Background Non-urgent emergency department attendances are a pervasive global problem, contributing to delayed treatment, patient dissatisfaction, and increased admissions. In paediatric emergency departments (PEDs), 41–79% of attendances are non-urgent. Nevertheless, parents and primary care practitioners continue to view PEDs as an appropriate place to seek treatment for minor ailments, with a common reason being its convenience in performing laboratory and radiological investigations in the same location. Resource utilisation is a commonly used measure of appropriateness of an attendance, and is a suitable measure in the unique paediatric population.
Objectives Our study aims to assess the appropriateness of PED attendances in a multi-ethnic Asian population, and identify predictors of inappropriate attendances (IAs). To our knowledge, no similar study has been performed in a multi-ethnic Asian population. This will allow identification of gaps in our healthcare system that can be addressed to decrease the proportion of inappropriate PED attendances. In the COVID-19 era, we also aim to review how these trends have changed in a pandemic.
Methods A retrospective study was performed on all attendances to the largest PED in Singapore from 1 January to 31 July 2019 and 2020. A total of 153,631 visits were included for analysis.
Attendances were classified into appropriate or inappropriate depending on resources used and eventual disposition. An appropriate attendance (AA) was defined as fulfilling any of the following criteria: (1) investigated in emergency department (excluding urine studies in children aged 3 years and older); (2) treated in emergency department (excluding basic enteral anti-pyretic medications, prescription medications, or performing of simple procedures); or (3) admitted to the inpatient ward or discharged with specialist follow-up. All other attendances were hence classified as inappropriate attendances (IAs).
Univariate and multivariate analysis was performed to identify predictors of inappropriate attendances.
Results A total of 31,657 attendances (20.6%) were classified as inappropriate attendances. On multivariate analysis, the three most significant factors predicting inappropriate attendances were lower triage acuity (P3 vs P1, OR 37.37, 95%CI 27.73–50.36), mode of arrival (self vs ambulance or police escort, OR 1.76, 95%CI 1.60–1.94), and first visits (re-attendance within 72 hours vs first visit, OR 0.56, 95%CI 0.50–0.64). Attendances in 2020 decreased by 40.2% from 2019, with a smaller proportion of inappropriate attendances in 2020 (21.7% in 2019 vs 18.8% in 2020, p < 0.001). Similarly, abscondment rates (0.41% in 2019 vs 0.31% in 2020) and re-attendance rates (1.4% in 2019 and 1.2% in 2020) decreased in 2020.
Conclusions This study identified the frequency of inappropriate visits, and predictors of these visits. From our data, possible initiatives to decrease inappropriate PED use would be to equip PCPs with facilities for basic fingerpick blood tests for the paediatric population. This study paves the way for direction of future research and educational efforts towards these groups to decrease inappropriate use of the emergency department.
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