Emergency Departments And Effects Of Non Urgent Cases

Emergency Departments And Effects Of Non Urgent CasesEmergency Departments (explosive detection system) ar under change magnitude pressure and increases in morsels of affected roles controled unbefitting or some which could be seen by alternative providers are all a burden on the ED and the health inspection and repair in general. everywhere recent historic period there has seen an increase of experienceances at EDs of more than 20% with the majority being aboriginal(a) manage cases. Recent changes to the GP contracts in 2003 have also had an impact on increases in attendance to EDs.There is a potential saving of in excess of 120 million if patients tended to(p) the confiscate health service provider either GPs, walk in centres or by self treating and asking a apothecary.Patient cultivation and not bad(predicate) promotion of the Choose easy campaign could reduce these numbers and therefore do outdoor(a) with the need to have to potentially turn away non-urgent cases. inductionEDs are under increasing pressure to deliver high quality care due to rising attendances. Over the period from 2007-2010 there has been an boilers suit increase in attendance at EDs of England of 20.9%.There was an increase of 10.7% in attendance amid the period 07/08 to 08/09 (12,318,051 attendances in 07/08 and 13,794,072 in 08/09) 11.4% increase between 08/09 and 09/10 (15,569736 attendances in the period 09/10).There have been numerous attempts to try and stem the vacate in ED attendances including offering patients guidance, making them aware of the consequences and communicate them of the alternative health services available.A GP ED Triage Pilot conducted by Sheffield Teaching Hospitals NHS Foundation Trust and Sheffield General Practitioner Collaborative in March 20101 which was conducted to ensure patients were seen in the most appropriate location and by the most appropriate health care professional found that cases deemed to be certain primary care c ases amounted to 19%. From this study it could be said that approximately 20% of attendees could potentially have been seen by a general practitioner in primary care rather than tending the ED merely this is very small sample and m all more studies would need to be carried come forth face at different segments to be able to draw a more definitive conclusion.Applying 20% would therefore estimate that for the year 2009/10 in England approximately 3 million attendees were candidates for primary care. The estimated hail of seeing these patient in the ED smalld on the comprise of 56 for treating a minor affection and 75 for a standard ( modal(a) cost 65.50) totals 196.5 million. Doctors consultations in primary care settings are the most cost effective part of the medical component of the NHS at 15-30 (averaging 22.50), GP consultations cost less(prenominal) than out-patients appointments, ED and ambulance calls (ambulance calls costing 255 per patient). Therefore the cost of t reating the 3 million potential primary care/GP patients in the GP setting would total 67.5million which would save the NHS a potential 129 million.2 These values are only for normal working hours. Most non-urgent cases actually occur out of hours which would actually increase this amount even further with even more potential savings.The above costings are currently being changed to new Health share Resource (HRG) code costings which are slightly less which could reflect lower savings than those calculated.3,4The choose well campaign North West estimated the issue cost to the NHS of treating minor maladyes is 2 billion a year.5The new system give have 11 different HRG groups, opposed to the current threeGroups. The new HRG codes blind drunk you must code both investigatings and sermons, as opposed to investigations alone6 (appendix 1).This review hopes to come to an understanding why these patients use the emergency department rather than GP surgeries, barriers to some other forms of care and access to GP surgeries and therefore answering the question whether emergency departments should be able to turn away non-urgent cases. Other points which will be taken into account are the ethical dilemmas associated with potentially bout patients away and the potential repercussions of doing so.Method and literature reviewA search was performed using Lancaster Universitys metalib data base which searched Scopus, Springerlink, Science Direct and Ovid Medline and Pub Med data bases.After accounting for duplicates and reviewing titles and abstracts, papers were selected for review. Search criteria admitd the terms, non-urgent, emergency department, primary care.The date was initially limited to 1996 2010 except on further searches earlier articles were allowed in order to search for historical articles. The search was also limited to humans and English language. The Department of Health website and the uncomplicated give care Foundation website were also ap ply to find current legislation and data.DatabaseLimitsResultsOVID Medlineemergency department, non-urgent primary careyear-1996-2010humans, English25Pub Med12Springerlink19Science Direct72Why patients attend the emergency departmentThere is no formal definition of what is deemed an appropriate attendee to the emergency department due to sights own impressions of what they believe to be an emergency. This leads to inappropriate attenders who could have legitimately seen their own GP. The types of patient who attend inappropriately