What’s Happened to the ‘Emergency’ in Emergency Medicine?

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A Look at the Cultural Shift and Non-Urgent Patient Populations

Abstract

Objective: To review literature focused on the cultural shift in modern emergency medicine systems, apply statistical value to the non-urgent patient population, and look at ways to prevent emergency room overcrowding and the misuse of prehospital systems. For this article, prehospital medicine and EMS will refer to public 911 systems instead of inner-facility transport or private ambulance companies.

Methods: A narrative literature review of non-urgent patient populations was conducted to include the effects on Emergency Medical Services (EMS) and the emergency room (ER). Using the National Emergency Medical Services Information System (NEMSIS), statistics were reviewed for EMS. Additional statistics were reviewed for emergency departments (ED) using statistics provided by the Centers for Disease Control (CDC) and the Agency for Healthcare Research and Quality (HCUP).

Results: Studies show there needs to be a unified definition of what “non-urgent” means, and there is a need for standardized triage systems for both EMS and the emergency room (ER) that would accurately identify acuity levels. Based on statistics, a disproportionate amount of non-urgent patients utilize emergency medical systems for both EMS and the ED. However, the database for emergency departments needs targeted acuity levels to make analysis more accurate. The literature review also shows that while high levels of non-urgent patient populations can negatively affect emergency medical systems, we can improve how we work with this patient population.

Keywords: culture, non-urgent, EMS, prehospital, emergency department, acuity, triage, NEMSIS, CDC, HCUP, shared decision-making, health literacy.

Introduction

It’s hard to imagine a time when people avoided the hospital at all costs, and a house call was the primary delivery of care. Hospitals were considered a place of last resort, having a social stigma with a negative connotation relating to the poor, travelers, or infirmities. In this age, however, every day across the country, there is a crisis with emergency rooms struggling to keep up with the high volume of patients. This crisis is coupled with staffing shortages and cutbacks that have occurred in the wake of COVID-19 as well as the constant review of best practices and throughput analysis that are under careful scrutiny.

There are disproportionate numbers of non-urgent patients checking in to the ER compared to the number of emergent patients, either through walk-ins or EMS transports. Both systems suffer as a result, which has the potential to cause a breakdown in the efficiency of the emergency health care system and, ultimately, patient care.

Early Emergency Medicine Culture

The modern field of prehospital medicine has its roots deeply linked to war. Despite this, it is surprising that the formality and recognition of EMS and the ED as independent specialties in the United States are relatively recent. It seems strange to think that prehospital medicine started as a cart and horse, and a hospital could have been a charitable guesthouse, a battlefield tent, a church, or someone’s home. However, that was a time when the culture of medicine was primarily that of women who cared for the sick in their homes and, if needed, called for a physician to come to them.

Paramedics and Naval Corpsmen arose from war.1-5 However, it was not until after WWII that hospitals started to organize emergency departments based on lessons learned from those wars. Combat medicine from the Korean and Vietnam wars accelerated significant advancements in prehospital care. During that era, the first academic departments of emergency medicine were created, and EMS was formally recognized.6-8 Six years later, the American Board of Emergency Medicine as a specialty board was also formally recognized.6,9,10 That was only 44 years ago.

A Cultural Shift

From the horse and cart of the battlefield to the ambulances and emergency departments of today, the culture of emergency medicine has shifted drastically from its roots. The tumultuous, humble, and noble beginnings of a time when the idea of ambulance transport was frightening because an emergency meant horrific trauma, deadly infections, and diseases that could wipe out populations. This meaning has taken an opposite turn today. Calling EMS and going to the ER has become the fallout, and emergency medical services represent a place where no one is turned away no matter what the problem is, and specially trained providers who save lives are using the highest standards and equipment available. How the fundamentals of emergency medicine came to this progressive shift is complex and requires an understanding of what motivates people to seek an emergency level of care in the first place.

