Patient Perceptions of the Emergency Department: Factors that Lead to Overcrowding

Emergency departments (EDs) have become increasingly important in providing access to medical care in the United States. An analysis of American Hospital Association Survey data found that the number of emergency visits between 1992 and 2012 increased by roughly 2.2 million visits a year, while the number of available EDs in the United States declined.(1) Along with steadily rising ED admissions, there has been an increase in the amount of people with emergent conditions who are choosing to leave before being seen. One study found that over a period of five years, there was an increase of more than 400% in the number of people leaving before receiving care.(2) The combination of growing demand and decreasing resources has led to ED overcrowding, which has become one of healthcare’s most serious problems.

According to a 2001 nationwide survey of ED directors, a third of the respondents believed that patients are experiencing poorer outcomes as a direct result of overcrowding.(3) The negative effect of overcrowding on the quality of patient care validates the need to further investigate its causes, as well as potential remedies. One factor that is largely blamed for overcrowding is patients who present to the ED without real emergencies, thus being deemed inappropriate for emergency treatment. Under the Emergency Medical Treatment and Labor Act (EMTALA), however, emergency treatment cannot be denied to those seeking emergency care; therefore, all patients must be seen regardless of their ability to pay or their actual need of care.(4) These nonemergent patients have become a target for cost-cutting efforts, because using ED resources for them is seen as wasteful and expensive.(5) However, for many people who are poor, uninsured, or homeless, the ED is both a last resort and a safety net for medical treatment.(6) Additional population groups that use the ED disproportionately include children, the elderly, drug addicts, and patients with a history of mental illness.(7) One article found that these frequent users of the ED represent as little as 2.7% of patients showing up to the ED, but make up to 67% of all ED visits over a given period of time.(8)

Additional reasons that lead patients to choose the ED over other alternatives include referrals by their primary care physician (PCP) or office staff, difficulty getting an appointment with their PCP, the convenience of accessing the ED, lack of insurance, or unavailability of other options.(9) Patients often are unaware of the services offered by their PCP or other providers outside the ED.(10) As a result, many patients seek care at the ED for complaints that could be addressed in an office setting. Unfortunately, patients avoid primary care services due to frustration with scheduling appointments, the perception of waiting for a long time before being able to access specialized services, and greater trust in hospital care.(11)

Our study was performed in a city on the border between the United States and Mexico. Due to the unique patient population of a border city, patients may face barriers to obtaining medical services. For undocumented immigrants, the ED may be the only available source of healthcare. Barriers that immigrants may encounter include insufficient understanding of the healthcare system, lack of financial ability, as well as communication issues due to limited language proficiency.

One way to address the issue of ED overcrowding is by extending the availability of primary care services.

Overcrowding has potential unintended consequences that can negatively affect the quality of care that patients receive. Patients with acute and time-sensitive conditions, such as myocardial infarctions, strokes, surgical emergencies, and sepsis, may not be seen in a timely manner, which may delay their treatment. In addition, some patients who require the resources and observation available only in the intensive care unit may be stuck waiting in the ED. Because these patients are not treated properly and efficiently, they may end up with poorer outcomes.(6)

One way to address the issue of ED overcrowding is by extending the availability of primary care services. When a recent study in Italy extended the availability of primary care services to 10 to 12 hours a day, the inappropriate utilization of emergency services was reduced by 10% to 15%.(11) Other attempts to address ED overcrowding include the implementation of walk-in clinics, urgent care centers, outpatient drug treatment clinics, and observation units, all of which would be more effective with proper patient education and awareness of these services.(7)

Our study sought to understand factors that affected patients’ decisions to come to the ED. We used a survey to collect data about the patients’ demographics and various factors that might influence their decisions to come to the ED. The study asked patients what they believed to be the level of urgency of their present condition on a scale of 1 to 10, and compared their view with the hospital’s triage rating of that patient’s urgency. The hospital triage system is designed to differentiate between patients who need immediate attention and those who can be helped by a more appropriate medical service. This comparison helps determine the accuracy of a patient’s sense of urgency. If the hospital rating is much less urgent than the patient’s self-rating, it suggests that patients may be unaware of what warrants a visit to the ED. The study also asked patients whether or not they had a PCP, how serious they believed their current condition was, and what specific factors influenced their decision to come to the ED.

By identifying possible factors that cause ED overcrowding, not only will ED staff be able to provide more timely care to patients who need immediate attention, but public health representatives will be able to structure out-of-hospital resources to combat these overcrowding issues. It is hoped that the information gathered by this study can be used to educate patients about the problem of ED overcrowding, provide alternative but equally convenient resources to patients with less urgent conditions, and potentially identify a set of minimum criteria that warrant use of the ED.

Methods

The study was conducted at the only Level 1 Trauma Center in a 300-mile radius, situated on the United States–Mexico border. Physicians in this center are presented with a unique opportunity in both the variety and severity of diseases that patients present with to the ED.