and their closings to do so are labyrinthine and involve loving, psychological and medical factors.7Urgency is also a term which is difficult to define and to measure. Studies have been carried out which have measured urgency but there is such wide variation on what is deemed urgent the results are subjective. Due to this subjective nature when defining urgent it is important to be lucid and have appropriate and qualified medical professionals determi ning the urgency of a situation using set criteria. In an early study Lavenhar et al draw an urgent problem as one that requires medical attention within a few hours.8 This definition is used in this review.It has also been found, what medical professionals deem as non-urgent is often not perceived the same in the patient and the urgency of the situation should be based on the presenting signs and symptoms and not the eventual nett diagnosis.9Patients have been seen to attend the ED for many reasons including, the followingThey deemed their condition/illness to be appropriate for the EDThey believed the GP would refer them anywayThe GP process was too far to travel toThe GP surgery was closedA friend or family member felt it appropriateFor those patients who deemed their attendance to be appropriate for their illness or condition it would be very difficult to convince them otherwise and such patients generally attend the ED for reassurance that there condition is not serious and is not going to get any worse. Such patients also have high anxiety, and a sense of urgency and self diagnose to date have no formal medical knowledge.9-12Those who believed that their GP would have referred them anyway thought they would cut out the middle man. The patients found to do this in a study carried out by Palmer et al deemed their condition to be bad enough and that their GP would refer them, and attending their GP prior to attending the ED would just be a waste of time13 this study also found that pain was a major factor patients took into consideration when deciding on where to attend. botheration itself being subjective and open to individual interpretation.Those that found the GP surgery to be too far to travel were patients who generally lived in rural eye sockets where the outgo to both GP and ED were significantly far away and patients therefore decided they may as well attend the ED rather than the GP to save time in the event that the GP would just refer the m anyway.Those patients for whom the GP surgery was closed mainly attended out of hours or at weekends. These patients generally thought their condition was urgent and couldnt waitress until the surgery reopened.11,12For attendees who were advised by friends and family to attend the ED did so purely on this advice and the majority of which would not have done so without this advice. This included people advised by colleagues, first aiders and schools where responsibility for the patient was in someone elses hands and the person advising did so in order to protect themselves.12,13Another major factor to consider when savoring at why patients attend the ED is the decision making capabilities of the patients themselves. This would include social, psychosocial and medical factors. Padgett and Brodsky14 proposed a three be model which outlined how the stages of decision making interacted between the three different stages within the model. The three factors were predisposing, enabling and need. The decision making stages being recognising the problem, deciding to seek treatment and the decision on where to get the treatment.Predisposing factors which are part of stage one included the age, sex, race, level of education, family and social support available. The enabling factors, stage 2 were the income of the patient, usual source of care, proximity of the source of care and the perceived accessibility of this care source and the factors contributing to the need, stage three, were symptom recognition, evaluation of need, level of distress and psychiatric co-morbidity.Padgett and Brodskys three stage model14Barriers to CareThe above predisposing factors are also forms of barriers to care and are dealt with by patients in many different ways. Patient education would be a major tool for breaking down such barriers.11 This is the aim of a local and national campaign called Choose Well. This is a campaign that is supported by the NHS and its staff and aims to ensure people who need advice and treatment for common complaints, get stiff and gifted care.5 The North West has seen an increase of 177,000 patients in the ED over the last two years and hoped the Choose Well campaign would reduce this over the overwinter of 2010/11. The North West NHS estimated that 1 in 4 ED attendances were due to patients who could have self treated or could have been seen by other health professionals elsewhere.Offering guidance in both GP surgeries and EDs would give patients the information for themselves to determine the urgency of their condition. This information could include what definitely should be seen at the ED and what definitely shouldnt. Where this is a good idea and has the potential to work well however it could potentially cause patients with urgent problems to believe that they are non-urgent therefore putting them at risk of harm. On the other hand it could also cause some patients to deem themselves urgent and attend the ED when they were init ially b correctly to attend their GP practice adding to the non-urgent caseload.The Choose