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Two Types of Prehospital Systems Interventions that Triage Low-Acuity Patients to Alternative Sites of Care
Abstract
This study retrospectively compared alternatives for navigating low-acuity patients in two emergency medical services systems. System A involved a response to every 9-1-1 request with an "evaluate, treat, and refer" process, in which paramedics decided whether patients could be treated on-scene and referred to a primary care provider or urgent care center. System B used a "telephone triage and referral" process, in which callers of low severity were diverted from 9-1-1 to call centers where nurses provided advice and/or a referral to a primary care provider/urgent care center. We hypothesized that systems A and B would differ in terms of the percentage of patients following referral instructions and the percentage of patients who were satisfied with their care.
Independent variables were age, sex, and ZIP code. The two outcome measures were whether the patient followed the instructions given and patient satisfaction. χ(2) tests and multivariate logistic regression were used.
Controlling for age, sex, income, and race, patients in system A had a lower likelihood of following instructions (odds ratio 0.31; 95% confidence interval 0.14-0.69). Satisfaction rates were high (>93%) but equivalent.
The odds were lower that callers in system A would follow instructions. Satisfaction rates suggest that people are willing to accept alternatives to transport to the emergency department and high percentages of patients follow the instructions given.
... Many studies have shown the mitigation of both low acuity EDU and cost of care via case management interventions [2,4,6,[11][12][13][14][15][16][17]. The use of community health workers and patient education has also resulted in a significant benefit [2][3]6,16,[18][19][20][21]. Other studies have analyzed various interventions that have been shown to decrease non-urgent EDU such as the creation of additional non-ED capacity (including walk-in hours or additional/extended business hours) [3,18,22]. ...
... While cost-sharing appears to reduce EDU [3], patient financial incentives seem to be not as effective [18,26]. Although some studies note equivocal rates of EDU reduction with diversion interventions [9,24], several studies have shown the success of pre-hospital diversions [27], including 911 telephone triaging and personally escorting patients from the ED to the clinic [18][19]21]. ...
... Finally, our study demonstrated a positive association between walk-in clinic availability and our practice census. We know that PCP follow-up [3][4]6,25] and office education [2][3]6,16,19,21] are investments that ultimately enhance value-based care by reducing unnecessary EDU. Thus, investing in PCP access via interventions like walk-in clinic hours has the feed-forward effect of enhancing PCP follow-up and the subsequent office education thereof. ...
Background
Emergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems.
Methods
A retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic.
Results
Over the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits (91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $825,902.
Conclusion
Extended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.
... High risk of bias in the studies was based on inadequate allocation concealment, 18 non-blinding of staff and participants, 12 13 19 20 selective outcome reporting 11 16 18 and lack of compliance with the study protocol among the participating staff. 16 The cohort studies were assessed as being of moderate [21][22][23][24][25] quality with the primary methodological limitation being a lack of details on comparability between the cohorts (see online supplementary file 3). 21-23 25 diversion characteristics ...
... the aid of computerised decision support, assessed, triaged and provided advice to the patients, including asking patients triaged and not requiring an ambulance whether they still preferred ambulance transport. In the study by Krumperman et al, 24 low-severity calls were diverted from emergency call centres to nurse call centres, in which nurses used evidence-based protocols to provide patients' instructions and referrals to primary care providers or urgent care. 24 Nine studies assessed the impact of an EMS-based strategy: five studies assessed a 'treat and release' strategy in which paramedics assessed and treated low-acuity patients at the scene 11 14 15 19 22 while four studies assessed strategies in which ambulance crews either diverted low-acuity patients to a minor injury unit (MIU), 16 a community-based falls service, 12 13 or transported intoxicated patients to a detoxification centre. ...
