Several hospitals in the United States have an Emergency Department (ED) to care for patients who have urgent diseases or injuries. In the United States, however, the majority of ED visits are non-emergent. Non-emergent visits to the ED are those made by patients for conditions where a wait of a few hours is unlikely to enhance the likelihood of a negative outcome (Uscher-Pines, Pines, Kellermann, Gillen & Mehrotra, 2013). Adults in the United States have a hazy awareness of the appropriate use and indications for seeking ED treatment. The visits to the ED for cases that are not emergent raise concerns due to the strain they cause on the resources and staff, thereby diverting them from critical patients and increasing the workload, which results to reduced satisfaction in patients and healthcare providers.
The Significance of the Problem
Allowing patients to visit the ED instead of other sites of care like physician’s office, urgent care, sobering facilities, charitable community clinics, and retail clinics for non-emergent cases result to excessive healthcare spending, testing and treatment that re not necessary as well as representing an opportunity that is missed to promote longitudinal associations with physicians of primary care. The EDs in hospitals in the United States face remarkable pressure to minimize the costs with an aim of having an efficient functioning system. In addition to being overcrowded, the EDs face pressures from federal and state healthcare like reducing the rates of reimbursement and raising regulatory oversight.
Description of the Current practice related to the Problem
To improve the efficiency of EDs in health system and reduce the costs associated with the over-use of ED for preventable and treatable conditions in other healthcare sites, measures like patient navigation have been applied as interventions to address the barriers especially in populations that are medically underserved including those of low income, uninsured, current immigrants and those that are publicly insured. In the patient navigation program, patients are connected with other medical facilities and related support services. In addition, the Community Health Workers provide education regarding the significance of primary car and follow up with the patients to check ad solve any additional barriers.
A Discussion of How the Problem Impacts the Organization And /Or the Patients’ Cultural Background Such As Values, Health Behavior and Preferences
In an effort to reduce the non - urgent visits to the ED, there have been policies to discourage the use of ED that have unconstructive and accidental consequences. For instance, the enrollees in health plans that are high-deductible that bear an increased cost share of an ED visit may not seek care for a real emergency. There are inconsistencies between the ED patients’ perceptions and those of the healthcare professionals. Generally, patients do not like being overwhelmed by many appointments with different specialists. On the other hand, the healthcare professionals usually face a problem when it comes to defining a non-emergent visit. In the long run, the EDs become overcrowded and the available resources get strained making it hard to serve the rightfully targeted patients that have serious conditions.
POCO Table
Example:
P (patient/problem)
In general adult patients in the United States
I (intervention/indicator)
An all-embracing education campaign
C (comparison)
No education
O (outcome)
reduced and controlled emergency department visits for non-emergent conditions
PICO Question
In general adult patients in the United States (P), does an all-embracing education campaign (I), compared to no education (C), reduce and control emergency department visits for non-emergent conditions (O)?
Search Strategy Used To Conduct the Literature Review
Keywords Used for the Search
The key words that were used for the search included emergency departments, emergency rooms, non-emergent, overuse of emergency rooms, frequent users, inappropriate use and non-urgent.
Description of the Number and Types of Articles that were Available for Consideration
Peer reviewed articles were found from professional online libraries, open access journals and databases such as the U.S. National library of Medicine, the National Center for Biotechnology Information, and BMJ that are dedicated to publishing research in medicine from every discipline and therapeutic area. To be included for consideration, the articles had to have been published not earlier than 2012 and had to address the problem of ED overuse with non-emergent conditions. The articles had to present some quantitative data as well as descriptive data on non-emergent use of ED. In addition, an article had to be published in English and had to have been peer reviewed. Each abstract was examined and if the abstract met the inclusion criteria, a more thorough full-text review followed. The full-text articles were evaluated on whether they met the inclusion criteria and data was then extracted. The initial search approach produced 60 abstracts. There were additional 4 abstracts that were obtained by manually searching the reference lists of the articles. However, only 12 articles were identified for full review, and 5 satisfied the inclusion criteria. The main reason for exclusion was that some of the articles lacked quantitative data.
Research Evidence and Non-Research Evidence Source
The study by Bodenmann et al. (2014) is a research evidence of level II as it is a designed randomized controlled trial. The authors evaluated the usefulness and efficiency of a mediation founded on case management care for recurrent users of emergency department, which was meant to minimize the use of emergency department by the patients to improve their life quality as well as minimize the cost following frequent use. Birmingham, Cochran, Frey, Stiffler & Wilber (2017) is another research evidence of level III where the authors did a prospective study that sought to find out the reasons behind presentation to the ED by the frequent users, the barriers that exist to care and the kind of service offerings that can assist the frequent users to realize an optimal level of health. Some non-research evidence sources include a report by Hiltzik (2017), in which the author, a columnist of Los Angeles Times tells of a health insurer whose plans are to punish patients for visiting emergency rooms with non-emergent conditions. In addition, Wood (2014) presented non-research evidence, in which the author reports measures that could be taken to reduce the overuse of ED.
Evidence Matrix
Authors
Journal Name/ WGU Library
Year of Publication
Research Design
Sample Size
Outcome Variables Measured
Level (I–III)
Quality (A, B, C)
Results/Author’s Suggested Conclusions
Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. (2013).
The American journal of managed care
2013
systematic literature review
26 articles
nonurgent ED use
I
A
Younger age, ED convinience compared to other health facilities, physicians’ referral to the ED and unconstructive perception concerning the alternatives have a role in increasing non-urgent use of ED.
Ogilvie, S., Hopgood, K., Higginson, I., Ives, A., & Smith, J. E. (2016).
