Introduction
The emergency department (ED) crowding is an important problem worldwide (1,2). One of the fundamental reasons for this problem is that non-urgent patients frequently prefer EDs (3,4). This situation negatively affects the quality of patient care and the satisfaction levels of the patients and the ED staff (1,2,5).
In several studies, it was determined that at least one-third of the patients applying to the ED were non-urgent (4-6). There is no specific universal definition of non-urgent patients. Generally, these are described as patients who can also be treated in the primary care (7). Even in a research study conducted with the assessments of general practitioners, 43% of ED patients were found to be eligible for being treated in primary care (8). Therefore, primary health care is an important factor affecting ED crowding.
In EDs, the severity of patients is determined according to triage levels. Regarding the 5-level triage system used in Turkey, the patients are classified as red (level 1 and 2), yellow (level 3 and 4) and green (level 5). This classification was derived from the Canadian Triage and Acuity Scale. Level 5 patients are in the lowest risk group and do not need urgent intervention. Most of these patients can also be treated in primary care (9).
Worldwide, primary health care is mostly provided by family physicians. In this system, it is aimed to have the patients examined initially by family physicians and then have them referred to the advanced healthcare centers if necessary. However, it is seen that non-urgent patients do not prefer family physicians frequently and they continue to use ED (4,10).
In this study, it was aimed to investigate the basic characteristics of the patients admitted to the ED, their level of interaction with their family physicians, and their further expectations from primary health care services. Ultimately, it was targeted to contribute to the more efficient utilization of EDs and primary health care services.
Materials and Methods
This cross-sectional observational study was conducted between 1-30 April 2018 at an ED of a training and research hospital with approximately 180,000 adult patient applications annually. In this central hospital in the Aegean Region of Turkey, comprehensive health services are delivered in all disciplines related to surgery and internal diseases. The research was commenced after obtaining approval from the local board of ethics.
This survey study was planned to be conducted with adult patients (>18 years of age) who were admitted to ED when family physicians were available (between 8 am and 4pm on weekdays). The five-level triage system was in use at the ED in which the study was conducted. Level 3, 4 and 5 patients who agreed to participate were included in the study by the triage nurses based on convenience sampling. Non-urgent patients were selected from Level 5 patients. The patients who were also suitable for treatment in the primary care were considered to be non-urgent. The nurses in the triage unit had at least one year of experience in ED.
The patients were asked to fill in the survey form and leave it to the triage unit before leaving ED. It was stated that they could get help from the triage nurses or their companions if needed. The center in which the study was conducted reached approximately 5000 ED applications per month, meeting the inclusion criteria. It was planned to conduct 30 to 40 surveys daily to include 15% of these patients in the study. Furthermore, it was planned to select half of the patients from the non-urgent group.
The patients who did not fill in the survey form or who did not complete the questionnaire were excluded from the study. The patients who were level 1 or 2, who did not accept to participate in the study, whose family physicians had changed in the last 3 months, who had language problems, who had low mental status and who were not suitable to fill in a survey because of reasons such as pain or anxiety were excluded.
The survey consisted of five sections. In the first section, the demographic characteristics (age, gender, marital status), socio-economic characteristics (health insurance, employment status, education level) and chronic diseases were investigated. In the second section, the patients were asked to grade their interactions with the family physicians using the satisfaction scale. In the third section, the patients were asked the reasons for their last visit to the family physicians. In the fourth section, the patients were required to answer some questions aiming to determine the level of interactions with their family physicians. In the fifth section, the expectations and recommendations of the patients regarding primary health care services were investigated. At the end of the study, answers given to the open-ended questions were grouped with respect to their frequency. The results obtained from non-urgent and urgent patient groups were compared and the statistical differences between them were determined.
Statistical Analysis
SPSS 22.0 (SPSS Inc., Chicago, Illinois, USA) software package was used in the analysis of the data obtained. Qualitative data were expressed as number and percentages, and quantitative data as median, interquartile range (IQR), minimum (min) and maximum (max). Pearson’s chi-square test or Fisher’s exact test was used for the analysis of qualitative variables and Mann-Whitney U test was used for the analysis of quantitative variables. In all analyses, the odds ratios were given with 95% confidence interval (95% confidence interval) and p<0.05 was considered statistically significant.
Results
Forty-three patients who did not complete the survey were excluded from the study. Results from to a total of 800 patients, half of which were non-urgent, were analyzed. The median age of the patients was 39 years (min=18, max=83, IQR= 28-48 years) in the non-urgent group and it was 54 years (min=18, max=93, IQR=40-68 years) in the urgent group (p<0.001). The median residence time in patients’ current residence was 12 years (IQR=5-12 years) in the non-urgent group and 19 years (IQR=5-35 years) in the urgent group. The basic characteristics of the patients with respect to the triage groups are shown in Table 1.
