSM. Two ED experts were asked to review
identical sets of ED case records, by using the proposed
decision flow chart. The agreement (Kappa statistic)
between the two experts was 0.851 (asymptotic standard
error of 0.07, p value <0.001), which was considered
almost perfect agreement12.
Detailed medical record for each of the study sample
was obtained from the record office. The data collected
were age, sex, address, date of visit, day of visit, time of
visit, mode of arrival and triage category. Other
information such as clinical presentation, findings of
physical examination, results of investigation done,
diagnosis made and the management or treatments
given were also collected. Based on our decision flow
chart, the cases were classified by the researcher into
appropriate or inappropriate ED utilization. With the
help of two experts from each study setting, the
classifications of cases were further verified. The
experts involved were a family physician from HUSM, a
senior registrar with long experience working in ED-
HUSM, the ED head unit of HKB, and a senior registrar
with long experience working in ED-HKB. In case of
any discrepancy of the classification, the researcher and
the ED experts came to a conclusion after further
discussion. However, there was almost complete
agreement with the classification made by the
researchers.
Data were entered and analyzed using SPSS version
10.013. Proportions of inappropriate ED cases with its
95% confidence interval (CI) were determined.
Frequencies, percentages and appropriate charts were
presented for the pattern of utilization over 24 hours,
within the week, and by diagnoses.
Results
Table II shows descriptive characteristics of ED cases
ED-HUSM in the year 2000. The total sample reviewed
for this study was 350 cases. Age of inappropriate cases
ranged between day 5 of life up to 80 years old. The
mean age was 31.8 years (SD 19.4). There were more
male than female in the inappropriate cases, while there
were slightly more female than male in the appropriate
cases.
From the total sample of 350 cases, the proportion of
inappropriate cases was 55%. Its 95% CI was 49.8% and
60.7%. The 24 hours utilization pattern was shown in
Figure 1. Three peaks of ED visits of inappropriate cases
are shown in Figure 2. These were between 8 to 10 AM,
2 to 4 PM and 8 to 10 PM. However, appropriate cases
as shown in Figure 3 increased gradually over 24 H with
its peak around 8 PM.
The day trend within weeks is shown in Figure 4.
Obviously inappropriate ED visits increased during and
near the weekend. In the study setting, the working
week-days start from Saturday till Thursday afternoon.
The diagnoses of inappropriate cases and their
distribution are presented in Table III. Upper respiratory
tract infection (URTI), mild acute gastroenteritis (AGE),
urinary tract infection (UTI) and conjunctivitis were the
most common diagnoses among inappropriate cases. It
represented more than half (57.8%) of the total
diagnoses of inappropriate cases.

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ORIGINAL ARTICLE
28 Med J Malaysia Vol 59 No 1 March 2004
Table I: Detail description of steps in the decision flowchart
Step 1: On arrival
Condition
Arrive by ambulance
Paramedic run
Referred cases
Walk-in
Step 2: Triage selection
Condition
By color coding
Red/yellow
Green/blue
Step 3: Presentation
A. The following presentations will be determined as "appropriate":
1. Severe chest pain
2. Respiratory distress/Failure
3. Severe concussion/Open fracture of skull
4. Severe asthma/Acute exacerbation of asthma
5. Severe burns - more than 20% of body surface in adult and 15% in children
6. Shock - Hypovolemic/Cardiogenic/Neurogenic/Anaphylactic or other causes of shock
7. Polytraumatised/Multiple injured patient
8. Unconsciousness/Comatose
9. Severe bleeding
B. The following presentations need further assessment:
1. Allergy or hay fever23. Diarrhea
2. Anxiety
3. Mild back pain, able to walk without assistance
4. Drug or alcohol detoxification
5. Dysuria (mild), female
6. Mild eye irritation without sign of infection
Decision
Appropriate
Appropriate
Appropriate
Further evaluation
Decision
Appropriate
Further evaluation
24. Chronic dizziness
25. Sexual disease exposure
26. Constipation, 3 days or less
27. Minor contusions or abrasions
28. Mild cough (without hemoptysis), ear pain or
respiratory impairment
29. Minor headache without neuralgic impairment
30. Minor rectal pain or itching
31. Chronic recurrent hematuria
32. Minor skin sore, not infected
33. Immunizations and (-globulin request
34. Joint pain,
35. Lice or scabies (suspected or real)
36. Trauma follow-up (minor injuries originally treated
elsewhere)
37. Mouth blisters
38. Wound check
39. Vaginal bleeding - minor (1 pad in past 6 hours)
40. Pregnancy testing
41. Prescription refills
42. Vaginal discharge
43. Upper respiratory infection symptoms
7. Foot problems (blister, pain, ingrowing toenail, wart)
8. Dental problems
9. Chronic sinusitis
10. Minor skin infection, sore
11. Hepatitis exposure or symptoms
12. Sore throat
13. Sleep disorder
14. Localized sunburn without blisters
15. Suture removal
16. Muscle aches
17. Neck pain (no history of acute trauma)
18. Painless urethra discharge
19. Physical examination requests
20. Pruritus without rash
21. Simple, localized rash
22. Weakness - appears well