... In the study by Krumperman et al, 24 low-severity calls were diverted from emergency call centres to nurse call centres, in which nurses used evidence-based protocols to provide patients' instructions and referrals to primary care providers or urgent care. 24 Nine studies assessed the impact of an EMS-based strategy: five studies assessed a 'treat and release' strategy in which paramedics assessed and treated low-acuity patients at the scene 11 14 15 19 22 while four studies assessed strategies in which ambulance crews either diverted low-acuity patients to a minor injury unit (MIU), 16 a community-based falls service, 12 13 or transported intoxicated patients to a detoxification centre. 25 Four studies evaluated ED-based diversion, of which one study was a randomised controlled trial 17 and three studies were controlled observational cohorts. ...
Objectives
Diverting patients away from the emergency department (ED) has been proposed as a solution for mitigating overcrowding. This systematic review examined the impact of interventions designed to either bypass the ED or direct patients to other alternative care after ED presentation.
Methods
Seven electronic databases and the grey literature were searched. Eligible studies included randomised/controlled trials or cohort studies that assessed the effectiveness of pre-hospital or ED-based diversion interventions. Two reviewers independently screened the studies for relevance, inclusion and risk of bias. Pooled statistics were calculated as relative risks (RR) with 95% confidence intervals (CI) using a random effects model.
Results
Fifteen studies were included evaluating pre-hospital (n=11) or ED-based (n=4) diversion interventions. The quality of the studies ranged from moderate to low. Patients deemed suitable for diversion among the pre-hospital studies (n=3) ranged from 19.2% to 90.4% and from 19% to 36% in ED-based studies (n=4). Of the eligible patients, the proportion of patients diverted via ED-based diversion tended to be higher (median 85%; IQR 76–93%) compared with pre-hospital diversion (median 40%; IQR 24–57%). Overall, pre-hospital diversion did not decrease the proportion of patients transferred to the ED compared with standard care (RR 0.92; 95% CI 0.80 to 1.06). There was no significant decrease in subsequent ED utilisation among patients diverted via pre-hospital diversion compared with non-diverted patients (RR 1.09; 95% CI 0.99 to 1.21). Of the three pre-hospital studies completing a cost analysis, none found a significant difference in total healthcare costs between diverted and non-diverted patients.
Conclusion
There was no conclusive evidence regarding the impact of diversion strategies on ED utilisation and subsequent healthcare utilisation. The overall quality of the research limited the ability of this review to draw definitive conclusions and more research is required prior to widespread implementation.
... One cross sectional study reported the same data in two publications [42,43], and the systematic review reported the results of one included trial, hence the reported data in this scoping review comes from the primary study [23]. The country of origin for the articles were United States (10) [26,27,[30][31][32][33][37][38][39][40], Australia (7) [2,22,24,25,29,35,45], United Kingdom (2) [28,44], Austria (2) [21,23] and Sweden (2) [34,41], Spain (2) [42,43] and Canada (1) [36]. Study characteristics are presented in Table 1. ...
... There were 1587 (47.9%) patients recorded as 'pain arising elsewhere' , 1151 (34.7%) as 'spinal pain' , and 471 (14.2%) as 'deferred diagnosis' that included 102 (3.1%) cases that were not recorded [44]. There was no definition of type of back pain in 11 studies [2,22,24,25,29,[34][35][36][37][38]41] and only two studies [21,23] reported duration of back pain, both as acute. ...
Background
Research examining paramedic care of back pain is limited.
Objective
To describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics.
Methods
We included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews.
Results
From 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data.
Conclusion
Paramedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.
... These primary care studies focused on reducing ambulance transports to the emergency department, and better utilization of paramedic resources. [45][46][47][48][49] Figure 2 summarizes telehealth treatment focus. ...
