Non-urgent patients in an Emergency Medical Service

Background: Emergency Medical Services (ES) are medical-surgical facilities where extremely ill patients, victims of accidents, intoxications and other urgent clinical situations should be rapidly and efficiently attended. However, a worldwide experience is that a large proportion of patients who require attention in an ES do not qualify as emergencies and they obstruct the possibilities of other patients that should be attended immediately. Aim: To evaluate the medical records in our ES and to assess whether patients understand what is a true emergency and which is the role of an ES. Methods: Patients attended in the ES of Haydarpasa Military Teaching Hospital in 2001-2002 were classified according to their diagnosis. A random sample of patients and relatives were surveyed about why they required medical attention in the ES. Results: 77,134 patients (39,327 female, 51%) were attended. The most common illness diagnosed was upper respiratory tract infection (18,423 patients, 23.9%). The true emergency condition rate in patients presenting to our ES was lower (44%) than the nonemergency condition rate. Conclusions: Improvements in public education are needed to solve this problem. Also, Primary Care facilities should be improved in order to reduce the demand for medical attention in ES by non-urgent patients (Rev Méd Chile 2004; 132: 1085-9). (


Antecedentes: Los Servicios de Urgencia son unidades médicoquirúrgicas donde deberían atenderse rápida y eficientemente pacientes graves, víctimas de accidentes, intoxicaciones y otras situaciones clínicas urgentes. Sin embargo, es una experiencia mundial que una proporción importante de los consultantes en Servicios de Urgencia no califican como emergencias, pero dificultan las posibilidades de atención para otros pacientes que deberían ser atendidos de inmediato. Propósito: Evaluar las fichas clínicas en nuestro Servicio de Urgencia y averiguar si los pacientes comprenden cuál es una verdadera emergencia y
E mergency Medical Services (ES) are among the most important hospital departments.In order to serve critical patients in a much more qualified and effective way, Emergency Medical Service personnel should not be unnecessarily engaged in the care of patients with minor problems which distracts the personnel's attention, impairs their concentration, and exhausts them physically as well.Non-urgent patients (patients apt to receive regular outpatient treatment) may adversely influence the treatment of critical patients.Emergency Medical Services worldwide are subject to misuse by patients who could be treated in outpatient clinics or in primary health care settings [1][2][3] .The aim of this study was to evaluate the degree of emergency condition in patients referred to the ES of GATA Haydarpasa Teaching Hospital during 2001-2002.For this retrospective evaluation we used the available medical records.

MATERIAL AND METHODS
Classification of the clinical diagnosis was made retrospectively by reviewing the medical charts of all the patients that presented to the ES of GATA Haydarpasa Teaching Hospital between January 1, 2001 and December 31, 2002.Each medical record had been filled-in by a triage general practitioner, a physician and a surgeon.The triage general practitioner elicited the patient's chief complaint, obtained a brief history, determined the vital signs and performed a directed examination to determine the urgency of the patient's condition.The physician and surgeon wrote the final diagnosis of the patients.We classified as urgent when «treatment was required immediately» or «treatment was required within a few hours», and as non-urgent when «treatment can be safely delayed».As a brief, a non-urgent visit was defined as a patient who had a problem or condition that could wait until the following day (ie, 12 to 24 hours) for treatment.Among the 43,205 patients having the diagnosis of a non-urgent illness, 9,000 patients or accompanying relatives were asked about the reason for presentation to ES (by using a poll) and their responses were categorized.