Well campaign briefly describes the types of conditions that should attend the ED as an emergency and gives contact numbers for patients to ring in order to get further information on where is best for them to attend. This may be difficult for some patients particularly the elderly as navigating around a website may be difficult or impossible and at a time when you are not well or believe to be in an emergency situation this could be valuable time needed for treatment. It does however offer valuable advice for minor injuries and illnesses known not to be life or limb threatening and could possibly eliminate the need for these patients to enter the health service at all reducing overall numbers and costs.Does Choose Well gather a difference?The Choose Well campaign North West sent out a survey (appendix 1) to determine the number of people who had made alternative decisions to attending the E D and whether the messages from the campaign had reached the local people. The survey results are not yet available but Merseyside NHS was successful in increasing the level of awareness amongst the people of Merseyside of the range of NHS services available to them over the winter of 2008 with 94,547 people using NHS Walk in centres in Merseyside, a rise of 18% from the year before and there was a drop in AE attendance of 6.4%, compared to the previous winter yet they still had high attendances to the ED with up to half of these potentially of the type that could have been treated by more appropriate NHS services.15 umpteen patients do not realise that there are cost implications and differences in cost between EDs and GPs and believe that it makes no difference whether they visit as all they want is a diagnosis regardless of who gives it to them.16 Many do not visit their GPs because of the appointment systems in place, and they are often unable to make an appointment and are ther efore more unbidden to wait around in the ED where they are guaranteed to be seen rather than wait for an appointment at their GP practice. It has also been noted that when patients were unable to see their unceasing GP and were offered an appointment to see an alternative the decision was made to attend the ED rather than see the alternative.17,18The opening hours of primary care facilities also do not satisfy the needs of some patients, those who work during the day may not be able to take time off from their daily activities to attend appointments which are set at the discretion of the GP practice rather than at the discretion of the patient such as in the evening, during the night and at weekends.Repeat attendees of the ED are found to make up a large proportion of cases. In a report by NHS Manchester19 who had registered 230,000 attendances per year at its three main sites showed that 13% of these attendances were frequent attendees (patients who attended the ED four or more times in a six month period) with the average number of times a frequent attender being 5.7 times. The report also suggested that this was inappropriate use of the ED and that patients needs were not being met by primary care providers. They decided to increase performance by putting in place best practice which was to include devising computer package that would identify the frequent attenders and allow GPs to see who they where so that they can make contact with the patients and inform them about their inappropriate use of the ED. The patients were sent letters stating break messages on the use of the ED and an information leaflet. The pro-forma letter which read An AE department is often not the best place to receive care for non-urgent problems or those that will need ongoing treatment. They do not have your medical records which included information about other medical problems both by and present, investigations, regular medication, and any allergies to medication. Not havi ng this information can compromise the treatment you receive. The enclosed leaflet contains information about services other than AE departments which are available to you. .AE departments should be used when the problem is an accident or requires emergency treatment. We would request that you contact the surgery first when you have a health problem that requires some advice and/or treatment.19This discussion was found in one GP practice to reduce the number of repeat attenders by 20%19 even though studies have shown that this would be the number of frequent attenders that would over time stop attending anyway without any form of intervention.20,21In order to validate the results found the intervention should be compared between surgeries with some surgeries having intervention and some not having the intervention.GP services within the EDThere has been an increase in the number of primary care doctors in EDs or based closely to EDs over recent years. This has been found to decreas e the numbers of non-urgent cases seeking ED treatment in favour of a GP and has also reduced the number of unnecessary admissions to hospital. This sort of initiative requires team work and close working partnerships with both EDs and GPs which at times has be proven to be tricky due to differences in culture and beliefs. The primary Care Foundation has carried out research licenced by the Department of Health, the study, which was carried out in May 2009, looked at different models of primary care across England practising within and alongside EDs. The number of patients deemed to be primary care patients were identified. It