... 11 Cardiovascular 2014 Store and forward Hungary Rasmussen et al. 12 Cardiovascular 2014 Store and forward Denmark Clemmensen et al. 13 Cardiovascular 2013 Store and forward Europe Ducas et al. 14 Cardiovascular 2012 Store and forward Canada Schoos et al. 15 Cardiovascular 2012 Store and forward Denmark Brunetti et al. 16 Cardiovascular 2011 Store and forward Italy Gonzalez et al. 17 Cardiovascular 2011 Combination USA Correa et al. 18 Cardiovascular 2011 Store and forward Brazil Sardi et al. 19 Cardiovascular 2011 Video conferencing USA Brunetti et al. 20 Cardiovascular 2010 Remote monitoring Italy Hsieh et al. 21 Cardiovascular 2010 Store and forward Taiwan Otsuka et al. 22 Cardiovascular 2009 Remote monitoring Japan Sejersten et al. 23 Cardiovascular 2008 Store and forward Denmark Strauss et al. 24 Cardiovascular 2007 Store and forward USA Drew et al. 25 Cardiovascular 2006 Store and forward USA Abrashkin et al. 26 General/acute 2016 Video conferencing USA Felzen, et al. 27 General/acute 2016 Combination Germany Cho et al. 28 General/acute 2015 Combination Korea Buscher et al. 29 General/acute 2014 Combination Germany Czaplik et al. 30 General/acute 2014 Video conferencing Germany Yperzeele et al. 31 General/acute 2014 Combination Brussels Widmer et al. 32 General/acute 2014 Video conferencing Switzerland Bergrath et al. 33 General/acute 2014 Combination Germany Bergrath et al. 34 General/acute 2014 Combination Germany Rortgen et al. 35 General/acute 2013 Combination Germany Skorning et al. 36 General/acute 2012 Video conferencing Germany Bergrath et al. 37 General/acute 2011 Combination Germany Kwak et al. 38 General/acute 2009 Video conferencing Korea Sibert et al. 39 General/acute 2008 Video conferencing USA Takeuchi et al. 40 General/acute 2008 Video conferencing Japan Kang et al. 41 General/acute 2006 Store and forward Korea Tachakra et al. 42 General/acute 2006 Video conferencing UK Ellis et al. 43 General/acute 2006 Video conferencing USA Haskins et al. 44 General/acute 2002 Video conferencing USA Langabeer et al. 45 Primary care 2016 Combination USA Krumperman et al. 46 Primary care 2015 Audio USA Morimura et al. 47 Primary care 2011 Audio Japan Gillen 48 Primary care 2010 Audio UK Barrett et al. 49 Stroke 2016 Video conferencing USA Belt et al. 50 Stroke 2016 Video conferencing USA Chapman Smith et al. 51 Stroke 2016 Video conferencing USA Itrat et al. 52 Stroke 2016 Store and forward USA Lippman et al. 53 Stroke 2016 Video conferencing USA Torres Zenteno et al. 54 Stroke 2016 Combination Spain Valenzuela Espinoza et al. 55 Stroke 2016 Video conferencing Belgium Bowry et al. 56 Stroke 2015 Video conferencing USA (continued) ...
Objective
There has been moderate evidence of telehealth utilization in the field of emergency medicine, but less is known about telehealth in prehospital emergency medical services (EMS). The objective of this study is to explore the extent, focus, and utilization of telehealth for prehospital emergency care through the analysis of published research.
Methods
The authors conducted a systematic literature review by extracting data from multiple research databases (including MEDLINE/PubMed, CINAHL Complete, and Google Scholar) published since 2000. We used consistent key search terms to identify clinical interventions and feasibility studies involving telehealth and EMS, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results
We identified 68 articles focused specifically on telehealth interventions in prehospital care. The majority (54%) of the studies involved stroke and acute cardiovascular care, while only 7% of these (4) focused on telehealth for primary care. The two most common delivery methods were real-time video-conferencing capabilities (38%) and store and forward (25%); and this variation was based upon the clinical focus. There has been a significant and positive trend towards greater telehealth utilization. European telehealth programs were most common (51% of the studies), while 38% were from the United States.
Discussion and Conclusions
Despite positive trends, telehealth utilization in prehospital emergency care is fairly limited given the sheer number of EMS agencies worldwide. The results of this study suggest there are significant opportunities for wider diffusion in prehospital care. Future work should examine barriers and incentives for telehealth adoption in EMS.