The satisfaction of the patients with primary health care services was investigated and patients were asked to grade their interactions with their family physicians. The results obtained using the satisfaction scale are shown in Table 2.
The patients were asked about the reasons of their last family physician visits and the answers obtained were grouped at the end of the study. The reasons of application according to patient groups are shown in Table 3.
The interaction levels of the patients with family physicians, which were previously investigated with satisfaction scale, were re-evaluated with some questions. These questions and answers according to patient groups are shown in Table 4.
The answers given to the 4th question in Table 4 were classified at the end of the study. It was determined that 627 patients (78.4%) applied to the ED on their own decision, 72 patients (9%) with the consent of someone who is not a health professional (family, employer, friend etc.), 68 patients (8.5%) with the guidance of the family physicians and 33 patients (4.1%) with the guidance of other health professionals (doctor, nurse, health officer etc.).
The expectations and recommendations of the patients regarding the primary health care were asked. The answers given were classified at the end of the study and are shown in Tablo 5.
Discussion
The ED crowding is an important issue that should be investigated in all aspects. In this study, it was seen that the patients applying to the ED with non-urgent complaints did not utilize the primary health care efficiently. Consistent with this result, it is noted in the literature that non-urgent patients can also be treated in primary care (7,10,11). Determination of basic characteristics of these patients, their levels of interaction with the family physicians, and their opinions and recommendations about primary health care can be guiding for the solution of this serious problem. In this study organized with that aim, the results coming from the urgent and non-urgent patients are given separately. There is limited data presented in the literature in this manner.
According to the results of the study, it was seen that urgent patients were mostly female patients between 40 and 68 years of age and mostly had one or more chronic diseases. It was determined that non-urgent patients, in turn, were males between 28 and 48 years of age and mostly had a high level of education and a full-time job. These results were found to be consistent with the literature (3,10,12).
According to the results of the study, it was seen that one third of the patients consulted their family physicians for having their regular drugs prescribed again. This rate was higher in the urgent patient group (odds ratio=1.83; 95% confidence interval=1.36-2.47). According to the literature, it was found that the most frequent reasons of complaint-based family physician visits were similar with that of the ED applications. These include upper respiratory tract infections and musculoskeletal system pain (5,7,13). These results show that many of the patients applying to ED can also be treated in primary care.
Of the patients of interest, 17% stated that they never consulted their family physicians for any reason. Also, 15% of the patients did not score in the satisfaction scale because they had no interaction with their family physicians. These remarkable rates indicate that a significant proportion of patients have serious communication problems with their family physicians.
As a result of the questions investigating the interaction levels of the patients with their family physicians, it was determined that approximately one third of the patients did not know the names of their family physicians. This ratio was found to be higher among non-urgent patients (odds ratio=1.44; 95% confidence interval=1.07-1.93). It was learned that one in ten patients did not even know the office addresses of their family physicians. The reasons for these remarkable results should be investigated in detail.
Approximately one third of the patients stated that they did not initally consult their family physicians for their health problems. It is seen that these patients often prefer ED. This was found to be consistent with the results of other studies (3,10,12). It was seen that only 9% of the patients were referred to ED by their family physicians. It was determined that the patients often admitted to ED by their own decision or with the recommendations of non-healthcare professionals. This was found to be consistent with the literature (3,6,12). All these results reveal that the patients applying to EDs do not have a good level of contact and communication with their family physicians.
Both patient groups wished that primary health care units were more accessible and provided more extensive medical analysis. The urgent patients with a higher rate of chronic diseases and a higher mean age wished family physicians to be closer to them and to provide home care when needed. The non-urgent patients having a higher rate of employment in a full-time job, in turn, wished family physicians to be available also outside the regular working hours.
Study Limitations
The main limitation of the study was that it was conducted in a single center with a limited number of patients who agreed to participate in the research. Failure to evaluate patients with triage levels of 1 and 2 might have affected the outcomes of the urgent patients. Furthermore, the results may vary from region to region.
Conclusion
The main limitation of the study was that it was conducted in a single center with a limited number of patients who agreed to participate in the research. Failure to evaluate patients with triage levels of 1 and 2 might have affected the outcomes of the urgent patients. Furthermore, the results may vary from region to region.
Ethics
Ethics Committee Approval: Ethical approval for this study was obtained from the Ethics Committee of University of Health Sciences - Tepecik Training and Research Hospital, İzmir, Turkey (approval number: 2018/1-53, date: 10/01/2018).
Informed Consent: Obtained.
Peer-review: Externally and internally peer-reviewed.
Authorship Contributions
Concept: H.İ., T.Y.K., C.Ü., M.Y., Design: H.İ., İ.A.B., C.Ü., Data Collection or Processing: Y.E., İ.A.B., C.Ü., Analysis or Interpretation: H.İ., T.Y.K., M.Y., Literature Search: Y.E., T.Y.K., İ.A.B.; Writing: H.İ., Y.E., M.Y.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.