	Table of contents

	Current issue

	Search journal

	Archived issues

	NZMJ Obituaries 1887-2008

	Classifieds

	Hotline (free ads)

	How to subscribe

	How to contribute

	How to advertise

	Contact Us

	Copyright

	Other journals

Journal of the New Zealand Medical Association, 21-April-2006, Vol 119 No 1232

New Zealand health professionals do not agree about what defines appropriate attendance at an emergency department

Sandra Richardson, Michael Ardagh, Philip Hider

Abstract:

Aims Emergency Departments (EDs) worldwide are facing a crisis from overcrowding—a common perception exists that inappropriate use of the ED is the major contributing factor. This study aims to examine the concept of ‘inappropriate’ ED attendances in relation to the Emergency Department at New Zealand’s Christchurch Hospital. It specifically seeks to determine whether there is a consensus opinion among healthcare providers regarding a definition of ‘inappropriate’.

Methods An exploratory survey of health professionals involved with the referral, assessment, transport, and treatment of ED patients in Christchurch was carried out. A range of health professionals, including ambulance personnel, general practitioners, emergency department physicians, emergency nurses, and hospital managers were approached. A series of questions relating to definition and response to ‘inappropriate’ patients was asked, with an additional open-ended question relating to the definition of ‘appropriateness’.

Results There are significant differences in the attitudes and perceptions of key health professionals involved in the referral, treatment, and admission of patients to the ED.

Conclusions While there are some areas of general agreement, there is no clear consensus between the professionals surveyed regarding the concept of ‘appropriateness.’ This has implications for any interventions aimed at addressing ED ‘overcrowding’ that assume the presence of a consensus understanding of this concept.

Over the previous two decades, concerns have been raised in a number of Western countries about increasing numbers of patients attending Emergency Departments (EDs), with particular attention given to the concept of ‘inappropriate’ ED use.1–7 It is perceived that some patient groups ‘inappropriately’ seek primary health care from the ED.8–11 Several writers have suggested limiting the number of patients presenting by tightening (or at least defining) the criteria by which ‘appropriate’ patient conditions are identified.11,14–20 The main purpose of these criteria is to permit the development of targeted interventions designed to change behaviour, and thus reduce the number of ‘inappropriate’ attendances.

The impetus to develop and disseminate an ED appropriateness survey arose following increased awareness of overcrowding within the ED of Christchurch Hospital. This ED is one of the busiest in Australasia, seeing an average of 65,000 patients per annum, and with an admission rate of approximately 48%.24 Initial planning to respond to overcrowding at the ED raised the question of whether there was a problem with ‘inappropriate’ attenders. It became apparent that to answer this question, a consensus definition of ‘appropriateness’ would be needed. From the limited available research conducted overseas there is little evidence to support the belief that a consensus opinion amongst health professionals exists.21 Moreover, there is no research specific to this in New Zealand.

Several guidelines and tools for assessing the prevalence of ‘inappropriate attenders’ have been developed.14–16,18 Attempts to categorise ‘appropriate’ patients have typically been derived following a retrospective audit of patient charts.7 Cases are then assessed by medical ‘experts’, usually focusing on patients whose triage codes indicate a low degree of urgency. The ‘gold standard’ against which cases are measured is the opinion of a group of emergency medicine specialists, or general/primary care practitioners. However, these groups may not in fact present a clear or united perspective.

The aims of this project were to examine attitudes and perceptions amongst health professionals regarding the concept of ‘inappropriate attenders’ and to provide the basis for possible interventions to reduce ED overcrowding and plan further research related to patient flow and ED attendance.

Methods

Sample—A purposive sample of health professionals was sought, including ambulance staff, ED doctors (the survey was disseminated to all medical staff working in the area and included house surgeons, registrars, and consultants), ED nurses, general practitioners, and hospital managers.

Inclusion criteria were that the participant was:

A member of one of the designated professional groups;
Involved in the referral, transport, assessment, or treatment of Christchurch ED patients; and
Willing to consent to participate.