Approval of the study was obtained from a university’s Institutional Review Board. Surveys were given to registered patients in the waiting room of the ED. Informed consent was obtained after ensuring that the patients were eligible to participate. Inclusion criteria stated that patients must be:

• 18 years of age or older;

• Oriented to person, place, time, and situation; and

• In no apparent distress.

• Exclusion criteria for this study ruled out:

• Patients who were wards of the state;

• Patients in need of immediate resuscitation, and

• Patients younger than 18.

The consent form was offered in both English and Spanish to account for a predominantly Hispanic population. It described all relevant and necessary information pertaining to the study, such as the purpose of the study, assurance of maintaining anonymity and confidentiality of sensitive patient information, and the ability to decline to participate in the survey without any penalty in terms of quality of care in the ED. The survey also was offered in both English and Spanish. It collected valuable patient information, such as their demographics, chief complaint, and a series of questions designed to help determine their reasons for coming to the ED.

Participants were asked to define how urgent they believed their condition was on a scale from 0 to 10, with 0 being “not an emergency” and 10 being “a serious emergency.” Another question assessed the participants’ access to other sources of care. Participants were asked if they currently have a PCP. The ability to access a PCP may eliminate the need to go to the ED. The next question asked patients for their perception of the severity of the condition that had brought them to the ED. The options were:

• A life-threatening condition;

• A dangerous but not life-threatening condition; or

• A condition that could be treated at a clinic if you had that opportunity.

The final question of the survey offered participants a checklist of various reasons commonly found in the literature that may or may not influence participants’ decisions to come to the ED for treatment, with instructions to check as many of the reasons as applied to them. The reasons were:

• You can be seen quickly and/or without an appointment;

• The emergency department is always open and allows you to work around your schedule;

• The emergency department will bill you later so you do not have to pay today;

• You get better care here than any other healthcare options in this area;

• There is always a doctor on duty;

• You do not have a primary care provider; and

• You do not know of anywhere else to go.

Once participants completed the survey, research personnel obtained their triage rating (via the Emergency Severity Index scoring system) from the participant’s medical records.

Results

In total, 504 participants completed a survey, with a slight variation in the number of responses to each question. Analysis of the data involved basic descriptive statistics with IBM SPSS Analytics 22 and Microsoft Excel.

Demographics

Participants’ demographic data including sex, age, race, and ethnicity are presented in Table 1.

Women accounted for a larger percentage of participants than men. The average age of the patients was 41. The minimum age did not fall below 18 because a minimum age of 18 was required for inclusion. An overwhelming majority of patients—94%—classified their race as white, with 89% of people categorizing themselves as Hispanic or Latino.

Urgency Comparison

Each participant was asked to rate the urgency of his or her condition on a scale from 0 to 10. A rating of 0 implied that the patient was not worried at all, and a rating of 10 implied that the condition was extremely urgent (Table 2).

Only 12% of the participants surveyed thought that their condition was a 4 or below. Most participants believed that their condition was more urgent, with a significant portion (56%) believing their condition was an 8 or higher. To compare the participants’ views of urgency with the ED’s view of urgency, the triage rating was recorded after the participants had been triaged (Table 3). The rating system, however, is slightly different, as the scores range from 1 to 5, with 1 meaning resuscitation and 5 considered as non-urgent. None of the patients were considered in need of resuscitation, because the inclusion criteria required participants to be alert and oriented as well as ambulatory in order to participate in the story. The ED staff viewed a significant portion—81%—as urgent and only 10% as truly emergent.

Other Sources of Care and Opinion of Condition

Participants were asked whether they did or did not currently have a PCP (Table 4). The purpose of this was to see if participants had other options than coming to the ED and if they had a regular source of care. A slight majority of participants (58%) said that they did not have a PCP, indicating that 42% of patients did have a PCP.

Finally, participants were asked to rate the severity of their condition in a different way. They were asked to state whether they believed they had a life-threatening condition, a dangerous but not life-threatening condition, or a condition that could be treated somewhere else (Table 5).

A significant percentage of participants—34%—reported that they thought their condition could be treated elsewhere if they had the chance, but even more—48%—thought their condition was dangerous but not severe enough to be life threatening. When asked why they went to the ED for care, half of the respondents answered that they “can be seen quickly and/or without an appointment,” and more than a third stated that, “The ED is always open and allows you to work around your schedule.”

Discussion

The study sought to determine the reasons behind patient’s decisions to seek care in the ED as opposed to other healthcare outlets. The study examined the patients’ accuracy in assessing the seriousness of their conditions. More than half (56%) of respondents stated that the urgency of their condition was greater than or equal to 8 on the 10-point scale, whereas almost half (48%) thought their condition was “dangerous, but not a life-threatening condition.” Based on these findings, it is possible to infer that the concepts of “urgency/emergency” and “life-threatening condition” are interpreted differently by this population. By comparison, in the medical staffs’ triage ratings of these participants, the vast majority (81%) were labeled as an urgent condition (ESI Level 3), rather than an emergent (Level 2) or resuscitation (Level 1) condition, which would be more likely to indicate a “life-threatening condition.”

