Drivers for low-acuity pediatric emergency department visits in two tertiary hospitals in Switzerland: a cross-sectional, questionnaire-based study.

PURPOSE: Low-acuity pediatric emergency department (PED) visits are frequent in high-income countries and have a negative impact on patient care at the individual and health system levels. Knowing what drives low-acuity PED visits is crucial to inform adaptations in health care delivery. We aimed to identify factors associated with low-acuity PED visits in Switzerland, including socioeconomic status, demographic features, and medical resources of families. METHODS: We conducted a prospective, questionnaire-based study in the PEDs of two Swiss tertiary care hospitals, Bern and Lausanne. We invited all consecutive children and their caregiver attending the PED during data collection times representative of the overall PED consultation structure (e.g. day/night, weekdays/weekends) to complete a questionnaire on demographic features, socioeconomic status, and medical resources. We collected medical and administrative data about the visit and defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed, and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits. RESULTS: We analysed 778 PED visits (September 2019 to July 2020). Most children visiting our PEDs had a designated primary care provider (92%), with only 6% not having seen them during the last year. Fifty-five per cent of caregivers had asked for medical advice before coming to the PED. The proportion of low-acuity visits was 58%. Low-acuity visits were associated with caregiver's difficulties paying bills (aOR 2.6, 95% CI 1.6 - 4.4), having already visited a PED in the last 6 months (aOR 1.7, 95% CI 1.1 - 2.5) but not with parental education status, nor parental country of birth, parental employment status or absence of family network. CONCLUSION: Economic precariousness is an important driver for low-acuity PED visits in Switzerland, a high-income country with compulsory health coverage where most children have a designated primary care provider and a regular pediatric follow-up. Primary care providers and PEDs should screen families for economic precariousness and offer anticipatory guidance and connect those in financial need to social support.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study.

BACKGROUND: This study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium. METHODS: A three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses. RESULTS: N = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason. CONCLUSION: Our findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

Factors associated with non-urgent presentations in the paediatric emergency department using Andersen's behavioural model: A cross-sectional descriptive study.

OBJECTIVES: To explore the rate of NUPs and associated factors in the PED of the 'Hospital Universitario y Politécnico La Fe' in Valencia (Spain) using Andersen's Behavioural Model. METHODS: We conducted a descriptive cross-sectional study using Andersen's Behavioural Model in parents visiting the PED with their children at the 'Hospital Universitario y Politécnico La Fe' in Valencia (Spain). RESULTS: The study involved a total of 530 participants, of whom 419 (79%) had made an NUP. The predisposing factors identified were: (I) paediatric patients brought in by their fathers (OR = 0.460; p = 0.005), (II) lower educational attainment (OR = 3.841; p = 0.000), (III) first-time parenthood (OR = 2.335; p = 0.000) and (IV) higher parental stress (OR = 1.974; p = 0.023). The enabling factors included: (I) responsibility for a significant part of the childcare shared with others (OR = 0.348; p = 0.041) and (II) the perception that PEDs provide better care than primary care (PC) services (OR = 1.628; p = 0.005). The need factors were: (I) existing chronic illness in the child seeking care (OR = 0.343; p = 0.000) and (II) the perceived severity of the urgency (OR = 0.440; p = 0.031). CONCLUSIONS: The NUP rates found in this study are similar to those found internationally. In accordance with Andersen's Behavioural Model, we identify predisposing, enabling and need factors to explain the multifactorial nature of NUPs in PEDs. IMPLICATIONS FOR PRACTICE: Identifying the factors associated with NUPs enables interventions to be targeted at those groups most likely to engage in NUPs, thereby optimising the functioning of the PED and improving the well-being of children and families. These interventions should focus on improving parental health literacy, providing education on making appropriate decisions about accessing health services and recognising severe symptoms in children, as well as improving access to high-quality PC services. Providing support to parents during the transition to parenthood would also be beneficial. REPORTING METHOD: This paper adheres to the STROBE initiative guidelines. CONTRIBUTION FROM PATIENTS OR MEMBERS OF THE PUBLIC: Participants, who voluntarily agreed to take part, contributed to the study by completing a paper-based questionnaire containing all the study variables as prepared by the research team.

Analysis of factors conditioning inappropriate visits in a paediatric emergency department.

