Inappropriate attendances blamed for ED overcrowding in SG

Emergency department (ED) attendances in Singapore are increasing, which then leads to a higher input and subsequently to overcrowding. Ambulatory (P3) patients, which account for a substantial number of ED turnout, may be diverted to primary care services that are appropriate for their concerns, suggests a recent study.

“Measures to further reduce these ED attendances would need to address their healthcare needs and health-seeking behaviour,” said lead author Dr Alston Guan Jie Ong from the Emergency Department of Sengkang General Hospital, Singapore.

Ong and his team conducted this retrospective study from 2019 to 2022 and collected information on demographics, attendance patterns, length of ED stay, diagnoses, and dispositions for analysis.

A total of 541,762 attendances were identified, of which 183,592 (33.9 percent) were ambulatory (P3) patients. Majority of these patients (n=149,846, 81.6 percent) were adults between the age of 16 and 65 years. [Proc Singap Healthc 2024;doi:10.1177/20101058241245236]

More ambulatory (P3) patients attended the ED during weekends and public holidays, and between 0800 and 2359 h (p<0.01), than emergent (P1) and urgent (P2) patients. A greater number of ambulatory (P3) patients also self-conveyed to the ED and had no referral from primary care physicians (p<0.01). Their median time was 9 min for wait for triage, 35 min for wait for consult, and 110 min for length of stay.

Among ambulatory (P3) patients, nearly one in 10 required hospital admission. Their top diagnosis was upper respiratory tract infection (11.0 percent), followed by musculoskeletal pain (9.7 percent) and laceration (4.3 percent).

“The findings of our study were similar to a paper by Alnasser et al. which found that nonurgent attendances at a Saudi Arabia ED were mostly by adults between 16- and 65-year old, a higher proportion of them attended ED on weekends compared to other triage categories, majority did not have referral from primary care physicians, and upper respiratory tract infection was the most common diagnosis,” Ong and colleagues said. [Int J Gen Med 2023;16:221-232; Int J Gen Med 2023;16:357-358]

These findings also supported those of another local study where mostly patients between 20 and 60 years of age who self-conveyed to the ED without referral from primary care physicians accounted for inappropriate attendances (defined as no investigation or procedure performed and discharged with no follow-up at a specialist outpatient clinic). [Singapore Med J 2020;61:75-80]

“Therefore, a significant proportion of ambulatory (P3) patients may not require attendance at the ED and interventions directed at right-siting them to more appropriate care services to receive the medical attention they require would help reduce input to the ED and ease ED overcrowding,” Ong said.

Timely care

EDs in hospitals are primarily tasted to attend to emergencies by providing timely resuscitation and care to patients in critical condition. However, those with mild or noncritical conditions still attend to ED for inappropriate reasons such as “overestimating the severity … of their conditions or convenience due to accessibility of medical services … on a round-the-clock basis.” [Scot Med J 2017;62:2-10; Scot Med J 2000;45:144-147; BMJ Open 2022;12:e054046]

“This accessibility was evidenced in our study by the higher proportions of ambulatory (P3) patients who attended ED on weekends and public holidays compared to other triage categories,” Ong said. “This can be attributed to primary care services not being available on weekends and public holidays when medical attention was required even though their conditions may be minor.”