Date Published: February 23, 2018
Publisher: Public Library of Science
Author(s): Colin O’Keeffe, Suzanne Mason, Richard Jacques, Jon Nicholl, Martijn van Griensven.
The pressures of patient demand on emergency departments (EDs) continue to be reported worldwide, with an associated negative impact on ED crowding and waiting times. It has also been reported that a proportion of attendances to EDs in different international systems could be managed in settings such as primary care. This study used routine ED data to define, measure and profile non-urgent ED attendances that were suitable for management in alternative, non-emergency settings.
We undertook a retrospective analysis of three years of Hospital Episode and Statistics Accident Emergency (HES A&E) data for one large region in England, United Kingdom (April 1st 2011 to March 31st 2014). Data was collected on all adult (>16 years) ED attendances from each of the 19 EDs in the region. A validated process based definition of non-urgent attendance was refined for this study and applied to the data. Using summary statistics non-urgent attenders were examined by variables hypothesised to influence them as follows: age at arrival, time of day and day of week and mode of arrival. Odds ratios were calculated to compare non-urgent attenders between groups.
There were 3,667,601 first time attendances to EDs, of which 554,564 were defined as non-urgent (15.1%). Non-urgent attendances were significantly more likely to present out of hours than in hours (OR = 1.19, 95% CI: 1.18 to 1.20, P<0.001). The odds of a non-urgent attendance were significantly higher for younger patients (aged 16–44) compared to those aged 45–64 (odds ratio: 1.42, 95% CI: 1.41 to 1.43, P<0.001) and the over 65’s (odds ratio: 3.81, 95% CI: 3.78 to 3.85, P<0.001). Younger patients were significantly more likely to attend non-urgently out of hours compared to the 45–64’s (OR = 1.24, 95% CI: 1.22 to 1.25, P<0.001) and the 65+’s (OR = 1.38, 95% CI: 1.35 to 1.40, P<0.001). 110,605/554,564 (19.9%) of the non-urgent attendances arrived by ambulance, increasing significantly out of hours versus in hours (OR = 2.12, 95% CI: 2.09 to 2.15, P<0.001). Younger adults are significantly more likely as older counterparts to use the ED to obtain healthcare that could be provided in a less urgent setting and also more likely to do this out of hours. Alternative services are required to manage non-urgent demand, currently being borne by the ED and the ambulance service, particularly in out of hours.
The pressures of patient demand on emergency care services continue to be reported in England evidenced by declining performance of Emergency Departments (EDs) against the national four hour performance target  and increased crowding,  evidenced by higher numbers of 12 hour trolley waits and diversions of ambulances [3, 4]. The ambulance service is also under considerable pressure with calls to the ambulance service doubling in the last 10 years (reaching over 9 million calls) .
The National Health Service (NHS) Health Research Authority (HRA): National Research Ethics Service Committee South West Exeter provided ethical approval for this study (Research Ethic Committee Reference: 14/SW/1014). As this study involved the analysis of pseudonymised routinely collected patient data it was deemed suitable for proportionate review. All adult (>16 years) attendances to type I EDs (consultant-led, multi-specialty 24-hour services with full resuscitation facilities and designated accommodation for the reception of ED patients) across the Yorkshire and Humber region of England were assessed by analysing three years of complete Hospital Episode Statistics Accident and Emergency (HES A&E) data for all 13 acute trusts in Yorkshire and Humber from April 1st 2011 to March 31st 2014.