The Patient’s Choice

Emergency department overcrowding has been a problem for decades, and many studies ask why people choose the ER over their primary care providers or urgent care for non-urgent problems. It has been suggested that primary care provider availability, ease of access to emergency care, and self-perceived severity of complaints are the most influential factors.11 This rings true in more recent years, as noted in Coster et al.’s12 study, published in 2017, which identified the following six themes describing why patients chose to access the ED or urgent care for low acuity problems:

  1. Access to and confidence in primary care providers.
  2. The patient’s perception of urgency, anxiety about the condition, and the value of reassurance from emergency‐based services.
  3.  Encouragement of family, friends, or healthcare professionals.
  4. Convenience, not having to make an appointment, and hours of operation.
  5. Individual patient factors such as cost.
  6. Perceived need for EMS or hospital care, treatment, or testing.

To put this cultural shift into perspective, the National Hospital Ambulatory Medical Care Survey (NHAMCS) provides data on ER visits beginning in 1992.13 In 1992, there were approximately 89.8 million ER visits. By 2019, prior to the COVID-19 pandemic, this number increased by more than 69% to almost 151 million visits.13,14 With the ER and EMS in crisis, what defines non-emergent, and how do these patients recognize that they may or may not need EMS or an ER level of care?

Definition of Non-Urgent

Determining the triage level of a patient’s presenting illness is a fundamental process in emergency medicine. It is easy to determine what’s urgent. It’s less clear to determine what is non-urgent. Much of the literature resounds with no clear definition of what non-urgent means, and the patient’s perception of urgent further complicates this. In a systematic review by Uscher-Pines et al., 15 twenty-six articles on this topic found no consistent definition of non-urgent. An article by Idil et al.16 highlighted the importance of how the non-urgent patient population is described in the studies and recognized that no worldwide accepted criteria exist for this definition.16

Another large study attempted to define, measure, and profile non-urgent ED patients that could be managed in alternative, non-emergency settings.17 The study included EMS transports and identified non-urgent patients based on the type care the patient received in the ED. It highlighted the need for an adequate definition of non-urgent patients applicable to other healthcare resources. It also states that the definition does not consider the patient’s perspective of non-urgent.17

Another study from Turkey asked a small group of nurses and physicians what their definition of non-urgent is, and again, the answers varied.18

Prehospital Triage

Prehospital medicine uses a dispatch system to link 911 callers and EMS teams. Dispatchers represent their frontline triage system and require special training. The Medical Priority Dispatch System is used worldwide to screen 911 calls and, if used properly, will enable dispatchers to send the appropriate unit and assist the caller while on the phone.19 Medics use a different triage system once on scene. Field triage systems most commonly used are Sort, Assess, Life-saving interventions, and Treatment/transport (SALT), and Simple Triage and Rapid Treatment (START). However, these systems primarily deal with trauma and mass casualty, and there is limited data to support their accuracy.20,21 There is no data to support a general triage system universally supported and used by EMS.

Emergency Department Triage

Hospital emergency rooms use a triage nurse as the frontline resource to initiate a triage level.

A study by Zachariasse et al.22 identified several systems used globally, including START; Emergency Severity Index (ESI); Australasian Triage Scale (ATS); Canadian Triage and Acuity System (CTAS); Chinese Four-level and Three District Triage Standard (CHS); Manchester Triage System (MTS); and SALT. The most commonly used triage system in the United States (U.S.) is ESI,22,23, butthe triage process is not standardized across the U.S. The authors found that while current triage systems have value, the performance of the systems could be more consistent. The authors also concluded that there is a need for more study regarding how CTAS, MTS, and ATS can be applied to different patterns of patient populations, as well as the need to study outcomes and consistency of the results among the different systems.

Non-Urgent Patient Populations

Data from the National Emergency Medical Services Information System (NEMSIS)

The most recent summary from NEMSIS was published on May 10, 2022, for the 2021 data collection cycle.24 The NEMIS database recorded 43.5 million calls to EMS, of which 19.5 million were 911 calls that were treated and transported.24 Of the total 911 calls, 16.3 million were categorized as non-emergent. This makes up 70% of the total call volume. Interestingly, 1.5% of calls (3.5 million) that started at an emergent level were downgraded to non-emergent. The opposite was true of 92,000 calls (0.4%) that started as non-emergent and were upgraded to emergent. The remaining 28% of calls (6.5 million) were emergent.24

Statistics from the Centers for Disease Control (CDC)

The National Center for Health Statistics (NCHS) has a national survey called The National Ambulatory Medical Care Survey (NAMCS). The survey collects data to study ambulatory medical care in emergency departments.25 The most recent summary from 2020 reveals an estimated 131 million ER visits nationwide. Although there are 26 tables to represent various patient complaints or demographic characteristics, the data is not broken down into triage or acuity levels, which presents a limitation to accurate analysis.