Potential ED and management participants were identified from staff lists, GPs were contacted through the largest local GP-contracting organisation, and ambulance staff were approached when delivering or uplifting patients from the ED. Consultation occurred with ED and hospital managers, GP liaison officers, and the ambulance authority. 210 survey forms were distributed;120 were returned complete thus giving an overall response rate of 57%.

Survey—Following an initial series of demographic questions, respondents were asked to estimate the percentage of local ED patients who could be treated appropriately in other settings, and to define the concept of ‘an inappropriate attender’.

A three point scale (agree, unsure, disagree) was used to gauge response to a range of patient scenarios, indicating whether these represented an appropriate primary reason for seeking ED care. The third section posed a range of potential responses for dealing with identified ‘inappropriate patients’ and respondents were again asked to indicate whether they agreed, disagreed, or were uncertain about these potential responses. The survey tool was piloted among a group of ED nurses, GP liaison officers, and ED doctors.

Thematic analysis—A single free-text question was included in the survey, asking respondents to define the concept of an ‘inappropriate ED attender.’ Responses were categorised by professional group, and within each group subject to thematic analysis. This involved the identification of central themes or ‘codes’. The themes were determined deductively on the basis of pre-existing understanding of the issues (from existing literature) and validated by an inductive review of the material. Content analysis of the participant’s responses occurred where specific instances of narrative data relating to the themes were identified.22,23

Results

Responses to survey statements—Overall, 120 responses were received from the survey, 27 from 40 distributed to general practitioners (68% response rate), 35 from 70 ED nurses (54% response rate), 14 from 30 ED physicians (47% response rate), 12 from 20 management personnel (60% response rate), and 32 from 50 surveys distributed to ambulance staff (64% response rate).

Respondents were evenly distributed between genders (47% female and 53% male) however there was some variation in age as shown in Figure 1.

Figure 1. ED Attendance Study’s respondent groups by age and occupation

The first question asked respondents to indicate whether “some patients attending the ED could be more appropriately treated elsewhere (e.g. GP or After Hours Service).” All ED doctors and management agreed with this statement, as did most (97%) ambulance staff, ED nurses (97%), and GPs (93%).

The second question asked, whether “patients have the right to choose care from the ED, rather than elsewhere.” The majority of ED doctors, ED nurses and ambulance staff agreed with this statement (64%, 60%, and 56% respectively), however relatively few GPs and managers agreed (18% and 15%; see Figure 2).

Most respondents, regardless of professional group, agreed that it was appropriate to present to the ED if the patient believed their condition to be ‘serious’ (see Figure 3). Indeed, four of the five occupational groups (except ambulance staff) agreed that the patient’s perception of urgency was an appropriate reason, and four of the five (all except GPs) agreed that it was appropriate to present with an acute psychiatric problem.

There was over 50% agreement within each of the groups that it was inappropriate for a patient to attend ED because they did not have a regular GP, or needed to have blood tests taken. All groups except ED nurses agreed that it was inappropriate to present to ED for a second opinion.

Figure 2. Agreement to survey question, ‘patients should have the right to choose care from the ED rather than elsewhere’

Over 50% of groups (except ambulance staff) felt it was inappropriate to present for care if the patient’s primary reason for attending was that they:

Required X-rays;
Could access the ED more easily than elsewhere; and
Had a chronic psychiatric problem.

There were clear divisions regarding several other statements. These included whether it was appropriate to attend the ED for social issues. Over 50% of ambulance, GPs, and management respondents disagreed with this statement, over 50% of ED doctors were in agreement with it, and ED nurses were conflicted. Ambulance staff, ED doctors, and ED nurses agreed that subsequent admission to hospital was indicative of an appropriate presentation, but GPs and managers disagreed. Ambulance staff and ED nurses did not agree that arrival by ambulance signified an appropriate presentation, while GPs, ED doctors, and managers felt it was an appropriate indicator (see Table 1).

Table 1: Percentage of agreement with given statement (is this an appropriate reason to present to ED?)