Recent studies estimated that about 20-30% of visits in a paediatric emergency department (PED) are inappropriate. Nonurgent visits have been negatively associated with crowding and costs, causing longer waiting and dissatisfaction among both parents and health workers. We aimed to analyze possible factors conditioning inappropriate visits and misuse in a PED. We performed a cross-sectional study enrolling children accessing an Italian PED from June 2022 to September 2022 who received a nonurgent code. The appropriateness of visits, as measured by the "Mattoni SSN" Project, comprises combination of the assigned triage code, the adopted diagnostic resources, and outcomes. A validated questionnaire was also administered to parents/caregivers of included children to correlate their perceptions with the risk of inappropriate visit. Data were analyzed using independent-samples t-tests, Wilcoxon-Mann-Whitney tests, chi-square tests, and Fisher's exact tests. The factors that were found to be associated with inappropriate visits to the PED were further evaluated by univariable and multivariable logistic regression analyses. Almost half (44.8%) of nonurgent visits resulted inappropriate. Main reasons for parents/caregivers to take their children to PED were (1) the perceived need to receive immediate care (31.5%), (2) the chance to immediately perform exams (26.7%), and (3) the reported difficulty in contacting family paediatrician (26.3%). Inappropriateness was directly related to child's age, male gender, acute illness occurred in the previous month, and skin rash or abdominal pain as complaining symptoms.     Conclusion: This study highlights the urgent need to finalize initiatives to reduce misuse in accessing PED. Empowering parents' awareness and education in the management of the most frequent health problems in paediatric age may help to achieve this goal. What is Known: • About 20-30% of pediatric urgent visits are estimated as inappropriate. • Several factors may be associated with this improper use of the emergency department, such as the misperception of parents who tend to overrate their children's health conditions or dissatisfaction with primary care services. What is New: • This study evaluated almost half of pediatric emergency department visits as inappropriate adopting objective criteria. • Inappropriateness was directly related to the child's age, male gender, acute illness that occurred in the previous month, and skin rash or abdominal pain as complaining symptoms. Educational interventions for parents aimed at improving healthcare resource utilization should be prioritized.

Characteristics of non-urgent neonatal presentations to an Australian metropolitan emergency department.

AIM: To determine characteristics and risk factors for non-urgent presentations (NUPs) (triage categories 4 and 5) in neonates to a Western Sydney metropolitan mixed adult emergency department (ED) and the effect of COVID-19 on presentations and admissions. METHODS: A retrospective medical record study examined neonates (age <4 weeks) presenting to the ED between October 2019 and September 2020 and assessed risk factors for NUPs including the impact of COVID-19. Regression analysis was used to determine which risk factors were significant for NUPs to ED and whether there were any significant differences in urgency of presentations and admissions during the post-COVID-19 time (on/after 11th March 2020). RESULTS: From 277 presentations, 114 (41%) were non-urgent. After regression analysis, being a mother born overseas (odds ratio 2.15, 95% confidence interval 1.13-4.12, P = 0.02) was a significant risk factor and maternal age (odds ratio 0.98, 95% confidence interval 0.96-0.1.00, P = 0.02) was a significant protective factor for NUPs in the neonatal period. There were 54 (47%) NUPs pre-COVID-19 and 60 (53%) NUPs post-COVID (P = 0.70). There were similar presenting complaints and diagnoses compared to the literature. CONCLUSIONS: Mothers born overseas and younger maternal age were found to be significant risk factors for NUPs in the neonatal period. There was no apparent impact on presentations and admissions to ED during the COVID-19 period. Further studies are warranted to further evaluate risk factors for NUPs in the neonatal period and further elucidate the impact of COVID-19 on presentations and admissions, specifically in later waves of the virus.

Identification of low-acuity attendances in routine clinical information documented in German Emergency Departments.