Another data collection bank called the Healthcare Cost and Utilization Project (HCUP) has collection efforts represented at the state level as well as through hospital associations, private organizations, and the Federal government.26 A data trend for patients treated and released between 2006-2020 shows that in 2006, there were 120 million total ER visits. Of that number, 84% (101 million) were treated and released. The total number of ER visits continued to rise and peaked in 2017 at 145 million, with 86% (124.6 million) of those being treated and released.26 The total numbers trended down in 2018 and stabilized through 2019 and dropped significantly during the COVID-19 pandemic. In 2020 the total number of ER visits decreased to 123 million, with the number of patients treated and released at 83% (103 million). Unfortunately, no triage or acuity levels are associated with this data set. Despite the lack of acuity, which would increase accuracy, the percentages of patients treated and released remained steady at around 80% across the years, leaving the emergent population at only 20%.26 The site does offer comprehensive ways to search for specific data, but the diagnostic complaints do not include acuity.

Effects on Emergency Health Care Systems

Many problems are created when a disproportionate amount of non-urgent patients utilize prehospital transport and emergency department levels of care. The cultural shift toward both systems has evolved through easy access, immediate high-quality care, quick feedback of test results, and administration of medications. Misuse of the emergency medical system creates a burden across the healthcare spectrum and increases the demands of the ER. A particular burden for EMS occurs when they transport non-urgent patients and take an integral unit out of service. If an emergent call comes in, it could cause a delay in care. In addition, much controversy exists over a paramedic’s ability to deem a patient non-urgent and not needing transport. In a systematic review of non-emergency transport services, the author concludes that more study is needed to support that paramedics are skilled enough to inform patients that they are non-urgent and do not need transport. The author also states that there is a need for improved triage protocols and training through pilot studies.27

Bridging the Gap

All providers in emergency medicine can help bridge the gap in the healthcare community. Ways to improve the burden of non-urgent patient populations in emergency medicine involve the concepts of shared decision-making, healthcare literacy, managing patient expectations, and understanding EMTALA law.

Shared Decision Making

Unlike informed consent, shared decision-making is a concept and a communication style in which the two parties participate. It can be a valuable tool for non-urgent patients who sometimes perceive their condition as worse than it may be and often seek emergency care because they are unsure of a condition. Shared decision-making involves evidence-based medicine in which patients engage in all aspects of their care and work with the provider to select treatment options they prefer. It is a skill that involves understanding and considering the patient’s values, preferences, and personal circumstances while respecting the right of the patient to make those decisions.

In an article by L. Bingaman, the author outlines three models that clinicians can use, each showing different conversation styles that physicians can have with patients.28 Effectively communicating, spending more time educating, and allowing patients to actively participate in their care can give patients more confidence in the system and the process.28 This offers a more positive outlook and outcome that could effectively reduce ER overcrowding of non-urgent patient populations. In addition, public awareness campaigns can inform patients about the appropriate use of EMS and the emergency department.

Health Literacy

Health literacy is an essential aspect of managing non-urgent patient populations. Understanding warning signs of disease processes, alternative available healthcare options, preventing non-urgent ER visits by improving communication with providers, and engaging in preventive care through improved nutrition, lifestyle, and exercise are all factors of health literacy. In a study by Liu et al.,29 the authors identified three broad themes in their literature review: (1) knowledge of health, healthcare, and health systems; (2) processing and using information in various formats concerning health and healthcare; and (3) ability to maintain health through self-management and working in partnerships with health providers.29

In a study by Shahid et al.,30, the authors concluded that only half of the patients admitted to general internal medicine units have adequate health literacy and concluded that patients with low health literacy scores are more likely to revisit the emergency department within 90 days.30 In a study by Kopulos,31, the author concludes that more ER research is needed to evaluate and improve provider teaching methods for patients with low health literacy, and there is a need to evaluate training methods for healthcare givers to identify and improve low health literacy.31

Among many things, better healthcare literacy can improve patient outcomes while decreasing non-urgent EMS transports and ER overcrowding with non-urgent patients. Improving health literacy could involve education initiatives, using the teach-back method,31 promoting shared decision-making, and addressing language and cultural barriers. Patients with increased health literacy may be more apt to recognize that a condition is non-emergent, understand their options, make informed decisions, and prevent unnecessary emergency room visits by better navigating the healthcare system.