Statements: The patient...	Ambulance n=32	ED drs n=14	ED nurses n=35	GPs n=27	Management n=12
Believes their condition to be urgent	44	86	69	65	64
Wished to be seen in ED	38	36	31	13	0
Does not have a regular GP	0	0	8	0	0
Is unable to see their usual GP	22	43	23	0	0
Requires blood tests	22	14	9	0	0
Requires X-rays	50	29	23	17	14
States they cannot afford to visit a GP or AHS	28	43	54	13	0
Believes their condition to be serious	50	79	86	56	58
(or their family) have social issues they that they believe can best be dealt with in the ED	16	58	29	9	0
Can access the ED more easily than elsewhere	50	0	14	0	0
Is subsequently admitted to hospital	78	65	63	39	43
Has a psychiatric problem (chronic)	44	7	26	13	14
Has a psychiatric problem (acute)	66	79	63	43	72
Wishes (to have) a second opinion	19	7	40	17	0
Arrives by ambulance	44	57	26	69	50

AHS=After Hours Service; ED=Emergency Department; drs=doctors; GPs=general practitioners.

The third section of the survey presented a range of statements offering various potential responses to the issue of overcrowding. Respondents were again asked to indicate whether they were in agreement, unsure, or disagreed with the potential effectiveness and acceptability of each of the interventions. Within and between members of all the professional groups there was a higher level of agreement with statements in this section. More than 50% of the ambulance respondents agreed with all statements, ED doctors agreed with 10 of the 12 statements, and ED nurses agreed with 11 of the 12 statements. The management group agreed with 9 out of 12 and the GP group with 7 of the 12 statements, respectively.

There was general agreement that ‘increased public education about the role of the ED and greater public awareness of social supports would lessen the number of inappropriate ED presentations.’ There was also agreement that ambulance staff should make the decision whether to transport a patient to the ED, GP, or After Hours Surgery. The management group disagreed that faster access to outpatient services would reduce ED presentations. Ninety-six percent of GPs surveyed agreed that inappropriate patients should be referred away from the ED; 43% of ED doctors agreed; and over 50% agreement was reached by ED nurses, ambulance, and management staff.

When asked whether inappropriate patients should be charged a fee for service, ED doctors, ambulance and GPs agreed (ranging from 57-81% support), while ED nurses and management disagreed. GPs also disagreed with the suggestion that there would be fewer ED presentations if GP fees were lower, (22% agreement), while the remaining groups agreed with this (from 57-71%).

Table 2. Percentage of agreement with given statement (responses to overcrowding)

Statement	Ambulance n=32	ED drs n=14	ED nurses n=35	GPs n=27	Management n=12
‘Inappropriate’ patients should be referred away from the ED	84	43	66	96	71
‘Inappropriate’ patients should be charged a fee for service	81	57	29	61	29
There would be fewer ED presentations if GP fees were lower	66	57	71	22	57
There would be fewer ED presentations if patients had faster access to OP services	65	79	89	65	43
Increased education would decrease inappropriate use	81	93	71	65	78
Access to GP services within the ED would decrease pt waiting times	75	57	69	39	71
Access to GP services within the ED would increase pt satisfaction	59	43	80	43	64
Access to a Nurse Practitioner would decrease ED waiting times	75	64	86	22	57
Access to a Nurse Practitioner would increase pt satisfaction	56	57	74	17	57
Greater awareness of support available in the community would decrease inappropriate ED presentations	84	71	77	61	86
Ambulance staff should have a choice of whether to deliver pt to the waiting room or resus(citation) area	81	57	71	65	29
Ambulance staff should have a choice of whether to transport a pt to the ED or an AHS	97	79	97	78	57

AHS=After Hours Service; ED=Emergency Department; drs=doctors; GPs=general practitioners; OP=orthopaedic; pt=patient;

Questions were asked regarding the potential impact of GP and Nurse Practitioner services offered within the ED environment. All groups except GPs agreed that access to GP services within the ED would decrease waiting times, but both GPs and ED doctors had only 43% agreement that this would increase patient satisfaction.