RESULTS
77,134 patients (39,327 male, 50,9%) presented to the ES during the study period.A significantly higher rate of presentation was detected in patients older than 40 years compared to those younger than 40 years (p <0.05).Table 1 shows some demographic characteristics of these patients.15,498 patients (20.3%) were hospitalized.The number of patients who qualified as having non-urgent conditions was 43,205 (56 %), whereas 33,929 (44 %) were urgent.One hundred The interview in randomly chosen 9,000 patients or accompanying relatives revealed that 40% of them had never thought of presenting to the primary care outpatient clinics and 35% had come to the ES because they thought that their present illness could be managed only in the ES condition.The remaining 20% of the group declared that they have always presented to ES for any health problem.Several patients said that they did this because their management could be achieved easier and faster in the ES.The presentation rate to ES of patients who did not like waiting in the outpatient clinics or were not able to make an appointment for examination was 4%.The rate of presentation of patients who applied to ES due to the difficulty of obtaining permission from their work place to leave for medical examination or who depended on a family member to come back from work to be able to take the patient for medical attention in the evening was 1%.They reported that 48% of patients did not first consider consulting family medicine, and that 30% thought they could be better treated in the hospital.Both figures are similar to our results.Vazquez et al, investigated the presentation rate to ES in 2000, and looked at patients who presented to ES on their own initiative 2 .This group of patients comprised 77% of all presenters.The reasons for patients to present to ES were as follows: 32% were unaware of the existence of other urgent care facilities other than that in the hospitals, 26% thought that ES had better technical equipment, 21% for faster medical intervention, 11.4% thought their problem was urgent, and 8% knew other services offered less qualified service to them.These rates are also similar to our results.
Bradshaw determined that the non-urgent presentation rate was 26% 3 .Among the reasons for presentation, 33% were anxious to wait, 32% claimed that the working hours in the ES were longer, and 25% of the patients felt that their illness was serious or their trauma was acute.Peterson had determined the presentation rate of non-urgent cases was 50% and did not identify any correlation regarding age, marital status, health and infectious disease 4 .Liu noted that more than 50% of patients presenting to ES were not urgent according to his studies over 4 years 5,6 .
Northington also determined that the majority of patients presenting to ES were acute cases 7 .The remaining cases noted that they preferred the ES as they could get any kind of medical service in the ES.Northington noted that the use of health insurance and examination by the same surgeon every time could decrease the presentation rate of non-urgent patients.
Ersoy showed that 37,316 patients presented to ES at Mediterranean University Medical Faculty Hospital in the year 2000.Six thousand and twenty five patients (16.2%) were admitted from ES 8 .This study showed different reasons for presentation than our present report.In Ersoy's report reasons for presentation to ES were: 45% reliability, 21% warm-hearted, 18% being a research hospital, 8% suggestion, 6% other causes.In 1995, Hu et al reported that 77% of patients managed in their ES were trauma cases 9 .The remaining cases were chronic cases (4%), unimportant diagnosis (2.6%), alcohol intake test (2.3%), severe mental illness (2.3%), suicides (2.2%), and cardiac arrest in 1.8%.
Kellermann and Mc Caig commented that the reasons for presentation to ES were related to finances 10,11 .Patients who did not have health insurance presented to ES for nonemergent health problems.
Burnett et al reported that the main reason for presentation to ES was that patients believed that it was the best location to solve their health problem (60%) 12 .This result is in accordance with our data.Baker et al also found similar results 13 .
Leeuwen et al reported that usually young adults who live close to the hospital recur to the ES immediately after minor traumas instead of to family medicine or the general medicine clinics.
Vazquez Quiroga et al 2 , Bradshaw 3 and Bond 14 have reported that the ES are considered by patients as fast clinics.Patients who wish to be evaluated in a short period of time present to ES.In addition, he suggested that better medical education to the ES patients must be offered to reduce their attendance to ES.
Bradshaw 3 , Liu 4 , Petersen 5 and Gill 15 notified that the non-urgent presentations are principally associated with socio-demographic factors.They suggested that primary health care locations should be increased in number.The larger proportion of elderly population attended in our ES is in accordance with the literature.
We determined that the non-urgent presentation rate was 56%.Among them, 40% had never thought of presenting to the primary care outpatient clinic and 35% had come to the ES because they thought that their present illness could be managed only in the ES condition.
In conclusion, the number of unnecessary visits to ES could be reduced through an improvement in the cultural and educational level of the community.An expansion of primary health care facilities would also affect this process positively.Also, if the working hours of the out-patient clinics are increased, the non-urgent presentation rate in ES should decrease.
Further studies are needed, using medical documentation data, the methods to determine the number of specialists necessary for arranging the rotational system, more objective assessment of supplies and medications, and the development of more effective Emergency Medical Services.
Méd Chile 2004; 132: 1085-1089 Corresponding Address: Op.Dr. Murat Kalemoglu.GATA Haydarpasa Egitim Hastanesi.Acil Servis Sefi.34680 Uskudar/Istanbul.Tel: 90216 346 26 00/2306-2111.Fax: 90216 3487880.E mail: mkalemoglu@hotmail.comA R T Í C U L O D E I N V E S T I G A C I Ó N PATIENTS IN AN EMERGENCY MEDICAL SERVICE -M Kalemoglu et al DISCUSSION Leeuwen et al, investigated the characteristics of patients who presented to ES in the year 2000 1 .

Table 4 .
Among patients examined in our ES, 2,499 (3.2%) had no sign of any illness.