... Emergency care systems in the developed world face increasing burdens due to an aging population [1][2][3][4], and in prehospital care it is often necessary to prioritize high-risk patients in situations where resources are scarce. Prehospital care systems have also increasingly sought to identify patients not in need of emergency care, and to direct these patients to appropriate forms of alternative care both upon contact via telephone with the dispatch center, and upon the arrival of an ambulance to a patient [5][6][7][8][9][10][11][12]. Performing these tasks safely and efficiently requires not only well trained prehospital care providers and carefully considered clinical guidelines, but also the employment of triage algorithms able to perform risk differentiation across the diverse cohort of patients presenting to prehospital care systems. ...
Background
The triage of patients in prehospital care is a difficult task, and improved risk assessment tools are needed both at the dispatch center and on the ambulance to differentiate between low- and high-risk patients. This study validates a machine learning-based approach to generating risk scores based on hospital outcomes using routinely collected prehospital data.
Methods
Dispatch, ambulance, and hospital data were collected in one Swedish region from 2016–2017. Dispatch center and ambulance records were used to develop gradient boosting models predicting hospital admission, critical care (defined as admission to an intensive care unit or in-hospital mortality), and two-day mortality. Composite risk scores were generated based on the models and compared to National Early Warning Scores (NEWS) and actual dispatched priorities in a prospectively gathered dataset from 2018.
Results
A total of 38203 patients were included from 2016–2018. Concordance indexes (or areas under the receiver operating characteristics curve) for dispatched priorities ranged from 0.51–0.66, while those for NEWS ranged from 0.66–0.85. Concordance ranged from 0.70–0.79 for risk scores based only on dispatch data, and 0.79–0.89 for risk scores including ambulance data. Dispatch data-based risk scores consistently outperformed dispatched priorities in predicting hospital outcomes, while models including ambulance data also consistently outperformed NEWS. Model performance in the prospective test dataset was similar to that found using cross-validation, and calibration was comparable to that of NEWS.
Conclusions
Machine learning-based risk scores outperformed a widely-used rule-based triage algorithm and human prioritization decisions in predicting hospital outcomes. Performance was robust in a prospectively gathered dataset, and scores demonstrated adequate calibration. Future research should explore the robustness of these methods when applied to other settings, establish appropriate outcome measures for use in determining the need for prehospital care, and investigate the clinical impact of interventions based on these methods.
... 26,51 Some organizations, including Memorial Hermann Community Benefit Corporation, have established 24-hour telephone advice lines, or implemented point-of-service interventions that navigate low-acuity patients to nearby primary care clinics in order to encourage patients to engage in continuous primary care. 25,[52][53][54][55][56] Additionally, providers can emphasize the coordination of medical and related nonmedical (eg, social) services as potentially value-added benefits of primary care, particularly given increased calls to address patients' unmet social needs, along with barriers to health care. 32,50,57 Limitations Key limitations of this exploratory study are that we did not ask participants to rate overall access to and quality of their USOC, to rank or rate the importance of each attribute of their USOC experiences, or to name additional attributes of importance. ...
Background:
An underlying assumption of strategies intended to promote appropriate primary care over emergency department (ED) use for ongoing health care needs is that patients will understand the "value proposition" of primary care: that they will receive specific benefits from primary care providers over and above what they receive from EDs. However, there is evidence that this value proposition may be unclear to safety-net patients. The goals of this study are to describe factors motivating ED use for low-acuity conditions; describe similarities and differences in usual source of care (USOC) experiences, by ED versus non-ED setting; and assess awareness and perceptions of the patient-centered medical home (PCMH) concept among safety-net patients.
Methods:
We conducted a cross-sectional descriptive study of adult patients (n = 329) at 3 safety-net hospitals in the Southwest.
