Should we tell patients to Get Out of the Emergency Room?
It seems a regular cycle: the public hospital emergency department (ED) waiting times are released and within minutes, media headlines start to expose those hospitals with the worst results. As an example, the wait time at my local hospital ‘blew out’ last year by five minutes, compared to the previous year, and the newspaper made a big deal of it. The paper declared the ED wait times to be “among the worst in the country”.
Yet examination of the trend shows that last year was the aberration and the wait times continue to improve, on average. However, examination of the averaged emergency department wait-times can cause a lack of understanding of the true, underlying picture.
The largest ‘blow out’ is typically in the non-urgent patient category. These are the patients whose condition will not worsen if they are left untreated for hours. Indeed, politically incorrect health industry humour says these people can safely wait for days before seeing a doctor.
Hold up! If patients that are triaged into this category can safely wait many hours to see a doctor, why is there a two-hour (120 minutes) KPI for 70% of ‘non-urgent’ Australasian Triage Scale (ATS) Category 5 patients? Just to be clear, that is for a non-urgent patient who have a minor medical condition and is waiting in the waiting room of a tertiary level hospital.
While the National Emergency Access Target (NEAT) stipulates that a pre-determined proportion of patients should be admitted, discharged or transferred from Australian emergency departments (EDs) within 4 hours of presentation, this seems to be an administrative or managerial, rather than clinical, concept. Certainty, it is important to note that prolonged length of stay was associated with increased in-hospital mortality and the 4-hour rule is based on its introduction in the UK to decreased wait time. While the KPI is great, I argue that it should not be applied to Cat 5 (non-urgent) patients.
If a non-urgent patient went down to a first-in, first-served GP clinic, they may have to wait more than two hours, so why are we putting such a short KPI timeframe on non-urgent patients in tertiary care facilities? (It is also important to note that they may be seen faster at the clinic, compared to the hospital) Let's face it, the person with the rash they have had for a week, or a person who got a head cold yesterday can wait longer than two hours.
If we have community resources available, regardless of whether they are public or private, why not re-direct the non-urgent (ATS Cat 5) people to those locations? One Australian study found 15% of ED visits by older people were avoidable GP-type presentations. A Scottish study redirected 139 study participants (patients) whose complaint was in excess of over three days duration, from the ED to their GP for assessment and treatment. Interestingly, only 48% of these people actually attendedtheir GP, yet no adverse outcomes were reported. Certainly, there are some risks as well as benefits associated with this action but a detailed risk analysis would reveal many, many benefits against a relatively low likelihood to consequences ratio.
The immediate effect would be the ability of emergency department staff to concentrate on true emergency patients, and hone their skills as emergency clinicians, and not primary healthcare (non-acute) services. The bonus would be a system that supported private and after-hour medical services, assuming such services exist.
There are two ‘elephants in the room’. The first elephant is that some areas do not have alternative healthcare services to the main hospital, especially over weekends and public holidays. The other elephant, which may be specific to an Australian context, is the cost for some patients associated with attending a GP clinic. Some GPs charge above the schedule fee, while the emergency department is free. For some patients, any out-of-pocket expense may exceed their ability to seek healthcare. However, it must be remembered that this article is focused on non-acute care and there is a range of healthcare services, such as local council health clinics, that can be accessed- at least during business hours- for non-acute conditions.
I propose a couple of things that can assist to address the issue of inappropriate patient presentations to the emergency department.
First, empower triage clinicians to say ‘No’. I mean that they should actively redirect patients to alternative care services and only after some form of clinical examination. This means a number of things need to be promoted, including an heightened awareness of other services people can be directed to, and an assessment of what the cost is going to be to the person by going to a different provider.
Secondly, it might be possible to provide some form of transport available to get the person to the other provider (and back again). The cost of providing this form of transport would be easily saved by the saving in resource costs. Remember that patients who present to EDs for non-acute conditions are often over-serviced compared to typical GP consultations.
Thirdly, if the patient wants to wait to be seen at the emergency department, that is certainly their prerogative. As a short-term intervention, what about introducing a minimum 90-minute wait for any patient who decides to wait to be seen with a Cat 5 condition. The department should actively work toward ensuring minimum 90-minute wait for non-acute patients.
Finally, revisit the two-hour wait KPI for non-acute patients to something more befitting a tertiary emergency trauma centre.
Not all answers are easy and the suggestions above require coordination, engagement and probably investment from a range of public and private stakeholders. Let’s have a look at some innovative, even arguably disruptive, ways to address the problem. And then put them into action.
 Mazza D, Pearce C, Lowthian J, Browning C, Shearer M, Joe A, Turner LR, Biezen R, Brijnath B. REDIRECT: Reducing older patients’ avoidable presentations for emergency care treatment. Melbourne (AU): The Department of General Practice, Monash University; 2015
 McGugan EA, Morrison W. 2000. Primary care or A&E? A study of patients redirected from an accident & emergency department. Scott Med J. 2000 Oct;45(5):144-7
Craig Hooper is a health management consultant who specialises in emergency and pre-hospital healthcare operations. He has over 25 years industry experience; strengthening health and ambulance services in the public and private sector of 10 countries. Craig is a member of the Australasian College of Health Service Management and Australia Malaysia Business Council. The views expressed in this article are his own and do not necessarily represent the views of Apis, Key Passions, Talisman or any other organisation.