Date Published: July 27, 2017
Author(s): Lize Crafford, Louis S. Jenkins.
The inappropriate use of emergency centres (ECs) is an expanding problem globally. The high attendance of non-urgent return presentations to ECs is recognised as part of the problem, placing an unnecessary demand on limited staff and resources. Of unscheduled returns 34% of cases had no change to diagnosis or treatment with the conclusion that 80% of re-attendance could be attributed to deficiencies in the initial consultation. This study aimed to evaluate the reasons why patients sought an early second consultation for the same complaint at a hospital EC in South Africa, by exploring the patient’s experience and shortcomings in the first consultation.
A qualitative study was conducted using in-depth, semi-structured interviews with 20 purposively selected participants who presented to a rural regional provincial hospital’s EC within 7 days of a prior consultation for the same complaint. Verbatim transcripts were analysed using the framework method.
The main reasons for a second consultation were symptom related factors and the need for diagnostic certainty. The major themes around patient experience of the initial consultation were shortcomings in effective evaluation and management of pain, diagnostic uncertainty including poor examination, poor explanation, uncertain access and follow-up and societal encouragement to utilise a hospital EC.
Further interventions should explore pain as a presenting symptom of the illness experience, and promote competence in addressing physical and psychological causative factors within a patient-centred approach for all health staff, especially in primary care services.
Globally, the increased utilisation of emergency centres (ECs) is an acknowledged problem in health care systems. This has not only led to crowding of units, prolonged waiting periods and delays to treatment, but also to patient dissatisfaction and reduced productivity of health care workers.1,2,3 Factors contributing to this increase of EC usage have been shown to be the lack of health care insurance, poor access to primary care, the increase in communicable diseases, inappropriate EC use for non-urgent complaints by patients and the return of patients to the ECs.3,4
Twenty participants, 9 female and 11 male, between the ages of 20 and 63 years (mean 42.6 years), fulfilled the inclusion criteria and participated. Seventy per cent of the participants’ first language was Afrikaans, 25% isiXhosa and 5% English, which is a true reflection of the Eden district demographics (70.8% Afrikaans, 18.3% isiXhosa, 7.5% English).25 Thirty-five per cent of participants relied on public transport to access health care. Two participants bypassed the primary health care services by utilising ambulance transport to the hospital EC. Eleven participants’ first consultations were at their local PHC, seven presented themselves to the EC after a prior visit and only two participants sought medical care at a private GP. The distance from home to the EC ranged from 2.5 km to 23.0 km.
The main reasons for seeking a second consultation were persistence of symptoms, particularly pain, closely associated with the need to understand the cause of the pain. This is in keeping with previous research as the main reason for unscheduled return visits to the emergency department being symptom related with inadequate pain management proven to be a significant problem.1,7,8,9 Milbrett identified that six of seven major reasons to visit an EC as having some relationship to pain, and White described pain-related diagnoses to be a major reason for unscheduled returns.2,4 Overdramatisation of pain, sometimes to the extreme of fear of death, raises the question of how well health care workers are addressing the presumed underlying physical or psycho-social contributing factors, and how this can be managed better.
The aim of this study was to explore patients’ experience of their first consultation and any shortcomings that led to seeking an early second consultation at a regional hospital EC. The main themes included shortcomings in effective evaluation and management of pain, diagnostic uncertainty including poor explanation, poor examination, uncertain access, uncertain follow-up and societal encouragement to utilise the hospital EC.