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Inappropriate Utilization of Emergency Department Services in Universiti Sains Malaysia Hospital
Med J Malaysia Vol 59 No 1 March 2004 29
Step 4: Physical examination
A. The following physical signs need further assessment:
1. Temperature
2. Respiration
3. Blood Pressure
35oto 38.5oC (38.3∫C for age >60 years old)
12 to 20 per minute
90 to 160 mm Hg systolic
60 to 110 mm Hg diastolic
60 to 110 per minute4. Pulse
B. The following physical signs will be determined as "appropriate":
1. Physical signs (listed in step 4.A) with outside the limits mentioned above
2. Glasgow Coma Scale of less than 12
3. Burns >20 % in adult and >15 % in children of body surface.
Step 5: Investigation
If the following investigation were requested, it will be considered "appropriate":
1. Imaging studies; radiography, ultrasound studies, computer tomography, Magnetic resonance imaging
2. Laboratory tests on body fluids: e.g. ABG, electrolytes, and blood urea nitrogen
3. Tests not on body fluids; e.g. ECG, EEG, slit lamp examination
4. Otherwise, further evaluation is needed.
Step 6: Management
The following management will determine as "appropriate":
1. Hospitalization or IV fluids treatment
2. Restraints
3. Oxygen
4. Specialty consultation
5. Prescription medications administered in ED (other than tetanus mmunization or oral analgesics)
6. Treatment of an orthopedic problem by splinting with plaster, knee immobilizer, crutches, or by reducing a fracture
or dislocation
7. Transfusion of blood products
Table II: Characteristics of 350 ED cases in HUSM in the year 2000
Inappropriate
(%) N
Characteristic Appropriate
(%) N
Age (year)
0-15
16-30
31-45
>45
76 (39.6)
39 (20.3)
23 (12.0)
54 (28.1)
45 (28.5)
41 (25.9)
36 (22.8)
36 (22.8)
Gender
Male
Female
106 (55.2)
86 (44.8)
75 (47.5)
83 (52.5)
Ethnic group
Malay
Chinese
Indian
Other
178 (92.7)
8 ( 4.2)
4 ( 2.1)
2 ( 1.0)
136 (91.3)
8 ( 5.1)
2 ( 1.3)
3 ( 1.9)

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ORIGINAL ARTICLE
30Med J Malaysia Vol 59 No 1 March 2004
Fig. 1: Utilization pattern over 24 hours of ED-HUSM in the year 2000
Table III: Diagnoses and distribution of inappropriate cases in ED-HUSM in 2000
Diagnosis
1. Upper Respiratory Tract Infection
3. Mild Acute Gastroenteritis
4. Urinary Tract Infection
5. Conjunctivitis
6. Wound Dressing
7. Nail Prick Injuries
8. Neonatal Jaundice
9. Chicken Pox
10. Eczema
11. Absconded
12. Measles
15. Hemorrhoid
16. Pyrexia of Unknown Origin for investigation
17. Request Medication
18. Mumps
19. Anxiety
20. Myalgia
21. Haemoptysis? Pulmonary Tuberculosis
22. Constipation
23. Lymphoma
24. Jaundice for Investigation (Adult)
25. Acne Vulgaris
26. PV Bleeding - Post menopause spotting
27. Uterine Fibroid
28. Change Continues Bladder Drainage
29. Cataract
Total
No ( % )
68 (35.4)
16 ( 8.3)
14 ( 7.3)
13 ( 6.8)
10 ( 5.2)
9 ( 4.7)
8 ( 4.2)
6 ( 3.1)
6 ( 3.1)
6 ( 3.1)
4 ( 2.1)
4 ( 2.1)
4 ( 2.1)
4 ( 2.1)
3 ( 1.6)
3 ( 1.6)
3 ( 1.6)
2 ( 1.0)
2 ( 1.0)
1 ( 0.5)
1 ( 0.5)
1 ( 0.5)
1 ( 0.5)
1 ( 0.5)
1 ( 0.5)
1 ( 0.5)
192 ( 100)