INTRODUCTION: It has not yet been possible to ascertain the exact proportion, characterization or impact of low-acuity emergency department (ED) attendances on the German Health Care System since valid and robust definitions to be applied in German ED routine data are missing. METHODS: Internationally used methods and parameters to identify low-acuity ED attendances were identified, analyzed and then applied to routine ED data from two EDs of the tertiary care hospitals Charité-Universitätsmedizin Berlin, Campus Mitte (CCM) and Campus Virchow (CVK). RESULTS: Based on the three routinely available parameters `disposition´, `transport to the ED´ and `triage´ 33.2% (n = 30 676) out of 92 477 presentations to the two EDs of Charité-Universitätsmedizin Berlin (CVK, CCM) in 2016 could be classified as low-acuity presentations. CONCLUSION: This study provides a reliable and replicable means of retrospective identification and quantification of low-acuity attendances in German ED routine data. This enables both intra-national and international comparisons of figures across future studies and health care monitoring.

Factors associated with the inappropriate use of the pediatric emergency department. A systematic review.

BACKGROUND: Pediatric emergency department (PED) admissions have risen in recent years, a trend not justified by the severity of the pathologies presented. The aim of this study is to analyse factors related to the inappropriate use of pediatric emergency departments. METHODS: This is a systematic review reported in accordance with the PRISMA statement. We searched the PubMed, Web of Science and Science Direct databases, using keywords extracted from MeSH, and conducted a reverse search using Google Scholar and Open Grey, for the period January 2017 to August 2022. The quality of the papers was assessed using STROBE, CASPe, AMSTAR-2, GRADE, Levels Of Evidence and Grades Of Recommendation. RESULTS: A total of 20 studies were selected. Factors related to inappropriate use included the younger age of children, black caregivers, lower socioeconomic status, lower parental educational attainment, perceived urgent demand for care, parental emotions in response to their children's health problems, psychological distress, the ineffective exercise of the parental role, the advantages of the PED and the nature of health insurance. CONCLUSIONS AND IMPLICATIONS: The results illustrate the heterogeneous nature of the phenomenon under investigation. Gaining an understanding of the factors related to the inappropriate demand of PEDs, from the perspective of health professionals, can help in developing interventions to reduce unnecessary consultations and relieve pressure on these healthcare services.

An integrative review of adult patient-reported reasons for non-urgent use of the emergency department.

OBJECTIVE: To conduct an integrative review of the scientific literature to explore adult patient-reported reasons for using the emergency department (ED) non-urgently. METHOD: A literature search of CINAHL, Cochrane, Embase, PsycINFO, and MEDLINE was conducted with filters for humans, published January 1, 1990-September 1, 2021, and English language. Methodological quality was assessed using Critical Appraisal Skills Programme Qualitative Checklist for qualitative and National Institutes Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for quantitative studies. Data was abstracted on study and sample characteristics, and themes/reasons for ED use. Cited reasons were coded using thematic analysis. RESULTS: Ninety-three studies met inclusion criteria. Seven themes were found: need to be risk averse with respect to the health issue; knowledge and awareness of alternative sources of care; dissatisfaction with primary care provider; satisfaction with ED; ED accessibility and convenience resulting in low access burden; referred to the ED by others; and relationships between patients and health care providers. DISCUSSION: This integrative review examined patient-reported reasons for attending the ED on a non-urgent basis. The results suggest that ED patients are heterogenous and many factors influence their decision-making. Considering the complexity with which patients live, treating them as a single entity may be problematic. Limiting excessive non-urgent visits likely requires a multi-pronged approach. CONCLUSION: For many ED patients, they have a very clear problem which needed to be addressed. Future studies should explore psychosocial factors driving decision-making (e.g., health literacy, health-related personal beliefs, stress and coping ability).

Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey.

BACKGROUND: The ambulance service is facing an increased number of calls and ambulance assignments. Between 12 and 42% of all assignments result in non-conveyance to the Accident and Emergency Department. However, there is limited knowledge regarding satisfaction among patients and significant others when patients are assessed as non-urgent and discharged at the scene. Therefore, the aim of the study was to explore and compare satisfaction with the ambulance service among patients and significant others when the patient was discharged at the scene. METHODS: The present study was designed as a cross-sectional exploratory survey with a consecutive sample employing the Consumer Emergency Care Satisfaction Scale questionnaire on patients and significant others. RESULTS: A total of 162 questionnaires were analysed, 87 patients and 75 significant others. Overall, satisfaction was high with no significant difference between patients and significant others, although 17-19% were dissatisfied with the discharge information. CONCLUSIONS: Generally, patients and significant others are satisfied with the care provided by the Ambulance Service when discharged at the scene and thus not conveyed the Accident and Emergency Department. The participants were especially satisfied with Specialist Ambulance Nurses' interpersonal skills, e.g., making time and providing thorough information. Guidelines for assignments involving non-conveyance, as well as information, instructions and what to expect when discharged at the scene can be improved.