Managing Patient Expectations

Managing patient expectations is a constant concern in the emergency department, where patients tend to have higher expectations. Although there is limited current literature on this topic, in a study by Lateef,32 the author discusses managing patient expectations based on patient-centered and value-based healthcare. By learning how to manage patient expectations appropriately, providers can set realistic goals for patient care. This is crucial for non-urgent patient populations as they may not understand the limitations of the ER, and by educating patients about other non-urgent care options, patients will better understand where to seek help for non-urgent problems. In addition, this is an opportunity to use shared decision-making to reduce anxiety and frustration when seeking healthcare.

EMTALA

EMTALA law impacts the emergency department standards for the transfer and acceptance of patients. Understanding the law helps to identify federal regulatory guidelines that define what an emergency room is and how such laws protect patients. While EMTALA is a controversial subject in the ER world, learning more about it may help providers understand how it may contribute to ER overcrowding, the misuse of resources, the burden of treating non-urgent patient populations, and how such laws can burden emergency rooms financially.33

EMTALA is tied to Medicare reimbursement, and violations can lead to termination of the hospital or provider’s Medicare Provider Agreement in addition to imposing fines.33 Hospitals may also be held liable for civil lawsuits from patients or from transferring or receiving hospitals. Every year, billions of dollars are lost due to uncompensated care.34 It is no secret that Anthem and United Healthcare are implementing policies to reduce reimbursement for ED visits retroactively deemed non-urgent, and these policies threaten to increase the amount of care that emergency departments provide without reimbursement.34 With EMTALA law, no one can be denied care. It is a difficult position when these two items are at play.

Analysis

The early history of emergency medicine has had a significant cultural shift. There is a crisis of ER overcrowding and disproportionate amounts of non-urgent patients utilizing emergency medical systems. The NEMSIS data shows a high number of non-urgent transports which are taken to the ER. The ER data from the CDC and HCUP is limited and needs a more targeted design, including acuity levels. Regardless, an inference can be made from the percentages of patients treated and released showing similar results.

The literature search reveals inconsistencies in triage systems for both EMS and the ER, with the most significant problem being the need for a unified definition of non-urgent. The literature search also reveals ways the emergency medical community can educate the public to improve health literacy so that patients can share decision-making and have more reasonable expectations. EMTALA seems like the elephant in the room. It exists to protect patients, which providers want, but it has a price. Combining this with the current insurance battles creates an unfavorable environment for success. 

Limitations

The narrative structure of this review has its limitations. An extensive search was done to select relevant literature regarding non-urgent patient populations (both EMS and emergency rooms), and statistical searches were performed for comparison; however, it was not a systematic method, and some primary literature may have been unintentionally excluded. There is also limited current literature and data available on these issues. Therefore, this review should be considered a broad overview precluding a more extensive study of the current issues regarding non-urgent patients, the definition of non-urgent, standardized triage systems, and ways to improve the ER culture.

Conclusion

While the non-urgent patient population is here to stay, we can improve how we work with them to prevent ER overcrowding and misuse of the prehospital systems. Although progress has been made with national-level data collection, more emphasis must be placed on acuity levels. This data can help monitor trends and explore ways to improve the healthcare network. Standardizing triage systems for both EMS and the ER will help to identify acuity levels more accurately.

In the wake of COVID-19, insurance battles, and increased costs, there is much uncertainty from the patient’s perspective.

Emergency room overcrowding frustrates providers, staff, and patients and could have potentially harmful outcomes. Creating pilot studies to see how we can expand provider roles in the community could help explore better ways to serve this patient population. Making the service more appropriate for the patient rather than trying to make the patient more appropriate for the service would decrease uncertainty and satisfy unmet needs on all sides.

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