GPs also disagreed with the suggestion that a Nurse Practitioner service could either decrease waiting times in ED (22% agreement) or increase patient satisfaction (17% agreement). However, all other groups agreed with these two statements; ranging from 57–86% support (see Table 2).

Free-text discussion (a thematic analysis)—Respondents’ comments were grouped within professions, and then within each group, subjected to thematic analysis. The following broad themes were identified and used to categorise responses: service issues, generic condition description, specific condition identification, time dependent, financial costing, personal characteristics, and comments which re-framed the question on the basis that no patient was ‘inappropriate’.

There was strong agreement that ‘inappropriateness’ was related to an inability or unwillingness by some patients to use sources of care other than the ED, in particular GP services.

One example of this is the definition of inappropriate ED attenders given by an ED nurse, all those whose care can be given at a facility other than the only Emergency Department in the city.

Many comments related to patients’ failure to seek initial GP assessment prior to presenting to ED. This can be seen in one GP’s description of inappropriate patients as those people who haven’t first attended their regular GP or 24hrs surgery. ED stands for Emergency Department! GP stands for General Practice!

The second theme identified was that of Generic Description, where the respondents described the concept of inappropriateness in terms of the general nature of the presenting complaint. This was typically coined in terms of acuity rather than by disease or injury, and included such concepts as ‘non urgent’ and ‘minor.’. Again, this theme was common to all groups with definitions given including a condition that is non-acute, non life-threatening (ED Nurse) and attending for minor or non-urgent medical problems (GP).

While there appears to be consensus that ‘non-acute’ conditions do not require ED care, there was little clarification of what made a condition acute or non-acute. An additional concern is whether members of the public are well enough informed to make this determination themselves. This was identified by one GP who noted that ‘inappropriate attenders’ might include those who conditions could be managed elsewhere but didn’t understand this at the time and a manager who suggested inappropriate attenders were those whose medical problems will definitely not lead to admission and not life and death situations, problem here is that as a patient, how would I know?

The role of the GPs as ‘gatekeeper’ to the hospital was emphasised in a number of responses. Examples include identification of an ‘inappropriate’ attender as one who makes no contact with own GP (ED Nurse), has not attended GP prior to presentation (Manager) and who presents without first seeking advice from primary care/GP/After Hours Service (GP).

One GP noted If they (patients) self refer they should be sent back to their GP or 24hr surgery unless it is an emergency. This begs the question, however, of who defines the ‘emergency’—the patient or the doctor? Comments made suggest that there is a range of opinion, with some clearly seeing this as a purely medical function, while others question whether the patient’s perception should play a part. This can be seen in the comment by an ED nurse, that: I believe patients by definition should be entitled to see their illness as acute or emergent and therefore attend the emergency service.’

A further theme was the attempt to specify particular injuries or illnesses, which might meet the criteria for ‘inappropriateness.’. Specific identification involved the listing or description of conditions or circumstances that were seen as inappropriate for ED care. These included flu-like symptoms/colds/upper respiratory tract infections (URTIs), minor musculoskeletal problems, including sprains/strains/bruising, requests for prescriptions and patients presenting with problems that were primarily related to alcohol intoxication.

Two further themes were linked with specific descriptions; these were time-dependant criteria and financial matters. Some respondents attempted to clarify the concept of ‘minor’ or the listing of specific conditions by adding in a time-related dimension.

Examples of this view include:

Problems more than 2 days without major deterioration, or those prepared to wait greater than 4 hours to be seen (ED Doctor);
Patients who are in the area and ‘pop’ in with their minor problems (ED Nurse); and
Patients presenting with problems or signs and symptoms that have been occurring over a long period ie 4–5 hours and could have been seen by GP (Ambulance Personnel).

Issues relating to finance were identified by participants from all groups except management as precipitating factors leading to ED presentations.

Descriptions given included the phrases:

Using the ED as GP service because of financial reasons and uses ED as a free service rather than paying for their GP (Ambulance Staff);
Some lower socioeconomic people do not have the finances to see a GP especially after hours; availability of GP and finances is acceptable [as a reason for presenting to ED] but still inappropriate (ED Nurses); and
People who could get safe effective treatment elsewhere but who attend due to cost reasons; and a person who attends for financial and other reasons... than for the perception that their need is an emergency (GPs).

