Hey everyone! I'm a current premed student working as an ER scribe interested in becoming an ER physician. For those of you who work or have been through rotations in the ER, you can attest to the increasing issue of nonurgent patients in emergency rooms. I've recently written a paper regarding this issue including the effects it causes on patients, providers, and healthcare prices along with possible solutions to help decrease the numbers of these unnecessary visits and would love to get your thoughts regarding the prevalence of the issue and any other solutions you have seen implemented with success or come up with on your own.
In the past 10 years, emergency room visits have increased by 20%, and research shows that anywhere from 56-65% of these visits are not in need or emergent care (“A Matter of Urgency: Reducing Emergency Department Overuse”). Research shows that these rates have risen mainly due to limited accessibility to primary care physicians, convenient hours and weekend care (“A Matter of Urgency: Reducing Emergency Department Overuse”), less hospitals nationwide, and nursing staff shortages (Johnson and Winkelman). This increasing problem has many implications on the cost of healthcare, decreased quality of care for urgent as well as nonurgent patients, and as you may know, increased frustration in ER staff. The average cost of an ER visit is $1200, and many Medicaid patients have no cost or copay, and all patients are to be evaluated regardless of their ability to pay for any testing. This has put a $4.4 billion strain on healthcare (“The Non-Emergency Emergency: Reducing Avoidable ER Visits”). Furthermore, this issue impacts these nonurgent patients as well as people in need of emergent care. Patients need continuous care through a primary care physician, and this can be disrupted by excessive use of emergency rooms and ineffective communication between ER physicians and patients' primary care physicians (PCPs). Even more affected are those patients with urgent problems; due to overcrowding and long wait times that increase with increasing numbers of nonurgent patients, these urgent patients may suffer. While their care takes precedent over these nonurgent patients, mortality rates still increase, and medication administration times may be delayed (Johnson and Winkelman). Working with the doctors in the ER, I have witnessed their frustration that comes with seeing patients that don't need emergency care. While there are many critical patients that come to the ER, we've seen some pretty ridiculous complaints including paper cuts, dry skin, and of course, narcotic seekers. Thankfully, some hospitals have implemented various solutions to decrease this problem with success that can hopefully be carried throughout other hospitals throughout the nation. These include diverting patients requesting ambulances, diverting patients to urgent care centers, implementing a copay for those on public aid, coordinating with patients' PCPs, and focusing on the deeper issues of many of these patients including substance abuse issues and mental health issues, and all of these solutions have been effective without affecting the quality of care.
The first solution focuses on close follow up and communication by patients' PCPs and ER providers along with referring patients without PCPs to primary physicians currently accepting new patients. With increased communication efforts between doctors, patients' PCPs are aware of when their patients are in the ER, and this may also avoid duplicate testing and access to patients' past medical history. At the hospital I work at, we don't even have access to the Clinics that we collaborate with, let alone other hospitals in the area, so oftentimes testing and imaging are repeated, even if a patient had testing done at their primary physician's office prior to arrival. Hospitals in Washington State have implemented such solutions, and collaboration with PCPs and tracking frequent visits has already led to savings of $31 million in six months (Wood).
Another solution focuses on diverting nonurgent patients to more appropriate care settings, and these can be implemented at the level of pre- and post-ER arrival. Ambulance services in Melbourne, Australia came up with a system of a secondary triage line involving a nurse speaking with patients that were deemed nonurgent upon calling for an ambulance; this nurse assessing patients' symptoms recommends them to continue on to the ER via private vehicle, wait and seek care from a primary physician, or gives advice on treating their symptoms at home. This system has shown great success by diverting 72.4% of nonurgent patients from ambulance services and 32.2% of these patients away from the ER, eventually followed by an overall 10% decrease in demand of ambulance transportation (Eastwood et al.). Up to 50% of US emergency departments report having to divert ambulances due to overcrowding (Bernstein et al.), so this system is promising for reducing these rates in the US as well.
Another idea is diverting patients once they have already arrived at the ER. Many patients who are deemed as nonurgent can be more effectively treated at an urgent care center. Wait times at urgent care centers are on average 45 minutes compared to 4 hours at an emergency room (“The Non-Emergency Emergency: Reducing Avoidable ER Visits”), and the cost of a visit is around $40 compared to a whopping $1200 ER visit (“The Non-Emergency Emergency: Reducing Avoidable ER Visits”. A study conducted in France assessed patients' willingness to be redirected to such convenient care centers called primary care units (PCUs). The greatest factors determining patients' willingness to be directed to these units are employment and perceived level or urgency; employed people were much more likely to be redirected, and those with higher levels of perceived urgency were less likely to be redirected. Of the patients that were deemed nonurgent, 68% of them were willing to be redirected to these PCUs (Gentile et al.). To be an effective means of diversion, convenient care clinics need to close to the hospital, open during times primary care physicians are unavailable, and accessible in rural and undeveloped areas (Mann).