To embrace and be present: The lived experiences of nurse-led consultations in Sweden from the perspective of pediatric nurses.

PURPOSE: This study describes the lived experiences of nurse-led consultations in pediatric emergency departments from the perspective of pediatric nurses. DESIGN AND METHODS: A descriptive qualitative study with a reflective lifeworld research approach was used to explore nurses' experiences of nurse-led consultations. The study was conducted through meaning-oriented individual interviews with ten pediatric nurses. RESULTS: The results are grouped into four themes: (a) embracing the encounter and being touched by it; (b) having time to be present and committed; (c) having the ability and trusting in one's intuition; and (d) negotiating between families' wishes and the organization's guidelines. CONCLUSIONS: Our study shows that nurse-led consultations conducted in separate nurse-led reception areas promote a positive experience of the consultations from the perspective of pediatric nurses. In a nurse-led consultation, a nurse's confidence in their ability to provide care is connected to time, broad skills and knowledge, and a supportive organization. PRACTICE IMPLICATIONS: As the rising global population increases the demand for healthcare services, pediatric emergency departments must streamline their services to provide patient-safe, high-quality health care. Nurse-led consultations are an effective means of meeting these growing demands. This study contributes to an understanding of pediatric nurses' experiences at both the individual level and a more structured level, namely that families' wishes and an organization's guidelines do not always coincide.

Trends in outpatient emergency department visits during the COVID-19 pandemic at a large, urban, academic hospital system.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions. RESULTS: While outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (-8.1%) than in 2019. The largest decrease occurred in April 2020 (-30.4%), followed by the May to August period (-12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020. CONCLUSIONS: Overall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.

Pediatric non-urgent emergency department visits and prior care-seeking at primary care.

BACKGROUND: We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits. METHODS: We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics. RESULTS: Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit. CONCLUSIONS: Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.

Identification of new demands regarding prehospital care based on 35,188 missions in 2018.

BACKGROUND: Population ageing and increased prevalence of chronic diseases result in the emergence of new demands in prehospital care. The prehospital system is facing an increase of cases without acute threat to life (so-called "non-urgent"), which generates tension due to a higher number of admissions to emergency departments and a greater use of prehospital resources. Our aim is to understand this transition in prehospital activities and to delineate the primary missions performed by paramedics in 2018 with a focus on the population concerned, the severity of cases encountered and the typology of health issues. METHOD: The study is retrospective, and descriptive, using a statistical description of 35,188 primary missions realized in 2018 in the State of Vaud (Switzerland). The characteristics taken into consideration are the age and gender of patients, as well as the health issue, the severity of cases based on National Advisory Committee for Aeronautics score (NACA score), and the time and place of intervention. RESULTS: The results describe the primary missions in the State of Vaud in 2018 and show that 87% of missions concern "non-urgent" situations (without acute threat to life). Over half of patients are 65 or older, the highest proportion of health issues, 49%, are medical and only 23% of missions are for traumas. Mission related to mental health issues reach 7% and those for intoxication 6%. Most missions take place between 7:00 am and 6:00 pm (67%), and around 12% of missions lead to the non-transport of the patient. CONCLUSION: The prehospital sector is confronted with a major transition in terms of patient care. An increase of non-urgent cases is observed, associated with the care of persons aged 65 or more. Our results question the adequacy between the needs in terms of prehospital care and the paramedic profession as it is currently defined, as well as the place of this profession within the health network. Reflecting upon the role of paramedics with respect to the socio-demographic evolution of populations appears necessary, to analyse the adequacy of the paramedics' skills to respond to the current needs.

Patterns of hospital utilization after elective minimally invasive foregut surgery.

