Abstract
Introduction
Overcrowding at Emergency Departments (EDs) has negative implications on healthcare systems, hospitals, staffs, and patients. We aimed to describe the characteristics of ambulatory (P3) patients to mitigate input of these patients to the ED to ease overcrowding.
Methods
A retrospective study was conducted from 2019 to 2022. Information on demographics, attendance patterns, length of ED stay, diagnoses and dispositions were collected and analysed.
Results
Among 541,762 attendances, there were 183,592 (33.9%) ambulatory (P3) patients. Adults between 16- to 65-year old accounted for the majority (
Conclusion
Ambulatory (P3) patients accounted for a sizeable load which can exacerbate overcrowding at the ED. They may be better sited at primary care services that are appropriate for their conditions. Measures should be directed at addressing their healthcare needs and health seeking behaviour.
Introduction
Overcrowding in Emergency Departments (ED) poses significant challenges to health systems, providers and patients worldwide.1,2 It is characterised by excessive patient volumes, prolonged wait times, inadequate space and suboptimal work processes. 3 Healthcare staff and resources are placed under considerable pressures leading to delayed assessment and treatment which compromise timeliness and quality of care services, as well as poor patient outcomes such as increased rates of adverse event, morbidity and mortality.2–7 These effects are not limited to the ED but flows downstream to impact the entire hospital.4,8
To discuss overcrowding in the ED, the input-throughput-output model is often used.2,9 Input factors refer to those related to patient accessing the ED, throughput factors refer to those related to patient journey from registration, triage, consultation to disposition within the ED, and output factors refer to those related to patient leaving the ED to inpatient units or discharged back to community.2,9 Addressing input factors at the upstream of this model would arguably have the largest impact on ED overcrowding as it would have downstream impact on throughput and output aspects.
Patients present to ED to seek medical attention for a variety of conditions. In order to determine the priority of care, triage is performed and patients are classified as emergent (P1), urgent (P2) or ambulatory (P3). While emergent (P1) and urgent (P2) patients often need to be cared for in ED, up to 45% of ambulatory (P3) patients have mild conditions that can be effectively managed by primary care physicians.10,11 Therein lies the importance of this study where we aimed to describe the characteristics of ambulatory (P3) patients attending the ED. Ultimately, measures to reduce attendances of these patients can be proposed to mitigate input to the ED, as well as ease overcrowding and the associated challenges.
Methods
Setting
This study was conducted at the ED of a tertiary public healthcare institution in Singapore with 1000 beds. The ED had an annual census of about 105,000 and was staffed by emergency physicians accredited by Specialists Accreditation Board. Upon arriving at the ED, patients were triaged by nurses to emergent (P1), urgent (P2) or ambulatory (P3) based on their presenting complaints and vital signs. They would then be consulted by the doctors who would decide on their management and disposition plans. ED diagnoses were classified by Systematised Nomenclature of Medicine Clinical Terms (SNOMED-CT).
Design
A retrospective study involving a review of case records was conducted. All ED attendances between 1 January 2019 to 31 December 2022 were included. Electronic medical records were accessed. Information including demographics, attendance patterns, length of ED stay, diagnoses and dispositions were collected using a standardised form and then analysed.
Ethics
This study was approved by the Institutional Review Board of SingHealth, Singapore (CRIB Reference 2020/2165 and 2020/2853).
Statistical methods
SPSS version 22 (SPSS, Chicago, IL) was used to perform the statistical analysis. Frequencies with percentages were used to present categorical data and medians with interquartile ranges (IQR) were used to present continuous data. Association between categorial variables was assessed using or chi-squared test. Statistical significance was taken at a
Results
There were 580,382 attendances to the ED during the study period – 38,620 (6.7%) attendances had missing information and were thus excluded from the study. The attendances included 35,061 emergent (P1) patients, 323,109 urgent (P2) patients and 183,592 ambulatory (P3) patients. Overall, there was an upward trend in attendances, with the number of ambulatory (P3) patients decreased by 19.3% over the 4 years. (Figure 1) Attendances to the emergency department by triage category.
Demographics
Attendances at the ED consisted of 513,173 (94.7%) adult patients and 28,589 (5.3%) paediatric patients who were less than 16-year old. Among the adult patients, there were 150,994 (29.4%) geriatric patients who were 65-year old or more. More than half (
Demographics of patients.
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Attendance patterns
Attendance patterns of patients.
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Patient journey
The median wait times for triage and consult increased across the triage categories from emergent (P1) patients to ambulatory (P3) patients [9 (4 to 19) and 35 (18 to 71) min respectively] (
Patient journey at the emergency department.
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Top 10 diagnoses of ambulatory (P3) patients.