A further theme associated with inappropriateness relates to the individual patient, and focuses on perceived characteristics and attitudes. These personal characteristics are generally portrayed in the negative, and include reference to non-medical reasons for presentation, as well as personality/behaviour traits. The most common groups identified here were simply referred to as regulars, social problems and those wanting a second opinion. The reference to regular attenders was particularly strong from the ambulance respondents, and there was an additional suggestion that many people were ‘using the system’ in an attempt to be seen earlier than their condition warranted.

Comments made included:

Regulars or time-wasters;
Repetitive attention seekers;
Someone who believes that ED maybe an easy way of getting care/drugs;
Patients who call an ambulance with the perception they will be seen quicker [given a] greater triage, and
Hypochondriac-type individuals who do not require ED attention, but demand to be taken to hospital (Ambulance Staff).

The concept of ‘using the system’ appeared in other group responses. ED nurses comments included: patients who turn up to ED to get access to tests/investigations that are taking too long (i.e. Outpatient appointments/CT /MRIs etc), and patients who feel they are going to fast track the system or waiting lists by presenting in ED.

The concept of ‘social admissions’ was noted by respondents and often grouped together with reference to ‘inappropriate’ transfers from rest homes or private hospitals. Examples include patients who are experiencing ‘social’ difficulties (e.g. heating); patients from resthomes whose condition has deteriorated and staff have called ambulance rather than doctor to attend (Management).

ED nurses also saw social issues as significant, with the comments, social disposition ie no fixed abode, requires a warm bed for the night and food; people who live alone.

Finally, the underlying concept of ‘inappropriateness’ was questioned by a number of ED doctors and nurses.

ED physicians presented a number of statements challenging this concept, including:

All ED presentations are appropriate. There are levels of appropriateness, however. An inappropriate attender may be someone who would choose treatment elsewhere given the means—educational—transport—financial—social; and
Inappropriate is completely different to ‘more appropriately treated elsewhere’. Inappropriate attenders are those patients who seem to have nothing better to do with their lives than attend ED.

ED nurses also questioned the validity of the underlying concept, with one suggesting that:

I would not define an attender as inappropriate. Some attenders may receive better long-term care by attending a regular medical service. Thus the regular medical service would provide more appropriate (continuity) of care; and
The phrase [inappropriate attender] is loaded with value judgments. It seems to be a way of negatively defining the purpose of ED. Appropriateness may equally apply to the service we offer. We have, currently, ample evidence of the uncertainty that health professionals may have about clinical judgments (e.g. meningitis management). How much more uncertain may a lay person be when presented with uncertain signs and symptoms.

Discussion

The survey results present a range of professional perceptions, based on a purposive survey carried out at a major New Zealand ED. This survey was limited in only sampling the opinions of health professionals. Consumer opinions are the subject of further study. The main finding from this survey is the recognition that there is a range of opinions both within and across professional groups.

While there is some clear consensus on general principles, for example some ED patients could be treated appropriately elsewhere, there is little evidence of clear agreement on how these individuals should be defined. Given the increasingly team-based nature of healthcare and the multiple entry points to the ED, lack of agreement on this basic concept may undermine any efforts to limit or re-direct ‘inappropriate’ patients.

While it was not possible to show consensus across the groups surveyed, there were indications of identifiable foci within professions. For example, ambulance staff were more likely to see patient admission as a clear indicator of appropriateness, whereas ED doctors and nurses were more likely to see patient perception of urgency or seriousness as a reliable indicator. This apparent support for the parameters of arrival method (ambulance) and outcome (admission) provides a starting point for planned further applications of the Delphi technique in a bid to determine whether consensus is a realistic outcome.

