Abstract
Objective
To identify the patient and case characteristics associated with emergency department (ED) suitability of cases referred for emergency ambulance dispatch following ambulance-based secondary telephone triage.
Methods
A retrospective cohort analysis was conducted of secondary telephone triage cases transported to an ED by emergency ambulance between September 2009 and June 2012 in Melbourne, Australia. Patients were considered ED suitable if they were triaged as a category 1, 2 or 3 according to the Australian Triage Scale, were admitted to hospital or referred to another hospital for admission, or died in the ED.
Descriptive statistics and multivariable binary logistic regression analysis were used to identify the variables associated with ED suitability.
Results
There were 2694 (21.2%) cases classified as ‘not ED suitable’. The mean age of this group was 51.7 years (SD 23.7 years) and 56.5% were female. Those that were ED suitable were older, with a mean age of 59.1 years (SD 22.6 years) and 53.6% were female. After adjusting for confounders the age (p<0.001), pain (p<0.001) and triage guideline groups (p<0.001) variables had statistically significant relationships with ED suitability. Gender (p=0.108), time of day (p=0.118), secondary triage call-taker qualification (p=0.237) and comorbidities (p=0.182) showed no association with ED suitability, and income status was approaching significance (95% CI 0.85–1.02, p=0.055).
Conclusion
There are patient and case characteristics associated with ED suitability that could be used to improve patient triage to better match patients with care pathways appropriate to their needs.
References
Redstone P, Vancura JL, Barry D, Kutner JS. Nonurgent use of the emergency department. J Ambul Care Manage 2008;31:370-6.
Lowthian JA, Curtis AJ, Jolley DJ, et al. Demand at the emergency department front door: 10-year trends in presentations. MJA 2012;196:128-32.
Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: a review of strategies to decrease future challenges. J Res Med Sci 2017;22:23.
Tenbensel T, Chalmers L, Jones P, et al. New Zealand’s emergency department target – did it reduce ED length of stay, and if so, how and when? BMC Health Serv Res 2017;17:678.
Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Deciding to Visit the emergency department for non-urgent conditions: a systematic review of the literature. Am J Manag Care 2013;19:47-59.
Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident and emergency department attendances. a systematic review of primary care service interventions. Br J Gen Pract 2013;63:e813-20.
Schoenfeld EM, McKay MP. Weekend emergency department visits in Nebraska: higher utilization, lower acuity. J Emerg Med 2010;38:542-5.
Farion KJ, Wright M, Zemek R, et al. Understanding low-acuity visits to the pediatric emergency department. PLoS ONE 2015;10:e0128927.
Jeffery MM, Bellolio MF, Wolfson J, et al. Validation of an algorithm to determine the primary care treatability of emergency department visits. BMJ Open 2016;6:e011739.
Ballard DW, Price M, Fung V, et al. Validation of an algorithm for categorizing the severity of hospital emergency department visits. Med Care 2010;48:58-63.
Wagner N. NYU ED Algorithm: Background/Introduction: NYU Wagner. Available at: http://wagner.nyu.edu/faculty/billings/nyued-background.php [Accessed 26 March 2013].
Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a substitute for primary care? Issue brief (Commonwealth Fund) 2000;(433):1-5.
Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying "nonemergency" emergency department visits. JAMA 2013;309:1145-53.
Lowe RA. Updating the emergency department algorithm: one patch is not enough. Health Serv Res 2017;52:1257-63.
Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009;25:7-28.
Nagree Y, Camarda VJ, Fatovich DM, et al. Quantifying the proportion of general practice and low-acuity patients in the emergency department. MJA 2013;198:612-5.
Lin C-H, Kao C-Y, Huang C-Y. Managing emergency department overcrowding via ambulance diversion: a discrete event simulation model. J Formos Med Assoc 2015;114:64-71.
Australian Institute of Health and Welfare. Australian hospital statistics 2011-2012 emergency department care. Canberra: AIHW; 2013.
Eastwood K, Smith K, Morgans A, Stoelwinder J. Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study. BMJ Open 2017;7(10).
Eastwood K, Morgans A, Smith K, Stoelwinder J. Secondary triage in prehospital emergency ambulance services: a systematic review. Emerg Med J 2014;32:486-92.
Eastwood K, Morgans A, Smith K, et al. A novel approach for managing the growing demand for ambulance services by low-acuity patients. Aust Health Rev 2016;40:378-84.
Gardett I, Scott G, Clawson J, et al. 911 emergency communication nurse triage reduces EMS patient costs and directs patients to high-satisfaction alternative point of care. Ann Emerg Dispatch Response 2015;3:8-13.
Barron T, Fivaz M, Overton J. Using EMS telephone triage data to assess the amount of ambulance resources saved through telephone triage. 8th European Congress on Emergency Medicine; 28 Sept -1 Oct 2014; Amsterdam 2014.
Eastwood K, Smith K, Morgans A, Stoelwinder J, editors. A novel solution for managing the growing demand for ambulance services by low-acuity patients. European Health Management Association: what healthcare can we afford? 2013; Bocconi University Milan, Italy. Belgium: European Health Management Association; 2013.
