Reasons for emergency department use of low-acuity attender: results from the prospective, multicentre, cross-sectional EPICS-9/PiNo-Bund study

Abstract

Background: The number of low-acuity emergency department (ED) visits varies across Europe and is often posited as a contributing factor to ED crowding. Many health policy-makers and health professionals assume that these cases are 'avoidable' ED visits or could be referred to other ambulatory healthcare providers.

Objectives: This study examines the care-seeking behaviour and the reasoning behind patients with low-acuity ED attendance according to emergency triage.

Design and setting: In a prospective multicentre cross-sectional survey, patients were invited to participate in an anonymised, paper-based survey in the waiting areas of nine EDs in Germany (2018-2020). The survey included questions on sociodemographic characteristics, reasons for using the ED, previous consultations in the outpatient healthcare system, self-rated urgency and knowledge of other emergency care structures. Due to the variance of missing values in the different responses, the valid percentages are shown.

Results: Of the 2752 survey respondents, 41.1% (n=1 120) indicated that 'pain' was the primary complaint for their ED attendance. Self-rated urgency was 'less urgent' for 58.7% (n=1552), 'urgent' for 41.3% (n=1093) and 57.7% reported the first episode of their symptoms (n=1505), with 30.8% (n=830) with symptom onset on the same day. The majority of patients completed the survey on weekdays (94.6%) between 08:00 and 18:00 (82.2%). 80.1% stated that they had a general practitioner (GP) (n=2103) and 55.8% contacted their GP before attending the ED (n=1403). In 77.8% of patients with GP contact, a visit to the ED was recommended by practice members or the GP (n=1068). The on-call service of the statutory health insurance physicians (SHIP) was contacted by 7.0% (n=172); in 64.6% of these cases (n=115), an ED visit was recommended. Of all patients without contact to the SHIP on-call service, 60.6% stated that they were not aware of these services (n=848).

Conclusions: Patients with low-acuity ED attendance stated acute onset and mainly new episodes of symptoms, with pain being the most common chief complaint. A high proportion reported having contacted their GP or SHIP on-call services (if known) but have been referred to the ED. As long as no fundamental changes are made to the provision of timely treatment options in the outpatient care sector, EDs may continue to be the foremost treatment option for these patients.

Keywords: ACCIDENT & EMERGENCY MEDICINE; Emergency Departments; Health Services; Health Services Accessibility; Quality in health care.

Figure 1. Presenting complaints of all low-acuity patients surveyed regarding the reasons and healthcare use prior to emergency department (ED) attendance in the waiting areas of the participating nine EDs in Germany in 2018–2020. Presenting complaints of the whole study population (n=2752). *Multiple responses were possible and therefore the individual percentages don’t add up to 100%.

Figure 2. Institutions and persons patients with a low-acuity emergency department (ED) attendance contacted for advice prior to ED attendance and directions to the ED given by the respective persons and institutions of all low-acuity patients surveyed in the waiting areas of the participating nine EDs in Germany in 2018–2020. The number of missing values for the respective variables varied between 418 and 886. Examples for ‘other’ persons or institutions: police, physician of the employer, lifeguard, passer-by and railroad staff. *Multiple responses were possible and therefore the individual percentages don’t add up to 100%; ED, emergency department; GP, general practitioner.

Figure 3. Patients’ rating of service features in the emergency department (ED) in contrast to the general practitioner (GP) practice of all low-acuity patients surveyed regarding the reasons and healthcare use prior to ED attendance in the waiting areas of the participating nine EDs in Germany in 2018–2020. nmiss: 462–694.