found that around half of all EDs did in actual fact have some form of primary care mien working within the ED and that between 10% and 30% of attendees were classified as primary care candidates.22DiscussionEthical dilemma of turning patients awayThe four principles of ethics developed by Beauchamp and Childress23 must be taken into account when coming to a decision as to whether to turn patients away from the ED. The 4 principles approach takes into account that whatever our personal beliefs, philosophy, moral theory or life stance the care of patients is the most important factor.It could be said that turning patients away from the ED was going against the ethics of the health service in that it is considered freely accessible to all at any time.The Four Ethical Principles shore leavePatients must be respected and must not be deceived and must be given adequate information. If patients are turned away then they are not given all the required information regarding their condition. Even though they would be advised to see their GP they may not do so. benignity and non-maleficenceIt may be seen as causing the patient harm by turning them away, they may suffer further pain or psychological distress by not being seen.JusticeJustice or fairness may be breached if patients are turned away. The health service is free at the point of entry and patients that are turned away may feel as if they are being denied care or treatment, even though they would be offered it at their GP practice for some this may not be possible or an option therefore denying them any form of care at all.ConclusionFrom the articles and documents reviewed it can be seen that non-urgent attendees at the ED are a drain on public funds and a time of economic derangement and when there is a keen focus on service cuts and delivering value for money.In spite of the evidence and from reviewing articles I feel that it could potentially be foul to the health and well being of patients if they were to be turned away from the ED for non-urgent or minor conditions that could be seen in general practice. Turning them away could make them stop seeking medical treatment and could make them lose faith in the health service altogether.I believe that more patient education and greater access to GPs and primary care health professionals is what is required in ord er to reduce the numbers and therefore the cost of treating such patients. It is not the vocation of the treating professional to determine the perceived severity of illness or injury a patient attends with but to offer them the care and support they need in order for them to continue their lives as they would like to. It is however the duty of health professionals to educate their patients and offer support on how they should deal with such illnesses and injuries so as not to have to attend or re-attend the ED. This could come in the form of information leaflets or just by talking to the patients and finding out their reasons for attending the ED rather than GPs and how things can be put in to place and organised for future patients to overcome the barriers to other forms of care.In 2003/4 there was a change in the GP contracts, following this there was an increase in ED attendances. The new contracts made changes to the after-hours access to GPs and allowed GPs to opt out of this area of care, this then resulted in the increase of after-hours presentations to the ED of GP cases.24So in order to increase access there would need to be more GPs not opting out of the after-hours work or changing the contracts to omit the option to opt out of such. Even though there are nourishment such as walk in centres and out-of-hours services people attend the ED, this could be due to the unfamiliarity of such places and lack of knowledge of the facilities available. More patient education and promotion of such centres would be required to ensure they are made aware to everyone in the event of requiring such services. Also the integration of primary and secondary care could help improve services for everyone by bringing GPs into the EDs and from a closer working partnership.Appendix 1HRG codeHRG spotBandAE tariff ()VB01ZAny investigation with category 5 treatment1183VB02ZCategory 3 investigation with category 4 treatment1183VB03ZCategory 3 investigation with category 1-3 treatment2133VB04ZCategory 2 investigation with category 4 treatment2133VB05ZCategory 2 investigation with category 3 treatment2133VB06ZCategory 1 investigation with category 3-4 treatment378VB07ZCategory 2 investigation with category 2 treatment4110VB08ZCategory 2 investigation with category 1 treatment4110VB09ZCategory 1 investigation with category 1-2 treatment378VB10ZDental Care552VB11ZNo investigation with no significant treatment552HRG codes and tariffs6Appendix 2North West Choose Well SurveyIf you or a family member had a minor illness or injury (for example a sore throat, backache, cough or cold), which is the first NHS service you would use for advice and treatment? (Please select one answer)Y/NY/NPharmacyMinor Injuries UnitGP/DoctorLook for advice on the net incomePhone NHS Direct or look on their website dial 999NHS Walk-in CentreGo to AEUrgent Care CentreNone of the above, I would look after myselfOther, enthrall assure belowIf your first pick service was unavailable , which other NHS service would you contact next? (Please select one answer)Y/NY/NPharmacyMinor Injuries UnitGP/DoctorLook for advice on the internetPhone NHS Direct or look on their websiteDial 