Results:
Key reasons for ED use were perceived urgency, lack of awareness about other options for care, payment flexibility, and perceived quality and convenience. Approximately half of participants indicated they would seek treatment in non-ED settings, if available, but agreement differed by group (non-ED USOC, 60.2%; ED USOC, 50.7%; no USOC, 45.3%; P = .025). Agreement that providers coordinated access to needed medical services was significantly higher among patients with non-ED USOCs; agreement that providers coordinated non-medical services that facilitate access to care was similar (approximately 45%) for patients with ED and non-ED USOCs. Approximately 70% of participants in both groups agreed that every person should have a medical home.
Conclusions:
Perceived experiences of care in ED and non-ED USOC settings suggest challenges and opportunities for increasing the value proposition of primary care for safety-net patients. Although patients are receptive to the PCMH concept, effective strategies to better highlight the value of primary care in coordinating both medical and related nonmedical services and other PCMH benefits warrant further investigation.
... [20][21][22] As a result, care for low-acuity patients can in some cases be concluded in the out-of-hospital setting or these patients may be transported to healthcare facilities other than emergency departments. 23,24 Nevertheless, ambulance services continue to provide pre-hospital emergency care which often cannot be definitive, and therefore transport to appropriate hospitals is required. ...
Review question/objective
: The current scoping review seeks to locate, examine and describe international literature on indicators used to measure pre-hospital care quality. Specifically, the review will: Map attributes of definitions or descriptions of “quality” in the context of pre-hospital care provided by ambulance services.
Chart indicators that have been developed to measure pre-hospital care quality and detail their development processes as well as how the indicators fit into respective measurement frameworks/matrixes.
Background
The NHS emergency and urgent care system is under pressure as demand for services increases each year. NHS 111 is a telephone triage service designed to provide advice and signposting to appropriate services for people with urgent health-care problems. A new service, NHS 111 Online, has been introduced across England as a digital alternative that can be accessed using a website or a smartphone application. The effects and usefulness of this service are unknown.
Objectives
To explore the impact of NHS 111 Online on the related telephone service and urgent care system activity and the experiences of people who use those services.
Design and methods
A mixed-methods design of five related work packages comprising an evidence review; a quantitative before-and-after time series analysis of changes in call activity (18/38 sites); a descriptive comparison of telephone and online services with qualitative survey (telephone, n = 795; online, n = 3728) and interview (32 participants) studies of service users; a qualitative interview study (16 participants) of staff; and a cost–consequences analysis.
Results
The online service had little impact on the number of triaged calls to the NHS 111 telephone service. For every 1000 online contacts, triaged telephone calls increased by 1.3% (1.013, 95% confidence interval 0.996 to 1.029; p = 0.127). Recommendations to attend emergency and urgent care services increased between 6.7% and 4.2%. NHS 111 Online users were less satisfied than users of the telephone service (50% vs. 71%; p < 0.001), and less likely to recommend to others (57% vs. 69%; p < 0.001) and to report full compliance with the advice given (67.5% vs. 88%; p < 0.001). Online users were less likely to report contacting emergency services and more likely to report not making any contact with a health service (31% vs. 16%; p < 0.001) within 7 days of contact. Thirty-five per cent of online users reported that they did not want to use the telephone service, whereas others preferred its convenience and speed. NHS 111 telephone staff reported no discernible increase or decrease in their workload during the first year of operation of NHS 111 Online. If online and telephone services operate in parallel, then the annual costs will be higher unless ≥ 38% of telephone contacts move to online contacts.
Conclusions
There is some evidence that the new service has the potential to create new demand. The service has expanded significantly, so it is important to find ways of promoting the right balance in numbers of people who use the online service instead of the telephone service if it is to be effective. There is a clear need and preference by some people for an online service. Better information about when to use this service and improvements to questioning may encourage more uptake.
Limitations
The lack of control arm means that impact could have been an effect of other factors. This work took place during the early implementation phase, so findings may change as the service expands.
Future work
Further development of the online triage process to make it more ‘user friendly’ and to enable users to trust the advice given online could improve use and increase satisfaction. Better understanding of the characteristics of the telephone and online populations could help identify who is most likely to benefit and could improve information about when to use the service.
