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Letters to the Editor

Reasons for inappropriate attendance of the Emergency Room in alarge metropolitan hospital☆'☆☆

Keywords:Emergency RoomInappropriate attendanceOvercrowding

Major changes in the health-care systems of western countriesoccurred in the last few years, owing to the increasing age of the popu-lation, need to balance with cost resource availability and developmentof new diagnostic tests. This has led to a significant overcrowding ofEmergency Rooms (ER) [1], resulting in a global impairment of thisservice, increasing waiting times for attendants and a heavy burden ofphysical and mental stress for ER operators. Many people attendingthe ER have non-urgent conditions, that should instead be dealt withby the family doctor or the specialist in non-urgent settings. The reasonsleading to the inappropriate use of the ER have been only partiallyinvestigated [2–5]. To develop and adopt organizational countermea-sures, it is necessary to understand those more in-depth reasons. Ourgoal was to investigate the inappropriate access to the ER of a majormetropolitan teaching hospital, as a first step towards the elaborationof alternative strategies to deal with non-urgent cases.

This survey was conducted in the ER of the Maggiore PoliclinicoHospital of Milan (Italy) by physicians and nurses of the EmergencyDepartment. A questionnaire-based interview, prepared with theadditional input from sociologists of the Bocconi Business University,was delivered by nurses to 583 people referring to the ER for non-urgent complaints over an 8-month period. According to the colorcodes assigned to ER patients, white codes and the majority of greencodes are assigned to people affected by mild complaints, who shouldtherefore be considered inappropriate users of the ER. However in thisstudy it was decided that interviewers should not be cognizant of thecomplete medical records of the patients. Therefore a definition ofappropriate and inappropriate uses of the ER was developed indepen-dently of the assigned code, but based on the time pattern of symptomonset according to the following criteria:

- appropriate cases: those who attended the ER for a sudden healthproblem

- inappropriate cases: those who attended the ER for a long-lastingproblem

- hybrid cases: those who attended the ER for a long-lasting problemthat had suddenly re-emerged, or for a long-lasting problem thathad worsened in the last few hours.

The questionnaire interview was administered by nurses to casesaccording to the forementioned criteria. The questionnaire consistedof forty questions, with limited possibilities of double answers, with

European Journal of Internal Medicine 24 (2013) e13–e14

a few control questions in order to verify the coherence of answers.The questions dealt with the demographic and socio-economic condi-tions of the interviewed cases, their reasons for attending the ER,degree of trust towards the ER and attitude towards other territorialmedical services, particularly their family doctor. Data were analyzedby means of SPSS.

Two-thirds (63.9%) of the interviewed patients were classified asgreen codes, and 36.1% as white codes. In terms of main demographicfeatures, the most notable finding was that people with higher educa-tion level had more frequently an appropriate attendance to the ER(59.3% vs. 49.5% for people with lower education levels). Table 1shows that the most frequent reasons for attending inappropriatelythe ER included the possibility to obtain all the necessary examinationsat the same time and pragmatic reasons such as that the ER being thefastest or the nearest solution to tackle the actual complaints. Otherreasons were the declared impossibility to wait for the scheduled visit-ing hours of the family physician and the advice given by pharmacists,relatives and friends to attend the ER. A minority of people mentionedan economic reason (ER chosen as the cheapest option). A relationbetween long-lasting complaints and need for a comprehensive andfast solution appeared evident. A relevant proportion of inappropriate at-tendances was by people with no family doctor (15.9%). This percentagereached 36.7% in the group of patients attending the ER to solve along-lasting problem (the most evident cases of inappropriate access tothe ER). 21.7% of patients with symptoms lasting three or more daysanswered that “it was not possible to wait for the visiting hours” oftheir family doctor: a reason very hard to be real, because it does implythat the doctor was not available for as long as three days.

Only 11.3% of people declared dissatisfaction for the services providedby their family doctor (particularly for what concerns the inconvenienceof their visiting hours). There was a higher degree of dissatisfactionamong people with a higher education level, with less dissatisfaction inelderly people. More than 95% of the interviewed people declared a sig-nificant confidence in the ER of the hospital, with a higher level of confi-dence among those who had already been in the ER. A specific questionconcerned the time interval between the decision to attend the ER andthemoment people started tomove to reach it. Assuming that a problemconsidered truly urgent leads the patient to take a rapid decision, inap-propriate use of the ER was confirmed by finding that 34% of peoplewaited for more than 2 h before moving to the ER, for various reasonslisted in Table 2.

ERs are, by definition, medical structures that should deal only withcases needing intensive and rapid interventions for acute clinical prob-lems. Accordingly, the pertinence of the services that the ER offers tonon-urgent cases is very limited, so that inappropriate attendants areoften obliged to prolonged waiting times, thereby causing their own dis-satisfaction andworsening of ER overcrowding [1–5].Moreover, ER inter-ventions lacks by definition continuity (follow-up procedures are notexpected). On the other hand, people are often attracted by the clinicaland diagnostic competences of the ER and the possibility to performlaboratory and instrumental investigations and specialist consultingwhile spending a relatively limited amount of time and money. In thisstudy the reasons for inappropriate access were evaluated through a

☆We wish to thank Dr. G. Cavalca and Dr. S. Sabatinelli.☆☆The questionnaire in Italian language is available upon request.