Discussion
In this study, we examined input to the ED arising from patients arriving to seek medical attention by comparing the demographics, attendance patterns and patient journey of ambulatory (P3) patients with emergent (P1) and urgent (P2) patients. We found that ED overall attendances had increased over the study period and there was a 19.3% fall in the number of ambulatory (P3) patients who were predominantly adults between 16- and 64-year-old. The proportions of ambulatory (P3) patients who attended ED on weekends and public holidays, as well as between 0800 and 2359 h, were higher than other triage categories. Most of the ambulatory (P3) patients self-conveyed to the ED without referral from primary care physicians. While their wait times for triage and consult were the longest, their time taken for assessment and management before reaching a disposition plan were not the longest as they had minor conditions with upper respiratory tract infection being the most common diagnoses. Overall, only 10.4% of ambulatory (P3) patients being admitted to the hospital for further care.
The findings of our study were similar to a paper by Alnasser et al. which found that non-urgent attendances at a Saudi Arabia ED were mostly by adults between 16 and 65-year old, a higher proportion of them attended ED on weekends compared to other triage categories, majority did not have referral from primary care physicians and upper respiratory tract infection was the most common diagnosis. 12 The findings were also similar to the findings at a local ED where inappropriate attendances, defined by the authors as no investigation or procedure performed, and discharged without follow-up at specialist outpatient clinic; were mostly patients between 20 and 60-year old who self-conveyed to the ED without referral from primary care physicians. 10 Therefore, a significant proportion of ambulatory (P3) patients may not require attendance at the ED and interventions directed at right-siting them to more appropriate care services to receive the medical attention they require would help reduce input to the ED and ease ED overcrowding.
The purpose of an ED is to attend to emergencies by providing timely resuscitation and care to patients with critical conditions. Despite this, patients with mild or non-critical conditions still attend to ED for multiple reasons such as overestimating the severity or urgency of their conditions, or convenience due to accessibility of medical services at ED on a round-the-clock basis.13–15 This accessibility was evidenced in our study by the higher proportions of ambulatory (P3) patients who attended ED on weekends and public holidays compared to other triage categories. This can be attributed to primary care services not being available on weekends and public holidays when medical attention was required even though their conditions may be minor.
To aid with right-siting of ambulatory (P3) patients to appropriate care services, Parkinson et al. have previously described the concept of clinically divertible attendances, clinically preventable attendances, and clinically unnecessary attendances. 5 Clinically divertible attendances refer to patients with clinical conditions which would be more appropriately treated elsewhere in the healthcare system. 5 For instance, self-limiting conditions such as upper respiratory tract infection or gastroenteritis, and chronic disease management such as optimisation of blood pressure control, would be more resource-efficient to be managed by primary care services such as polyclinics or general practitioner (GP) clinics. These conditions do not require resources or services which are only available at the ED.
EDs in other countries have redirection policies that aim to divert patients from ED to other primary care settings. In Scotland, there is a redirection policy that targets patients who present with conditions that have been ongoing for at least 3 days. 13 They were identified at triage and reviewed by a senior doctor who would then decide if they should receive full ED assessment, redirected to primary care, or be given healthcare advice and self-observation. While sub-optimal care might be a concern, evaluation of the policy showed no adverse outcomes.13,14 Similarly, in Norway, an intervention was implemented to encourage patients to call prior to attending ED so that advice for redirection can be given. 15 This had ultimately led to ED attendance decreasing from 68.7% to 23.4%.
However, it should be cautioned that inaccurate redirections in our local context may be fraught with potential public relations and medicolegal issues from aggrieved patients and their next-of-kins. Therefore, instead of redirection, the emphasis locally is on having patients seek primary care as the first port of call for their conditions. Started by Changi General Hospital in 2014, the GPFirst program is an initiative to encourage patients with mild to moderate conditions to visit their primary care physicians or general practitioners first rather than attending to the EDs directly as most of these conditions can be managed by GPs. If ED visit is deemed necessary after assessment, the patients would be referred to the ED and receive a monetary incentive to help partially offset the cost of the ED attendance, as well as allow them to be seen earlier than non-emergency cases. 16 This program expanded to all public healthcare institutions across Singapore and may have contributed to the drop in ambulatory (P3) attendances in our ED over the study period. However, a sizeable 96.1% of ambulatory (P3) patients were still presenting to the ED on their own without referrals from primary care physicians. Furthermore, based on their attendance pattern, majority attended between 0800 and 2359 h where primary care services would be available, suggesting that they did not consider primary care services as their first option. More public education campaigns may be necessary to increase awareness of GPFirst program and change health seeking behaviour of these patients. Perhaps these campaigns should be targeted at school-going children and adolescents given that behavioural impacts of national health campaigns were more effective in these age groups compared to working adults. 17 Specific to the effect on ED attendances, previous public education campaigns conducted in 1980s to 1990s in Singapore were found to be effective with ED attendances by ambulatory (P3) patients falling between 25.1 and 26.5%. 18 However, more recent studies from other countries did not show public education campaigns to be effective.13,19,20
In addition, there are efforts in Singapore to augment resources within the primary care services. Continuing medical education for primary care physicians are conducted by specialists from public healthcare institutions in order to upskill them to manage more complex conditions. Recently, urgent care centres have also been established to provide some resources or services which used to be only available at the ED so that patients can access these urgent care centres for their conditions instead of the ED. 21 These urgent care centres bridge the gap between ED and primary care services by making available resources and services such as blood and radiology investigations, provision of intravenous medications and hydration, as well as performing procedures like toilet and suture, incision and drainage or backslab application. These additional services would help to address common minor conditions among ambulatory (P3) patients such as trauma-related presentations like lacerations and fractures, surgical-related presentations like abscess, or medical-related presentations like cellulitis or gastroenteritis.