Trial registration
Current Controlled Trials ISRCTN51801112.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 9, No. 21. See the NIHR Journals Library website for further project information.
“Treat and release” and “treat and refer” protocols or practices refer to the onsite treatment of patients by responding emergency medical services personnel that does not involve transporting patients to health care facilities for additional assessment and treatment. The goal of these protocols is to allow patients to be released from care or to be referred directly to non-emergency services by emergency medical services personnel when appropriate, diverting patients from emergency departments. One health technology assessment that included a relevant randomized controlled trial and economic evaluation and 2 non-randomized studies were identified for inclusion. These studies examined treat and release or treat and refer protocols for treating hypoglycemia and exertional heat stroke, and for attending to older people following a fall. Overall, the clinical evidence summarized in this report suggests that treat and release protocols are as good as, or better than, usual care (i.e., onsite treatment of immediate medical care followed by transportation to health care facilities). Across most reported outcomes, there were no significant differences between patients who received care using treat and release or treat and refer protocols, and those who received usual care; however, there were some instances where the use of these protocols was associated with improvements in some clinical outcomes, such as patient satisfaction, risk for future falls or fractures, and some measures of repeat access to health care services. Findings related to the cost-effectiveness of treat and refer protocols were inconclusive because of the limited generalizability of the findings from the included economic evaluation. The economic evaluation estimated that implementing a treat and refer protocol for older patients who experienced a fall did not result in significant changes to health care resource utilization and did not generate improved health-related quality of life compared to usual care. No evidence-based guidelines regarding the use of treat and release protocols for patients requiring emergency medical services were identified.
Background
The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known.
Methods
This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages.
Results
Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood.
Conclusions
This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.
This report presents the most current (2006) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics.
Data are from the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates.
In 2006 there were 119.2 million visits to hospital EDs, or 40.5 visits per 100 persons, continuing a long-term rise in both indices. The rate of visits per 100 persons was 36.1 for white persons, 79.9 for black persons, and 35.3 for Hispanic persons. ED occupancy (the count of patients who had arrived, but not yet discharged, transferred, or admitted) varied from 19,000 patients at 6 a.m. to 58,000 at 7 p.m. on an average day nationally. Though overall ED visits increased, the number of visits considered emergent or urgent (15.9 million) did not change significantly from 2005, nor did the number of patients arriving by ambulance (18.4 million). At 3.6 percent of visits, the patient had been seen in the same ED within the previous 72 hours. Median time to see a clinician was 31 minutes. Of all ED visits, 35.6 percent were for an injury. Patients had computerized tomography or magnetic resonance imaging at 12.1 percent of visits, blood drawn at 38.8 percent, an intravenous line started at 24.0 percent, an x ray performed at 34.9 percent, and an electrocardiogram done at 17.1 percent. Patients were admitted to the hospital at 12.8 percent of ED visits in 2006. The ED was the portal of admission for 50.2 percent of all nonobstetric admissions in the United States in 2006, an increase from 36.0 percent in 1996. Patients were admitted to an intensive care unit at 1.9 percent of visits.
Our objective was to evaluate whether referral to primary care settings would be clinically appropriate for and acceptable to patients waiting for emergency department care for nonemergency conditions.
We studied 700 patients waiting for emergency department care at a public hospital. Access to alternative sources of medical care, clinical appropriateness of emergency department use, and patients' willingness to use nonemergency services were measured and compared between patients with and without a regular source of care.
Nearly half (45%) of the patients cited access barriers to primary care as their reason for using the emergency department. Only 13% of the patients waiting for care had conditions that were clinically appropriate for emergency department services. Patients with a regular source of care used the emergency department more appropriately than did patients without a regular source of care. Thirty-eight percent of the patients expressed a willingness to trade their emergency department visit for an appointment with a physician within 3 days.