Another solution presented by a PA that I work with is charging $5 copays for those who are on public aid that currently have no cost or copay. Many of these patients, due to their low or no cost to visit an ER, tend to abuse the system, some even seeking out narcotics and visiting multiple ERs in a day. While this may not seem like much money, it may be enough to make them think about abusing the system. I've witnessed his and many other doctors' frustration when it comes to patients abusing the ER, and it's time that we start implementing these solutions to limit the amount of unnecessary ER visits to prevent this frustration, improve care for all patients, and cut down on wasteful healthcare spending. Please let me know your thoughts on this issue.
Works Cited
“A Matter of Urgency: Reducing Emergency Department Overuse.” New England Healthcare Institiute, Mar. 2010.
Bernstein, Steven L., et al. “The Effect of Emergency Department Crowding on Clinically Oriented Outcomes.” Academic Emergency Medicine, Blackwell Publishing Ltd, 10 Nov. 2008.
Eastwood, Kathryn, et al. “Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study.” BMJ Open, BMJ Publishing Group, 15 Oct. 2017.
Gentile, Stéphanie, et al. “Nonurgent Patients in the Emergency Department? A French Formula to Prevent Misuse.” BMC Health Services Research, vol. 10, no. 1, 2010, pp. 66–71., doi:10.1186/1472-6963-10-66.
Johnson, Kimberly D., and Chris Winkelman. “The Effect of Emergency Department Crowding on Patient Outcomes.” Advanced Emergency Nursing Journal, vol. 33, no. 1, 2011, pp. 39–54., doi:10.1097/tme.0b013e318207e86a.
Mann, Cindy. “Reducing Nonurgent Use of Emergency Departments and Improving Appropriate Care in Appropriate Settings.” Centers for Medicare & Medicaid Services, 16 Jan. 2014.
“The Non-Emergency Emergency: Reducing Avoidable ER Visits.” BlueCross BlueShield of North Carolina, Blue Cross and Blue Shield of North Carolina.
Wood, Debra. “Strategies for Reducing Emergency Department Overuse.” AMN Healthcare, AMN Healthcare, Inc., 19 May 2014.
In the past 10 years, emergency room visits have increased by 20%, and research shows that anywhere from 56-65% of these visits are not in need or emergent care (“A Matter of Urgency: Reducing Emergency Department Overuse”). Research shows that these rates have risen mainly due to limited accessibility to primary care physicians, convenient hours and weekend care (“A Matter of Urgency: Reducing Emergency Department Overuse”), less hospitals nationwide, and nursing staff shortages (Johnson and Winkelman). This increasing problem has many implications on the cost of healthcare, decreased quality of care for urgent as well as nonurgent patients, and as you may know, increased frustration in ER staff. The average cost of an ER visit is $1200, and many Medicaid patients have no cost or copay, and all patients are to be evaluated regardless of their ability to pay for any testing. This has put a $4.4 billion strain on healthcare (“The Non-Emergency Emergency: Reducing Avoidable ER Visits”). Furthermore, this issue impacts these nonurgent patients as well as people in need of emergent care. Patients need continuous care through a primary care physician, and this can be disrupted by excessive use of emergency rooms and ineffective communication between ER physicians and patients' primary care physicians (PCPs). Even more affected are those patients with urgent problems; due to overcrowding and long wait times that increase with increasing numbers of nonurgent patients, these urgent patients may suffer. While their care takes precedent over these nonurgent patients, mortality rates still increase, and medication administration times may be delayed (Johnson and Winkelman). Working with the doctors in the ER, I have witnessed their frustration that comes with seeing patients that don't need emergency care. While there are many critical patients that come to the ER, we've seen some pretty ridiculous complaints including paper cuts, dry skin, and of course, narcotic seekers. Thankfully, some hospitals have implemented various solutions to decrease this problem with success that can hopefully be carried throughout other hospitals throughout the nation. These include diverting patients requesting ambulances, diverting patients to urgent care centers, implementing a copay for those on public aid, coordinating with patients' PCPs, and focusing on the deeper issues of many of these patients including substance abuse issues and mental health issues, and all of these solutions have been effective without affecting the quality of care.