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Inappropriate Utilization of Emergency Department Services in Universiti Sains Malaysia Hospital
Med J Malaysia Vol 59 No 1 March 200431
Fig. 2: Time pattern of inappropriate cases over 24 hour in the year 2000
Fig. 4: Utilization pattern by days of the week of ED-HUSM in the year 2000
Fig. 3: Time pattern of appropriate cases over 24 hour in the year 2000

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ORIGINAL ARTICLE
32Med J Malaysia Vol 59 No 1 March 2004
Discussion
Three hundred and fifty cases that attended ED-HUSM in
the year 2000 were sampled. Classification of
inappropriate ED attendance based on our decision
flowchart showed reasonable agreement between the
researcher and ED experts. Therefore, it has been
considered that the decision flow-chart developed in
this study is reasonably appropriate in the local setting.
This study revealed that the proportion of inappropriate
cases were 55% in ED-HUSM. Although there may be
differences in classifying appropriate and inappropriate
cases, our finding of a considerably high proportion of
inappropriate cases is comparable with other studies:
59.4% in a study done in Saudi Arabia,1455.4% in a study
in US,6and 40.9% in another study done in US15. This
indicates widespread inappropriate utilization of ED for
non-emergency conditions.
Burnett and Grover revealed in his study that the peak
arrival time at the ED was around 10 AM and 1 PM16. In
our setting, the obvious increase of inappropriate cases
(Figure 2) between 8 to 10 AM. It is interesting to note
that this is the beginning of office hours. The second
small peak, 2 to 4 PM is the final part of office hours.
The last biggest peak is between 8 to 10 PM which
coincide with the highest peak work load of appropriate
cases (Figure 3).
It is worth noting that during the first peak, primary
health clinics or Outpatient Department (OPD) are
accessible. The possible explanation for this is that the
OPDs are crowded and the waiting times are long.
Patients felt that by going to ED, they would get earlier
treatment and be able to go back to work or schools. It
was also suggested that some patients came to ED for
medical leave certificate in the early morning17.
The evening peak might be their most free time. Asaari
reported that the attitude of public seeking treatment at
ED was at their convenient time and avoiding traffic
congestion during daytime.8Furthermore, type of
occupation, such as day-workers or night-time-workers
or shift-workers might determine the reason for seeking
ED treatment at their convenient hour 8.
There was an increasing trend during the weekend
when all outpatient clinics and primary health clinics are
closed. Burnett and Grover also reported that the lack
of regular source of primary care might be a factor that
brings such patients to the emergency department16.
The heavy attendance in outpatient clinics just after the
weekend may also explain why inappropriate cases are
still high in ED during the early part of the weekdays. It
is understandable that over crowding at out patient
departments may drive patients to ED as they expect to
get faster treatment. URTI contributed the most common
diagnosis of inappropriate cases (35.4%), mild AGE was
8.3%, and UTI was 7.3%. The ED was also utilized for
other inappropriate cases such as to change continuous
bladder drainage urinary catheter, skin diseases,
gynecological problems, wound dressing and others as
in Table II. These cases can easily be managed at the
out patient clinics or other primary health clinics.
For wound dressing, ED was particularly utilized during
the weekends or public holidays. This cannot be
avoided in our setting, as the continued treatment is
actually needed for these cases while the primary care
are not accessible. Perhaps health care providers should
consider alternative solution, which should be
community-based to overcome these problems.
Patients who absconded after registering (3.1%) in ED-
HUSM were also noted. The reason for this might be
explained by long waiting time as well as over crowding
of the ED. Similarly, Bindman suggested that long
waiting times resulted in number of patients leaving ED
without being seen18. This also suggests that they were
most probably inappropriate attendees.
Several research questions were raised. Who are these
inappropriate users? What are the reasons and factors
for this peak inappropriate utilization? What would be
the appropriate services for them? Are the ED services
compromised due to this peak inappropriate utilization?
It is important to answer these questions before taking
any intervention for this problem.
The main limitation in this study is the lack of a standard
measurement to determine the difference between
appropriate and inappropriate utilization condition of
ED services. Patients presenting to the ED sometimes
did not fall neatly into the two categories of appropriate
or inappropriate but instead lie somewhere in a
continuum. It is possible that some may be
misclassified. However, the decision flowchart used in
this study was validated as best as possible with locally
available expertise.

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Inappropriate Utilization of Emergency Department Services in Universiti Sains Malaysia Hospital
Med J Malaysia Vol 59 No 1 March 2004 33
Acknowledgements
We would like to thank the Universiti Sains Malaysia for
providing us with the Short Term Grant No. 304/PPSP/
6131173 which enabled this study to be conducted.
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Conclusion
Inappropriate utilization of ED services in HKB and
HUSM during the year 2000 were more than 50%. This
is a high level of inappropriate ED utilization. The study
also revealed the utilization pattern in ED and has open
for several research questions.