Public emergency departments could refer large numbers of patients to appointments at primary care facilities. This alternative would be viable only if the availability and coordination of primary care services were enhanced for low-income populations.
International comparisons of health care systems have shown a relationship at the macro level between a well-structured primary health care plan and lower total health care costs. The objective of this study was to assess whether provider continuity with a family physician is related to lower health care costs using the individual patient as the unit of analysis.
We undertook a study of a stratified sample of patients (age, sex, region, insurance company) for which 2 cohorts were constructed based on the patients' utilization pattern of family medicine (provider continuity or not). Patient utilization patterns were observed for 2 years. The setting was the Belgian health care system. The participants were 4,134 members of the 2 largest health insurance companies in 2 regions (Aalst and Liège). The main outcome measures were the total health care costs of patients with and without provider continuity with a family physician, controlling for variables known to influence health care utilization (need factors, predisposing factors, enabling factors).
Bivariate analyses showed that patients who were visiting the same family physician had a lower total cost for medical care. A multivariate linear regression showed that provider continuity with a family physician was one of the most important explanatory variables related to the total health care cost.
Provider continuity with a family physician is related to lower total health care costs. This finding brings evidence to the debate on the importance of structured primary health care (with high continuity for family practice) for a cost-effective health policy.
Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments.
Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport.
PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated.
From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.
The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.
Crowding is an increasingly common occurrence in hospital-based emergency departments (EDs) across the globe. This 2-article series offers an ethical and policy analysis of ED crowding. Part 1 begins with a discussion of terms used to describe this situation and proposes that the term "crowding" be preferred to "overcrowding." The article discusses definitions, measures, and causes of ED crowding and concludes that the inability to transfer emergency patients to inpatient beds and resultant boarding of admitted patients in the ED are among the root causes of ED crowding. Finally, the article identifies and describes a variety of adverse moral consequences of ED crowding, including increased risks of harm to patients, delays in providing needed care, compromised privacy and confidentiality, impaired communication, and diminished access to care. Part 2 of the series examines barriers to resolving the problem of ED crowding and strategies proposed to overcome those barriers.
To determine the social and demographic factors associated with medically unnecessary ambulance utilization, and to determine the willingness of patients to use alternate modes of transportation to the ED.
A multisite prospective survey was conducted of all patients arriving by ambulance to 1 suburban and 4 urban EDs in New York State during a 1-week period.
For 626 patients surveyed, 71 (11.3%) transports were judged medically unnecessary by the receiving emergency physicians using preestablished guidelines. The patient's type of medical insurance and age were significant predictors of unnecessary ambulance transport (stepwise forward logistic regression analysis). Of the 71 patients whose ambulance transports were deemed medically unnecessary, 42 (59%) were Medicaid recipients and 53 (74%) were < 40 years of age. The most common reason for using ambulance transport was lack of an alternate mode of transportation (38.5%), although 82% would have been willing to use an alternate mode of transportation if it had been available. Of those who had medically unnecessary ambulance use, 30% indicated that they would not pay for the ambulance service if billed and 50% believed the cost of their ambulance transports was < 20,000. While 33% had a primary care provider, only 22% had attempted to contact their doctors before requesting an ambulance.
Patient age < 40 years and Medicaid coverage were associated with medically unnecessary ambulance use. Those patients for whom ambulance use was considered medically unnecessary commonly had no alternate means of transportation. Providing alternate means of unscheduled transportation may reduce the incidence of unnecessary ambulance use.
We determine whether paramedics, using written guidelines, can accurately triage patients in the field.
This prospective, descriptive study was conducted at an urban county emergency medical services (EMS) system and county hospital. Paramedics triaged patients, for study purposes only, according to 4 categories: (1) needing to come to the emergency department by advanced life support (ALS) transport, (2) needing to come to the ED by any transport, (3) needing to see a physician within 24 hours, or (4) not needing any further physician evaluation. Medical records that provided patient treatment information to the point of ED disposition were subsequently reviewed (blinded to the paramedic rating) to determine which of the categories was appropriate. The protocol of the EMS system of the study site dictates that all patients should be transported except for those who refuse care and leave against medical advice. Only transported patients were included in the present study. Fifty-four paramedics triaged 1,180 patients.