The first solution focuses on close follow up and communication by patients' PCPs and ER providers along with referring patients without PCPs to primary physicians currently accepting new patients. With increased communication efforts between doctors, patients' PCPs are aware of when their patients are in the ER, and this may also avoid duplicate testing and access to patients' past medical history. At the hospital I work at, we don't even have access to the Clinics that we collaborate with, let alone other hospitals in the area, so oftentimes testing and imaging are repeated, even if a patient had testing done at their primary physician's office prior to arrival. Hospitals in Washington State have implemented such solutions, and collaboration with PCPs and tracking frequent visits has already led to savings of $31 million in six months (Wood).
Another solution focuses on diverting nonurgent patients to more appropriate care settings, and these can be implemented at the level of pre- and post-ER arrival. Ambulance services in Melbourne, Australia came up with a system of a secondary triage line involving a nurse speaking with patients that were deemed nonurgent upon calling for an ambulance; this nurse assessing patients' symptoms recommends them to continue on to the ER via private vehicle, wait and seek care from a primary physician, or gives advice on treating their symptoms at home. This system has shown great success by diverting 72.4% of nonurgent patients from ambulance services and 32.2% of these patients away from the ER, eventually followed by an overall 10% decrease in demand of ambulance transportation (Eastwood et al.). Up to 50% of US emergency departments report having to divert ambulances due to overcrowding (Bernstein et al.), so this system is promising for reducing these rates in the US as well.
Another idea is diverting patients once they have already arrived at the ER. Many patients who are deemed as nonurgent can be more effectively treated at an urgent care center. Wait times at urgent care centers are on average 45 minutes compared to 4 hours at an emergency room (“The Non-Emergency Emergency: Reducing Avoidable ER Visits”), and the cost of a visit is around $40 compared to a whopping $1200 ER visit (“The Non-Emergency Emergency: Reducing Avoidable ER Visits”. A study conducted in France assessed patients' willingness to be redirected to such convenient care centers called primary care units (PCUs). The greatest factors determining patients' willingness to be directed to these units are employment and perceived level or urgency; employed people were much more likely to be redirected, and those with higher levels of perceived urgency were less likely to be redirected. Of the patients that were deemed nonurgent, 68% of them were willing to be redirected to these PCUs (Gentile et al.). To be an effective means of diversion, convenient care clinics need to close to the hospital, open during times primary care physicians are unavailable, and accessible in rural and undeveloped areas (Mann).
Another solution presented by a PA that I work with is charging $5 copays for those who are on public aid that currently have no cost or copay. Many of these patients, due to their low or no cost to visit an ER, tend to abuse the system, some even seeking out narcotics and visiting multiple ERs in a day. While this may not seem like much money, it may be enough to make them think about abusing the system. I've witnessed his and many other doctors' frustration when it comes to patients abusing the ER, and it's time that we start implementing these solutions to limit the amount of unnecessary ER visits to prevent this frustration, improve care for all patients, and cut down on wasteful healthcare spending. Please let me know your thoughts on this issue.
Works Cited
“A Matter of Urgency: Reducing Emergency Department Overuse.” New England Healthcare Institiute, Mar. 2010.
Bernstein, Steven L., et al. “The Effect of Emergency Department Crowding on Clinically Oriented Outcomes.” Academic Emergency Medicine, Blackwell Publishing Ltd, 10 Nov. 2008.
Eastwood, Kathryn, et al. “Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study.” BMJ Open, BMJ Publishing Group, 15 Oct. 2017.
Gentile, Stéphanie, et al. “Nonurgent Patients in the Emergency Department? A French Formula to Prevent Misuse.” BMC Health Services Research, vol. 10, no. 1, 2010, pp. 66–71., doi:10.1186/1472-6963-10-66.
Johnson, Kimberly D., and Chris Winkelman. “The Effect of Emergency Department Crowding on Patient Outcomes.” Advanced Emergency Nursing Journal, vol. 33, no. 1, 2011, pp. 39–54., doi:10.1097/tme.0b013e318207e86a.
Mann, Cindy. “Reducing Nonurgent Use of Emergency Departments and Improving Appropriate Care in Appropriate Settings.” Centers for Medicare & Medicaid Services, 16 Jan. 2014.
“The Non-Emergency Emergency: Reducing Avoidable ER Visits.” BlueCross BlueShield of North Carolina, Blue Cross and Blue Shield of North Carolina.
Wood, Debra. “Strategies for Reducing Emergency Department Overuse.” AMN Healthcare, AMN Healthcare, Inc., 19 May 2014.