INTRODUCTION: Post-operative non-urgent hospital visits (NUR-HV) are an important quality target for reducing unnecessary healthcare utilization. The primary objective of this study was to characterize 90-day post-operative hospital use and determine independent predictors for NUR-HV and urgent (UR)-HV after elective laparoscopic paraesophageal hernia repair (LPEHR) and Nissen Fundoplication (LNF). METHODS: Five hundred and sixty-two primary LPEHR and LNF patients were retrospectively reviewed at a single institution. Ninety-day NUR-HV and UR-HV were compared to patients without post-operative HV using baseline medical and demographic data, preoperative work-up (manometry, pH testing, disease-specific quality of life and symptom scale scores (GERSS), and hospital course. Multiple logistic models were created using univariate associations (p < 0.1) to model independent predictors of NUR-HV and UR-HV. RESULTS: NUR-HV accounted for 52% (n = 30) of all 90-HV, while the remaining were UR-HV (n = 28, 48.3%). Compared to controls, NUR-HV were younger (51.2 ± 16.8 years vs. 57.6 ± 15.2, p = 0.05), had a lower baseline BMI (28.2 ± 6.4 vs. 31.3 ± 5.4, p = 0.003) and ASA scores (p = 0.02), presented with higher GERSS (46 (28-60) vs. 35 (19-48), p = 0.02) and dysphagia scores (3 (1-5) vs. 2 (0-4), p = 0.02), were associated with LNF (77.7% vs. 54.6%, p = 0.02), and experienced more post-operative dysphagia (13.3% vs. 4.6%, p = 0.06). UR-HV were older (64.0 ± 13.2 vs. 57.6 ± 15.2, p = 0.03), associated with LPEHR (67.9% vs. 45.4%, p = 0.02), longer hospital stay (2 (1-3) vs. 1 (1-2), p = 0.003), and increased overall (39.3% vs. 15.1%, p = 0.001) and urgent complications (34.6% vs. 8.3%, p < 0.005). Positive predictors of NUR-HV included ASA score < 3 (OR 4.4, p = 0.02), increasing GERSS (1.04, p = 0.01), and reduced peristalsis (OR 4.7, p = 0.01), while UR-HV were independently predicted by urgent complications (5.0, p < 0.00005). CONCLUSIONS: NUR-HV accounted for half of post-operative visits following LNF/LPEHR and were predicted by distinct characteristics compared to UR-HV. This stratification provides novel insight that will guide both preoperative counseling and post-operative quality initiatives.

Emergency consultations in obstetrics: identification of decisive, contributing and associated factors.

PURPOSE: Psychosocial and biological factors influence the perception of physical changes during pregnancy. Some pregnant women present to the obstetric emergency department (ED) with diverse symptoms not requiring urgent medical action. These visits result in over-consultation, tying up resources and inflating health care expenses. This study outlines factors associated with multiple ED visits during pregnancy, measures the prevalence of anxiety and depression, and explores the choice of maternity clinic for delivery aiming to elucidate options for care strategies. METHODS: This prospective, cross-sectional, questionnaire-based bicentric study was performed in the obstetric outpatient departments of two university hospitals in Germany and recruited pregnant women between 12/2016 and 11/2017. The questionnaire included socio-demographics, obstetric history, anxiety (GAD-7), depression (PHQ-9), and health status (WHO-5, SF-12). RESULTS: This analysis included 496 women and showed that women with numerous ED visits were significantly younger (p < 0.0001), less educated (p = 0.0002), and more likely to be unemployed and single. Different prevalences for anxiety and depression were detected correlating with the number of ED visits although each showing only low effect sizes (0.024 resp. 0.015). CONCLUSIONS: Pregnant women attending the ED more often might benefit from health education, psychosomatic interventions, and social support to overcome their depression and anxiety to avoid non-urgent ED consultations. Further prospective studies are needed to support these findings.

Non-urgent paediatric emergency department presentation: A systematic review.

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.

Cross-sectional study in an out-of-hours primary care centre in northwestern Germany - patient characteristics and the urgency of their treatment.