Clinically preventable attendances refer to patients who require resources and services available in the ED for their conditions, but their ED attendance can have potentially been prevented with earlier intervention or better management of their chronic conditions. 5 Examples include acute exacerbations or clinical progression of chronic conditions such as asthma, chronic obstructive pulmonary disease, chronic kidney disease or diabetes mellitus. These patients would benefit from regular follow-up with a primary care physician to optimise control of their chronic conditions through compliance to medications and lifestyle modifications. These efforts would allow deteriorations to be detected early and treated promptly to prevent worsening such that ED attendance would be necessary.
Starting in 2023, the HealthierSG initiative is led by the Singapore government to bring about a major transformation of the healthcare system by shifting the emphasis from reactively providing care to the population who are sick to proactively preventing the population from falling sick. This initiative can impact the clinically preventable ED attendances of ambulatory (P3) patients in the following ways: firstly, there is a national enrolment exercise for residents to commit to seeing one primary care physician who can monitor their health longitudinally over time and intervene early in the course of disease, and secondly, the primary care physicians would prioritise delivery of preventive care through adoption of health plans that include health screening, vaccinations and lifestyle modifications. Over time, this initiative is likely to improve the health of the population and result in reduced ED attendances.
Clinically unnecessary attendances refer to patients who do not require any clinical care. 5 This category is thought to be the most heterogenous and ranges from patients who only require self-care to individuals who present with complex social needs such as those who are destitute, alcohol intoxicated and chronic malingerers. These patients may present to the ED frequently due to social stressors with decompensatory mechanisms. 22 Measures to reach out to this group include family support, patient support, crisis intervention and discharge planning; all of which have varying levels of successes and these patients may still be unresponsive to the interventions and continue to present to the ED. 23
Variations exist among the patients with regards to their health seeking behaviours and medical needs. Therefore, it would be important to recognise that successful measures in certain populations may not yield the same result in others – there is no ‘one-size-fits-all’ measure to reduce ED attendances by ambulatory (P3) patients. With the rollout of HealthierSG initiative, the healthcare system transformation guided by policy changes and supported by healthcare clusters, primary care services and community partners may be the most important factor for success in mitigating the input to ED and ease overcrowding.
Limitations
There were several limitations to our study. Firstly, this study was based on the experience of a single ED in Singapore and therefore, the results and recommendations must be interpreted in the context of our setting. Next, this was a retrospective study so documentation by ED personnel could not be standardised and led to missing information which accounted for 6.7% of all ED attendances to be excluded. Furthermore, we were unable to determine the reasons for ED attendances by the patients, whether ED attendances were clinically divertible, preventable or unnecessary, and the subsequent impact of these ED attendances on healthcare resource utilisation and healthcare cost.
Conclusion
ED attendances are on the rise leading to an increased input which can exacerbate ED overcrowding. While the number of ambulatory (P3) patients had fallen, they still accounted for a sizeable load at the ED which may potentially be diverted to other primary care services, or prevented by early and optimal management of their conditions. Measures to further reduce these ED attendances would need to address their healthcare needs and health seeking behaviour.
Footnotes
Author contributions
Dr Alston Ong – conceived idea, collected data, literature search, analysed results and drafted initial manuscript. Dr Shao Hui Koh – analysed results, reviewed and edited manuscript. Dr Jen Heng Pek – conceived idea, analysed results, reviewed and edited manuscript. Dr Kuhan Venugopal – analysed results, reviewed and edited manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical statement
Data availability statement
The data is not available for sharing as per IRB approval.