Mean patient age was 43.4+/-17 years; 62.0% were male. Paramedics rated 1,000 (84.7%) of the patients as needing to come to the ED and 180 (15.3%) as not needing to come to the ED. Ratings according to triage category were as follows: 804 (68.1%) category 1, 196 (16.6%) category 2, 148 (12.5%) category 3, and 32 (2.7%) category 4. Seven hundred thirty-six (62.4%) patients were discharged, 298 (25.3%) were admitted, 90 (7.6%) were transferred, 36 (3.1%) left against medical advice, and 20 (1.7%) died. The review panel determined that 113 (9.6%) patients were undertriaged; 55 (48.7%) of these patients were misclassified because the paramedics misused the guidelines. Ninety-nine patients (8.4% of the total sample) were incorrectly classified as not needing to come to the ED. This represented 55% of the patients (99/180) categorized as 3 or 4 by the paramedics. Fourteen patients (1.2% of total) were incorrectly classified as category 4 instead of 3. Of the 113 undertriaged patients, 22 (19.6%) were admitted, 86 (76.1%) were discharged, and 4 (3.5%) were transferred.
Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.
To assess patient comprehension of emergency department discharge instructions and to describe other predictors of patient compliance with discharge instructions.
Patients departing from the emergency department of an inner-city teaching hospital were invited to undergo a structured interview and reading test, and to participate in a follow-up telephone interview 2 weeks later. Two physicians, blinded to the other's data, scored patient comprehension of discharge information and compliance with discharge instructions. Inter-rater reliability was assessed using a kappa-weighted statistic, and correlations were assessed using Spearman's rank correlation coefficient and Fisher's exact test.
Of 106 patients approached, 88 (83%) were enrolled. The inter-rater reliability of physician rating scores was high (kappa = 0.66). Approximately 60% of subjects demonstrated reading ability at or below a Grade 7 level. Comprehension was positively associated with reading ability (r = 0.29, p = 0.01) and English as first language (r = 0.27, p = 0.01). Reading ability was positively associated with years of education (r = 0.43, p < 0.0001) and first language (r = 0.24, p = 0.03), and inversely associated with age (r = -0.21, p = 0.05). Non-English first language and need for translator were associated with poorer comprehension of discharge instructions but not related to compliance. Compliance with discharge instructions was correlated with comprehension (r = 0.31, p = 0.01) but not associated with age, language, education, years in anglophone country, reading ability, format of discharge instructions, follow-up modality or association with a family physician.
Emergency department patients demonstrated poor reading skills. Comprehension was the only factor significantly related to compliance; therefore, future interventions to improve compliance with emergency department instructions will be most effective if they focus on improving comprehension.
National health surveys have played an important role in the development of health services research. They have contributed to the advancement of concepts, methods, and the policy relevance of the field. One product of these surveys was the Behavioral Model of Health Services Use. This article documents a 75-year legacy by reviewing the series of national studies that have given to the form and function of health services research. It further examines the Behavioral Model through 40 years of considerable application and alteration.
The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.
Emergency department crowding, part 1Vconcept, causes, and moral consequences
- J C Moskop
- D P Sklar
- J M Geiderman
Moskop JC, Sklar DP, Geiderman JM, et al. Emergency department
crowding, part 1Vconcept, causes, and moral consequences. Ann Emerg
Med 2009;53:605Y611.
Orange County Emergency Medical Services system overview; pamphlet
- N Waters
- J Jones
- G Mears
Waters N, Jones J, Mears G. Orange County Emergency Medical Services
system overview; pamphlet; 1998.
- Institute Of Medicine
Institute of Medicine. Emergency Medical Services at the Crossroads.
Washington, DC, The National Academies Press, 2007.