Australian Bureau of Statistics. 3218.0 Regional population growth Australia 2012-2013 Canberra: Australian Government; 2015 [Updated 2015]. Available at: www.abs.gov.au/ausstats/abs@.nsf/Products/3218.0~2012-13~Main+Features~Victoria?OpenDocument#PARALINK3 [Accessed 3 February 2016].
Australian Bureau of Statistics. Greater Melbourne (GCCSA) Canberra: Australian Government; 2015 [updated 29 June 2015]. Available at: http://stat.abs.gov.au/itt/r.jsp?RegionSummary®ion=2GMEL&dataset=ABS_REGIONAL_ASGS&geoconcept=REGION&measure=MEASURE&datasetASGS=ABS_REGIONAL_ASGS&datasetLGA=ABS_REGIONAL_LGA®ionLGA=REGION®ionASGS=REGION [Accessed 22 March 2016].
Eastwood K, Morgans A, Stoelwinder J, Smith K. Patient and case characteristics associated with ‘no paramedic treatment’ for low-acuity cases referred for emergency ambulance dispatch following a secondary telephone triage: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2018;26:8.
Ambulance Victoria. Delivering our patients the right care, at the right time, at the right place: revised clinical response model evaluation report. Doncaster: 2017. Available at: www.ambulance.vic.gov.au/wp-content/uploads/2017/06/av-revised-clinical-response-model-evaluation-report.pdf
Australasian College for Emergency Medicine. Guidelines on the implementation of the Australasian triage scale in emergency department. West Melbourne: 2013 Contract No.: G24. Available at: file:///C:/Users/eastwood/Downloads/G24_04_Guidelines_on_Implementation_of_ATS_Jul-16.pdf [Accessed 3 February 2016].
Murad H, Fleischman A, Sadetzki S, Geyer O, Freedman LS. Small samples and ordered logistic regression: does it help to collapse categories of outcome? Am Stat 2003;57:155-60.
Lund B, Raimi S, editors. Collapsing levels of predictor variables for logistic rgression and weight of evidence coding. MidWest SAS Users Group 2012; Minneapolis, MN. Minneapolis, MN2012.
Tabachnick B, Fidell L. Using multivariate statistics. Boston: Pearson; 2001.
IMB Corp. IBM SPSS Statistics for Windows. 23.0 edn. Armonk, NY: IBM Corp.; 2015.
Berchet C. Emergency care services: Trends, drivers and interventions to manage the demand. In: Division H, editor. Paris: Organisation for Economic Co-operation and Development (OECD); 2015.
Anderson A, Roland M. Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study. BMJ Open 2015;5:e009444-e.
Lowthian J, Curtis A, Stoelwinder J, McNeil J, Cameron P. Emergency demand and repeat attendances by older patients. Intern Med J 2013;43:554-60.
Townsend CH, Maxwell W, Sears LT. Nurse practitioner patient centered telephone calls in a VA primary care geriatric clinic. J Am Assoc Nurse Pract 2001;13:269-75.
Latham LP, Ackroyd-Stolarz S. Emergency department utilization by older adults: a descriptive study. Can Geriatr J 2014;17:118-25.
Baum SA, Rubenstein LZ. Old people in the emergency room: age-related differences in emergency department use and care. J Am Geriatr Soc 1987;35:398-404.
Biber R, Bail HJ, Sieber C, et al. Correlation between age, emergency department length of stay and hospital admission rate in emergency department patients aged >/=70 years. Gerontology 2013;59:17-22.
Pines JM, Mullins PM, Cooper JK, Feng LB, Roth KE. National trends in emergency department use, care patterns, and quality of care of older adults in the United States. J Am Geriatr Soc 2013;61:12-7.
Eastwood K, Morgans A, Stoelwinder J, Smith K. The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: a retrospective cohort study. PLoS ONE 2019;14: e0221158. https://doi.org/10.1371/journal. pone.0221158.
Poulin PA, Nelli J, Tremblay S, et al. Chronic pain in the emergency department: a pilot mixed-methods cross-sectional study examining patient characteristics and reasons for presentations. Pain Res Manag 2016;2016:3092391.
Nunn ML, Hayden JA, Magee K. Current management practices for patients presenting with low back pain to a large emergency department in Canada. BMC Musculoskelet Disord 2017;18:92.
Baker K. Chronic pain syndromes in the emergency department: identifying guidelines for management. Emerg Med Australas 2005;17:57-64.
Cordell WH, Keene KK, Giles BK, et al. The high prevalence of pain in emergency medical care. Am J Emerg Med 2002;20:165-9.
McLeod D, Nelson K. The role of the emergency department in the acute management of chronic or recurrent pain. Australas Emerg Nurs J 2016(1):30-6.
Todd KH, Cowan P, Kelly N, Homel P. Chronic or recurrent pain in the emergency department: national telephone survey of patient experience. West J Emerg Med 2010;11:408-15.
Wilsey BL, Fishman SM, Crandall M, Casamalhuapa C, Bertakis KD. A qualitative study of the barriers to chronic pain management in the ED. Am J Emerg Med 2008;26:255-63.
Lowe RA, Abbuhl SB. Appropriate standards for 'appropriateness' research. Ann Emerg Med 2001;37:629-32.