BACKGROUND: Due to the increasing number of non-urgent visits to emergency departments, it is becoming increasingly important to also investigate emergency care in out-of-hours (OOH) primary care. The aim of this study was to provide an insight into the care structures of an OOH primary care centre, to evaluate the reasons for encounter (RFE) and to assess the urgency of the treatment from the physicians´ point of view. METHODS: In the summer of 2017, we conducted a cross-sectional study over four weeks in the OOH primary care centre of Oldenburg, a city in Lower Saxony with about 160,000 inhabitants. We collected socio-demographic data, RFE and the duration of the complaints. The International Classification for Primary Care 2nd Edition (ICPC-2) was used to categorize symptoms. The attending physicians supplemented information on further treatment (including hospitalization) and the urgency of consultation in the OOH primary care centre. RESULTS: A total of 892 of the 1098 OOH patients which were visiting the OOH primary care centre took part in the study (participation: 81.2%). More than half of the patients were between 18 and 39 years old. A quarter of all RFE named by study participants were in the ICPC-2 category "skin". More than 60% of patients had the symptoms for more than two days before visiting the OOH primary care centre. In 34.5% of all cases no medication was prescribed and one in six patients received further diagnostic tests such as urinalysis and blood tests (15.8%). From the physicians' point of view, 26.3% of all study participants could have been treated by the family doctor during the regular consultation hours. CONCLUSION: The study shows that in the OOH primary care centre about a quarter of all patients could have waited until regular consultation hours. Mostly young patients used the easily accessible and free care in the OOH primary care centre. Further studies are necessary to better understand the individual reasons of patients to use the OOH primary care centre.

Reducing repeat paediatric emergency department attendance for non-urgent care: a systematic review of the effectiveness of interventions.

OBJECTIVE: Non-urgent paediatric ED (PED) visits appear to contribute a large portion to the growing use of EDs globally. Several interventions have tried to curb repeated non-urgent attendances, but no systematic review of their effectiveness exists. This review examines the effectiveness of interventions designed to reduce subsequent non-urgent PED visits after a non-urgent attendance. METHOD: A systematic review design. A systematic search of four databases and key journals was conducted from their inception to November 2018. Experimental studies, involving children aged 0-18 years presenting to an ED for non-urgent care, which assessed the effectiveness of interventions on subsequent non-urgent attendance were considered. RESULTS: 2120 studies were identified. Six studies, including four randomised controlled trials (RCTs) and two quasi-experimental, were included. Studies were of moderate quality methodologically. All studies originated from the USA and involved informational and/or follow-up support interventions. Only two RCTs demonstrated the longest duration of intervention effects on reducing subsequent non-urgent PED attendance. These studies identified participants retrospectively after ED evaluation. The RCT with the largest number of participants involved follow-up support by primary physicians. Meta-analysis was impractical due to wide heterogeneity of the interventions. CONCLUSIONS: There is inconclusive evidence to support any intervention aimed at reducing subsequent non-urgent PED visits following a non-urgent attendance. The long-term impact of interventions is limited, although the effect may be maximised if delivered by primary care providers in children identified after their ED attendance. However, further research is required to evaluate the impact of any such strategies in settings outside the USA.

Investigating the referral of patients with non-urgent conditions to a regional Australian emergency department: a study protocol.

BACKGROUND: Australia's only island state, Tasmania, experiences one of the nation's highest incidences of non-urgent emergency department (ED) presentations in a healthcare system regularly faced with service demands that exceed resource availability. Service-demand mismatches are acknowledged to contribute to ED crowding which in turn, has been documented to have a correlation with poorer patient outcomes. Crowding within EDs is complex, non-urgent presentations alone are not the primary cause, but have been reported to be a contributing factor. In 2015-16 Tasmania recorded over 153,000 ED attendances, 55% of these fell into the two least urgent triage categories. Recent research in the State's North established that 29% of non-urgent presentations were referred, formally or informally, from primary healthcare providers and that, for many patients (39%), the ED was not their first choice of service provider. This study aims to identify the service needs of patients referred to a regional Australian ED and subsequently triaged as non-urgent. METHOD: In order to achieve this aim, three objectives have been identified. The first two objectives use an explanatory sequential mixed-method approach while the third objective will incorporate an implementation science approach. These three objectives are: first, a retrospective analysis of seven years of routinely collected hospital data to identify trends in referral of patients with non-urgent conditions; second, focus group interviews with patients and primary care providers to further understand perceived need and service requirements of those referred to the ED, and third, translation of findings into local health service recommendations. DISCUSSION: Identification of the needs of patients referred to the ED with non-urgent conditions will inform future service planning aiming to facilitate access to the right service at the right time and in the right place.