999NHS Walk-in CentreGo to AEUrgent Care CentreNone of the above, I would look after myselfOther, please state belowIf you are a parent or carer for boorren under 16 years of age, please complete questions 3 4. Otherwise go straight to question 5.Which age group are your children in?Y/NY/N0 4 years10 13 years5 9 years14 16 yearsIf your children had a minor illness or injury (for example a temperature, a sore throat, cough or cold, a small cut or a sprain), which is the first NHS service you would use for advice and treatment? (Please select one)Y/NY/NPharmacyMinor Injuries UnitGP/DoctorLook for advice on the internetPhone NHS Direct or look on their websiteDial 999NHS Walk-in CentreGo to AEUrgent Care CentreNone of the above, I would look after myselfOther, please state below5. If you have selected AE or 999 in answer to questions 1, 2 or 4 above, please answer this question. Otherwise go straight to question 6. If you have selected AE or 999 in answer to questions 1, 2 or 4 above, can you tell us why you would make this alternative? (Select as many as apply)Y/NY/NYou will receive the best quality care and adviceYou know that you are guaranteed to be treatedYou will be seen quicker than any other serviceThe AE is closest to where you liveYou do not know where else to goIn the past your GP sent you to your AE or told you to call 999You would have chosen a GP, but are not registered with oneIn the past you were told to go to AE or to call 999 by anotherhealth service, e.g. apothecarys shop/NHS DirectYou would have chosen a GP, but it is difficult to get an appointmentOther, please state belowWhich of the following services do you currently use your local pharmacist store for? (Select as many as apply)Y/NY/NPicking up a prescriptionAdvice if your child has a high temperatureAdvice and treatment for a headacheAdvice and treatment for backache and other aches painsAdvice and treatment for an upset stomachAdvice and treatment for a urine transmittanceAdvice and treatment for treating coughs, colds fluContraceptive adviceOther, please state belowDid you know that your local pharmacist store provides a confidential consultation area?Yes/NoDid you know that your local pharmacist can offer you confidential advice and treatment without an appointment?Yes/NoWould you consider using your local pharmacist for any of the following? (Select as many as apply)Y/NY/NContraceptive adviceAdvice if your child has a high temperatureAdvice and treatment for a headacheAdvice and treatment for backache and other aches painsAdvice and treatment for an upset stomachAdvice and treatment for a urine infectionAdvice and treatment for treating coughs, colds fluOther, please state belowDo you know where to find information about late night and weekend opening hours for your local pharmacist?Yes/NoChoose Well is an NHS campaign that aims to help people in the North West to understand which NHS service to use if they need fast and effective treatment for minor illnesses and ailments and how to use 999 and AE services appropriately.Have you heard of the Choose Well campaign?Yes/NoIf yes go to Q 12 if no go to Q 13Where have you seen or heard about the Choose Well campaign? (Select as many as apply)Y/NY/NLocal newspaperLocal news websitesPCT websiteCommunity radioLocal radioLife Channel (GP TV)Bus advertLeafletSigns on ambulancesOther postersWord of mouth (someone mentioned it to you)Other, please state belowHave you heard any of the following messages? Tick as many as appropriate.The number of people using AE and 999 services is continuing to riseOne out of every four people who go to AE could have either treated themselves at home, or used another local NHS serviceYou can get three free text messages, with expound of your three nearest pharmac ies by texting pharmacy to 64746Your local pharmacy provides expert, convenient advice and treatment for minor ailmentsAE and 999 services are for life-threatening and serious conditions such as heart-attacks, strokes, breathing problems and serious accidentsGet the right NHS treatmentAs a result of seeing these messages, if you or a member of your family has a minor illness or ailment are you less likely or more likely to use the following services (please select as appropriate).Less LikelyMore LikelyYour local pharmacyYour local GPNHS Walk-in Centre or similar serviceMinor Injuries UnitUrgent Care CentreNHS DirectNHS Choices WebsiteAE999To help us to get our campaign right, it would be really helpful if you could give us some information about yourself.Which age group do you fall in to?Y/NY/NY/N16 1940 4970 7920 2950 5980 8930 3960 6990+Gender please delete as appropriateMale femalePlease could you tell us the first part of your postcode e.g. M22 or SK6EthnicityPlease can you select the group that best describes your ethnic background colourY/NY/NEnglish/Welsh/Scottish/Northern Irish/BritishIrishGypsy or TravellerOther, please give detailsMixed/Multiple Ethnic GroupsY/NY/NWhite and blue CaribbeanWhite and AsianWhite and Black AfricanOther, please give detailsAsian/Asian BritishY/NY/NIndianBangladeshiPakistaniChineseOther, please give detailsBlack/African/Caribbean/Black BritishY/NY/NAfricanCaribbeanOther, please give detailsOther EthnicY/NY/NArabOther, please give detailsThank you for your time we really appreciate your help. If you are willing to help us to develop this project further, please fill in your contact details belowNameAddressTel. No.Email lectureTaken directly from the Choose Well questionnaire5