When asked whether they had a PCP, 58% of participants stated that they did not have one. (This is evident when only 17% of people reported that they believed they had a life-threatening condition.) A further 34% of the participants even reported that they had a condition that could be treated at a clinic if they had the chance. Because they do not have a more appropriate source of care, these participants are presenting to the ED in hopes of getting treatment for health conditions that could be treated elsewhere if other options were available to them. Many of these participants are clearly aware of their misuse of the ED, but due to a lack of options, they are still presenting to the ED.

Half of the study respondents answered that one of their reasons for coming to the ED was that they “can be seen quickly and/or without an appointment,” and more than a third stated that “The ED is always open and allows you to work around your schedule,” a finding that is in line with prior studies. Unfortunately, the idea of “just showing up and being seen without an appointment” runs contrary to the harsh reality of ED overcrowding and lengthy wait times, to the point where consumer groups make such data publicly available to aid patients in choosing which ED to go to.

The resulting overcrowding then impairs the ED’s true purpose, a situation that is not beneficial for either healthcare providers or the patient.

Our study attempted to determine the motivation behind a patient’s ED visit, and we recommend that future research be conducted to better clarify these reasons. Based on the study findings, the convenience of an ED or a patient’s perceived medical condition are the predominant reasons why patients go to an ED. Additional research can be done to determine ways of combating ED overcrowding. Potential interventions to prevent overcrowding might include expanding the operational hours of other medical resources and improving public health education in terms of what is considered an “emergency.” Another improvement would be to include answer choices that speak better to the economic choices behind an ED visit. EMTALA prohibits EDs from withholding emergency treatment from patients regardless of their ability to pay and actual need of care. In other words, patients will be treated even if the ED has insufficient funds. Many patients, especially those who are indigent or from a lower socioeconomic background, choose the ED because they cannot afford to provide a copay for an office visit to a PCP. Although patients may be hesitant to choose these answers for fear of the perception it casts on them as patients and concern that they will receive subsequent suboptimal care as a result, adding answers such as “I have no insurance,” “I lack the ability to pay,” or “I don’t have to pay for treatment because this is a county hospital” will allow providers to determine the financial motivations of a patient’s ED visit, thereby allowing public health advocates to better adjust the medical system accordingly.

In summary, many patients are aware that they are using the ED inappropriately and do not have a firm grasp of the concept of medical emergencies. Having patients describe their condition in terms of threats to life, however, leads to a more accurate description of their condition. Additionally, we found that the perception of convenience and lack of access to other medical resources are the main motivating factors behind a patient’s ED visit. Addressing these factors will allow EDs to provide appropriate and timely care to patients with true emergencies.

References

1. Trendwatch Chartbook 2016. Ahaorg. 2016. www.aha.org/system/files/research/reports/tw/chartbook/2016/2016chartbook.pdf . Accessed October 19, 2017.

2. Bullard M, Villa-Roel C, Bond K, Vester M, Holroyd B, Rowe B. Tracking emergency department overcrowding in a tertiary care academic institution. Healthcare Quarterly. 2009;12(3):99-106. doi:10.12927/hcq.2013.20884.

3. Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001;8(2):151-155. doi:10.1111/j.1553-2712.2001.tb01280.x.

4. Hyman D, Studdert D. Emergency Medical Treatment and Labor Act. Chest. 2015;147:1691-1696. doi:10.1378/chest.14-2046.

5. Steinbrook R. The role of the emergency department. N Engl J Med. 1996;334(10):657-658. doi:10.1056/nejm199603073341010.

6. Trzeciak S. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20(5):402-405. doi:10.1136/emj.20.5.402.

7. Simonet D. Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability. Health Care Analysis. 2008;17(1):1-19. doi:10.1007/s10728-008-0081-0.

8. Krieg C, Hudon C, Chouinard M, Dufour I. Individual predictors of frequent emergency department use: a scoping review. BMC Health Serv Res. 2016;16(1). doi:10.1186/s12913-016-1852-1.

9. Howard M, Davis B, Anderson C, Cherry D, Koller P, Shelton D. Patients’ perspective on choosing the emergency department for nonurgent medical care: A qualitative study exploring one reason for overcrowding. J Emerg Nurs. 2005;31(5):429-435. doi:10.1016/j.jen.2005.06.023.

10. Northington W, Brice J, Zou B. Use of an emergency department by nonurgent patients. Am J Emerg Med. 2005;23(2):131-137. doi:10.1016/j.ajem.2004.05.006.

11. Lippi Bruni M, Mammi I, Ugolini C. Does the extension of primary care practice opening hours reduce the use of emergency services?. J Health Econ. 2016;50:144-155. doi:10.1016/j.jhealeco.2016.09.011.