ReviewContributing factors of frequent use of the emergency department: A synthesis
Introduction
In 1976, James Mannon published a research article in which he discussed the definition and treatment of what he termed as ‘problem patients’ in the emergency department (ED) of a hospital located in the Midwestern United States (US) [1]. Within this article, he refers to a group of patients as ‘regulars’, defining these patients based upon the staff’s description as those who visited the ED multiple times during a given week [1]. He goes on to state that some communities had ED’s that were understaffed and underdeveloped and this, coupled with the influx of regulars, could cause conflicting and increasing demands [1]. His insight of the impact of frequent users was foreshadowing of a growing issue that has reached epic proportions in present day.
Highlighting the growth of ED use, in 1987 there were 51.9 million visits by patients in the US [2], a figure that rose to 93.1 million in 1996, again increased to 129.5 million in 2006 [3], and in 2011 statistics show 136.3 million visits [4]. Looking at these numbers from a different perspective, between 1996 and 2006 use of the ED in the US grew by 36% [5]. This increased usage has translated into the overcrowding of ED’s in the US, where many facilities report they are at or over capacity 50% of the time [6].
The frequent user has been discussed as a contributing factor to overcrowding in the ED [6]. A definitive number of visits to classify a patient as a frequent user is not agreed upon across the literature [7], [6], as researchers have used values of more than two [8], more than three ([3], [9], [10], more than four [11], [6], [5], [12], [13], [14], more than five [15], more than six (Milbrett & Halm), and more than twelve [16], most using a year as their time frame for number of visits. The salient point, however, is that no matter the number of visits attributed to frequent use the impact upon such frequency is staggering. Researchers have shown that a small portion of the ED patient population, ranging from as little as 1% [15], to between 4% and 8% [5], [3], [10], [16] contributes to somewhere between 17% and 30% of all visits annually [16], [3], [15], [6], [12], [5], [10]. Referring again to the total visits made in 2011 – 136.3 million [4] – coupled with even the most modest of percentage use by a frequent user – 17% – this translates into over 23 million visits annually by patients considered frequent users.
Section snippets
Methods
A CINAHL Plus search was completed using the terms ‘emergency department or emergency room’, ‘frequent’, ‘use∗’, and ‘factor∗’. The CINAHL Plus search returned a total of 257 results, and abstracts reviewed for appropriateness to be included. PubMed was consulted next, utilizing the same search words, with 242 results returned. Results were reviewed, with duplicate articles removed. Reviewing the abstracts, three articles applicable for this paper were identified. One additional article was
Results
A synthesis of the factors that frequent users state as their reasons for using an ED was conducted. Included in this synthesis are factors related to misunderstanding medical necessity and access to care.
Misunderstanding medical necessity
The first factor to highlight was that of a frequent user experiencing a medical issue that they believe was serious enough that it could not wait for an alternative other than the ED. Hayes [8] found that all of the frequent users in her study believed their medical issue was too serious to go anywhere but the ED. When she looked closer at their medical records, however, 81% of the frequent users were triaged in a non-urgent category [8]. Doran et al. [3] had similar findings, with a majority
Access to other healthcare alternatives
A second factor related to frequent users contributing to ED overcrowding is limited access to other healthcare alternatives. Within this factor, three contributing concepts were found, those being ease of care, time of care, and physical/geographical access to care.
Discussion
A culture has developed within healthcare in which patients expect immediate treatment for any level of medical complaint or issue. This immediacy has drawn patients away from the primary care setting and the clinics due to the difficulty in getting an appointment or traveling to those locations, or feeling that their condition warranted more emergent and invasive care [22] This is a culture that needs to be addressed and changed if the issue of frequent user and overcrowding is ever to be
Misunderstanding medical necessity
Patients’ misunderstanding of medical necessity was the most prevalent in the literature found. Researchers found a difference between frequent users’ perceptions of their medical complaint and actual triaged severity; the majority of the frequent users presented to the ED with complaints that would not be considered a medical emergency [17], [3], [8], [18]. An opportunity exists here to educate frequent users as to the difference between medical emergencies and non-urgent medical complaints
Access to care
The second contributing factor of frequent users identified is that of access. In one study, Capp et al. [11] found that some of their frequent users believed it was easier to call an ambulance for transport to the hospital rather than finding alternative ways of getting there, or to other healthcare options. There exists an opportunity within this statement for ambulance services and hospitals to partner and develop programs to address frequent users before they arrive at the ED.
One such
Limitations
Although every effort was made to include all available research regarding frequent users and the ED, the potential exists that some studies were inadvertently not included. Findings were interpreted based upon what was reported by the researchers and not directly observed so a judgment of what actually occurred is not possible. The number of visits to identify frequent users was not consistent across all studies, potentially skewing the final data. Specifically regarding the nurse practitioner
Conclusions
The use of ED’s continues to increase. Within this usage, a subpopulation that contributes a disproportionate amount of use – known as the frequent user – exists. This synthesis identified factors that contribute to the frequent use of the ED, which include medical necessity and access issues. Implications for practice include educating the frequent user population about when to use the ED for emergent conditions and when to use alternative healthcare options for non-emergent complaints. Also,
Conflict of interest
There is no conflict of interest for this paper.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical statement
I, Timothy Burns, testify that this material has not been published in whole or in part elsewhere; the manuscript is not currently being considered for publication in another journal; I have been personally and actively involved in substantive work leading to the manuscript, and will hold myself jointly and responsible for its content.
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