Journal of Royal Society of Medicine
2016.
cross-sectional survey
373 Responses
-Parental and child characteristics
-injury/illness characteristics
-advice seeking behavior
-views regarding emergency department service improvement
-GP access and determinants of emergency department use
III
B
It is very hard for parents to conclude if the symptoms of their children mirror minor conditions and efforts should emphasize of building the confidence ad self-help of parents.
Rocovich, C., & Patel, T. (2012).
World journal of emergency medicine
(2012).
Descriptive study with questionnaire
262 patients
Patients characteristics
III
B
The authors found out that being single and employed are some of the factors behid the reasoning of patients to choose the emergency department.
Birmingham, L. E., Cochran, T., Frey, J. A., Stiffler, K. A., & Wilber, S. T. (2017).
BMC emergency medicine
2017
prospective study
1,523 patients
-Demographics
-ED usage
-Perceived barriers to care -potential aids to maintaining health.
III
C
The authors concluded that the health systems have a potential to address the unmet needs if there is an understanding of barriers to care from the perspective of the parents.
Vinton, D. T., Capp, R., Rooks, S. P., Abbott, J. T., & Ginde, A. A. (2014).
Emergency Medicine Journal
2014
Secondary analysis of survey
157 818
Patients characteristics of ED use
III
C
Focus should be laid on the management of chronic disease and access to outpatient services
Bodenmann, P., Velonaki, V. S., Ruggeri, O., Hugli, O., Burnand, B., Wasserfallen, J. B., ... & Daeppen, J. B. (2014).
BMC health services research
2014
a randomized controlled trial
250 patients
-emergency department visits
- quality of life
- efficiency
-cost-utility
III
B
The study is useful I the clarification of knowledge gaps concerning the constructive outcomes of an intervention based on case management care
A Recommended Practice Change That Addresses the Pico Question within the Framework of the Evidence Collected and Used In the Attached “Evidence Matrix
Based on the collected evidence from the reviewed articles, people should be educated regarding the use of ED. The practice change should be focused on a comprehensive education campaign that will target the adults in the United States. This campaign will help in encouraging dialogue among patients and educators to optimize the use of ED and avoid overuse for non-emergent conditions.
A Process for Implementing the Recommendation
Various media will be used in the implementation of a comprehensive education campaign. Three major stakeholders will be the American adults, the healthcare providers and the different media agencies that will be used to disseminate materials that will contain information about the proper use of ED. Healthcare providers will have a role of designing useful information detailing what emergent conditions are and why other medical facilities can be trusted to address non-emergent cases. The media houses will be required to disseminate the designed educational materials without any alterations for them to reach the public as intended.
One of the major barriers to be encountered in this project is concerned with the perception of the patients. Many people believe in the services of the ED than those of alternatives, which will make it hard to convince them to take their minor concerned to medical sites like clinics. Another major issue is concerned with medical insurances, which have increased the usage of ED by the patients. Patients might find it challenging if asked to visit other medical alternative sites, than using their insurance cover to visit the ED even for non-emergent cases. It will also be hard to classify emergent cases from non-emergent cases, as each adult has his or her own definition and worry when encountered by an illness or injury.
To overcome these barriers, the educational materials should include information on the effectiveness of other medical alternatives in addressing minor cases and helping them schedule timely appointments with their primary care physicians. The campaign should focus on a change of behavior and attitude of the American adults. Additionally, the medical insurers need to set strict standards on which ED should be visited by the insured adults.
One of the indicators to measure reduction and control of emergency department visits for non-emergent conditions is reduction of ED costs. Evidence has shown that ED cost increases with overuse of the ED. Therefore, if people stop visiting the ED with non- urgent cases, resources will be used for the intended serious cases and costs will be significantly reduced.
References
Birmingham, L. E., Cochran, T., Frey, J. A., Stiffler, K. A., & Wilber, S. T. (2017). Emergency department use and barriers to wellness: a survey of emergency department frequent users. BMC emergency medicine, 17(1), 16. Retrieved online on 6th July, 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5424308/
Bodenmann, P., Velonaki, V. S., Ruggeri, O., Hugli, O., Burnand, B., Wasserfallen, J. B., ... & Daeppen, J. B. (2014). Case management for frequent users of the emergency department: study protocol of a randomised controlled trial. BMC health services research, 14(1), 264. Retrieved online on 6th July, 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4071797/
Hiltzik, Michael. (2017). A big health insurer is planning to punish patients for 'unnecessary' ER visits. Retrieved online on 6th July, 2017 from http://www.latimes.com/business/hiltzik/la-fi-hiltzik-insurance-er-20170602-story.html
Ogilvie, S., Hopgood, K., Higginson, I., Ives, A., & Smith, J. E. (2016). Why do parents use the emergency department for minor injury and illness? A cross-sectional questionnaire. JRSM open, 7(3), 2054270415623695. Retrieved online on 6th July, 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780204/
Rocovich, C., & Patel, T. (2012). Emergency department visits: Why adults choose the emergency room over a primary care physician visit during regular office hours?. World journal of emergency medicine, 3(2), 91. Retrieved online on 6th July, 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129795/
Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. (2013). Deciding to visit the emergency department for non-urgent conditions: a systematic review of the literature. The American journal of managed care, 19(1), 47. Retrieved online on 5th July, 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/
Vinton, D. T., Capp, R., Rooks, S. P., Abbott, J. T., & Ginde, A. A. (2014). Frequent users of US emergency departments: characteristics and opportunities for intervention. Emerg Med J, emermed-2013. Retrieved online on 6th July, 2017 from http://emj.bmj.com/content/31/7/526
Wood, Debra. (2014). Strategies for Reducing Emergency Department Overuse. Retrieved online on 6th July, 2017 from https://www.amnhealthcare.com/latest-healthcare-news/strategies-reducing-emergency-department-overuse/