0953-6205/$ – see front matter © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.ejim.2012.11.016

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questionnaire administered by nurses to the peoplewho attended the ERof a large metropolitan hospital, in which 86% of cases are classified aswhite or green codes. Inappropriate ER attendance resulted to be 12%among white codes, but this prevalence is lower than the real one, be-cause it was obtained according to the study definition of inappropriateaccess, considering only the time of onset of the problem rather than itsclinical relevance. The main reasons for attending the ER were relatedto convenience: facilities for a quick and complete clinical evaluation,possibility to do all the necessary exams and to be visited by competentspecialists. A high confidence in the ER does partially explain the inappro-priate behavior, especially if associated to a difficulty to reach the familydoctor during their visiting hours, even though no real dissatisfactionfor the services of the family doctor was declared. A high educationlevel was associated with a more appropriate use of the ER, thus empha-sizing the positive role of information campaignswith the aim to contrib-ute to solve the problem. In conclusion, the decisional process that takes aperson to the inappropriate attendance of the ER is complex and calls fora number of social, psychological, medical and organizational factors. Thespecific combination of these elements is probably unique for each ERand each patient and also depends on the local supply and organizationof health care facilities.

At least three possibilities are suggested to improve the inappropriateuse of the ER:

- the creation of offices with multiple family doctors available 24 hdaily, to give a real-time answer to health complaints of people innon-critical conditions;

- the organization of family doctors offices close to the ER wherenon-urgent cases should be addressed, with the possibility of anER evaluation if necessary;

- the development of an information campaign to emphasize whyand when attendance to the ER is inappropriate, and the negativeconsequence of this for the community.

Limitations of this survey are the definition of appropriate andinappropriate attendances to the ER, based upon the onset of the prob-lems leading to the ER, without considering the clinical relevance of theproblem and that probably led to a significant under-estimation ofinappropriate cases, and the limited number of patients included in

the study, even if representative of the overall proportion of whiteand green codes. Some characteristics of our hospital (i.e. the presenceof specialists like ear–nose–throat 24/24 h) are not present in otherhospitals, but they only partially explain the overcrowding and inappro-priate attendance of the ER.

Conflict of interest

All authors declare that there is no actual or potential conflict ofinterest, including any financial, personal or other relationships withother people or organizations within three years of beginning thesubmitted work that could inappropriately influence or be perceivedto influence their work.

References

[1] Davidson SM. Understanding the growth of emergency department utilization.Med Care 1978;16:122–32.

[2] Elshove-Bolk J, Mencl F, van Rijswijck BTF, Weiss IM, Simons MP, van Vugt AB.Emergency department patient characteristics: potential impact on emergencymedicine residency programs in the Netherlands. Eur J Emerg Med 2006;13:325–9.

[3] Kooiman CG, Van De Wetering BJM, Van Der Mast RC. Clinical and demographiccharacteristics of emergency department patients in the Netherlands: a review ofthe literature and a preliminary study. Am J Emerg Med 1992;7:632–8.

[4] Murphy LAW. Inappropriate attenders at accident and emergency department I:definition, incidence and reasons for attendance. Fam Pract 1998;15:23–32.

[5] Padgett DK, Brodsky B. Psychosocial factors influencing non-urgent use of theemergency room: a review of the literature and recommendations for researchand improved service delivery. Soc Sci Med 1992;35:1189–97.

Fernando PorroValter MonzaniChristian Folli⁎

Division of Emergency Medicine, Fondazione IRCCS Ca' Granda OspedaleMaggiore Policlinico di Milano, Milan, Italy

⁎Corresponding author. Tel.: +39 0255033602; fax: +39 0255033600.E-mail address: christian.folli@policlinico.mi.it.(C. Folli)

26 October 2012

Table 1Reasons for inappropriate access to the Emergency Room(multiple answerswere possible).

N of answers % answers % cases

Possibility to carry out all necessaryexaminations

232 27% 41%

Fastest solution for the complaint 187 22% 32%Closest solution 169 20% 30%Cheapest solution 12 1% 2%Suggested by a pharmacist 99 12% 18%Could not wait for family doctor visiting hours 97 11% 17%Suggested by relatives/friends 60 7% 10%Total 856 100 153

Table 2Time awaited before moving to ER and reasons for waiting.

1–2 h 2–3 h 4 or more hours N

At work/studying 21% 52% 27% 86Unpostponable engagement 12% 44% 44% 34Sudden impediment 15% 52% 33% 27Could wait some more hours 10% 30% 60% 69Waited for health improvement 3% 15% 82% 39Transport problems 26% 41% 33% 99Difficult access to specialist offices duringreceiving hours

– 77% 23% 13

Others 50% 50% – 4Total 17% 41% 42% 371

e14 Letters to the Editor