The findings from this study suggest that the existing reliance on a ‘gold standard’ that assumes consensus may be misplaced. Indeed, there appears to be little evidence to suggest that there is agreement regarding this concept within individual professions, much less between professions. Failure to acknowledge this fact thus limits the ability to accurately identify/forecast likely percentages of ‘inappropriateness’ amongst presenting patients. The assumption that such inappropriateness does exist and can be quantified may be based on a fundamental inaccuracy—that those involved are working from the same principles. If there is misconception, it follows that specific interventions that lead to the re-direction of patients away from the ED may themselves be flawed.

The underlying purpose of identifying ‘inappropriate’ patients seems to be to quantify a group of individuals whose care could be provided in an alternative venue or by an alternative service provider. There is no doubt that EDs are under pressure to refer patients with non-urgent conditions to other settings.25–28 What is debated, however, is whether the removal of this group would significantly impact on overcrowding. The first issue here is how such patients are quantified—is there a consensus agreement and means of determining the size of the presumed ‘problem’? This article has sought to raise awareness of the underlying assumptions associated with this process.

Further issues are apparent when considering the use to which such information (percentage of ‘inappropriate’ patients) is put. There is an assumption that these ‘inappropriate’ patients are necessarily ‘non-urgent’, and that therefore it is acceptable and appropriate to defer their care. Little specific follow-up has been carried out to determine the accuracy of this assumption—in terms of whether such patients do seek the alternative care pathway they are directed to, and what the ultimate outcome is.7 Washington et al carried out a randomised controlled trial with the aim of ‘evaluating the safety and acceptability of deferring emergency department care’ (p707).25

Their findings suggested that 36% of the screened patients (n=1176) met the explicit deferred care guidelines. Study participants in both groups (usual care and deferred care) showed improvement in health status, and no patient in either group was hospitalised or died. The authors did acknowledge a number of limitations, in particular lack of generalisability to centres where next-day care could not be guaranteed. In addition, several patients declined to participate in the study, so that the acceptability of this option can not be clearly determined. A potential factor if such a system were introduced into NZ EDs is the impact of additional cost—patients presenting to ED are not charged a fee for service, and although alternative care venues are often available, the necessity to pay for care may be a limiting factor in the uptake of such services.

Vertesi (2004) also examined the possibility of deferring non-urgent patients away from the ED as a means of reducing overcrowding.27 This study identified that the greatest access problem and longest delays were associated with patients waiting for placement in the acute care cubicles. It was found that non-urgent patients take up only a small number of urgent ‘ED stretchers and acute care resources’ (p337), and as such their diversion is unlikely to improve access for more acute patients. Not only was little benefit seen to attach from a deferral system, but it was felt that this was ‘measurably unsafe’ and would lead to the inappropriate refusal of care to patients who required hospital treatment. This retrospective study revealed that of those patients who would have been identified as ‘non-urgent’ (using the Canadian ED triage and acuity scale), 7.3% still required admission.

Most of the literature around patient deferral from the ED-setting aims to identify the impact of this on the ED (in terms of waiting times, patient flow, and overcrowding). The Society for Academic Medicine (SAEM) takes a more explicit look at the ethical issues associated with policies that triage patients out of the ED prior to complete evaluation and treatment.28 It is suggested that decisions around the availability of emergency care and rationing of this service (whether implicit or explicit) should be a societal decision, a position supported by other authors.8,28,29 These authors suggest that the ethical and legal issues are influenced by whether the practice of deferring patients involves ‘triage away’ or ‘triage to’, and conclude that there is no system whereby a brief ‘triage’ exam can identify all patients with potentially serious emergencies.

It is apparent that the data (generated in attempts to quantify ‘inappropriate’ reasons for ED presentation) can be used in several ways, with significant implication for patient care. It is essential, therefore, that in developing a valid and reliable method of determining ‘appropriateness’ recognition be given to the range of assumptions and interpretations underlying this concept.

While the data gathered in this study may not be generalised to a wider group (it is neither a random sample nor statistically representative), it does appear indicative of significant variation of attitude and opinion, and calls into dispute the concept of a general consensus which would allow the formation of criteria defining ‘appropriateness’. Without a core definition, it is hard to say what contribution ‘inappropriate attenders’ make to the problem of ED overcrowding.

While this study has not given evidence to support a consensus definition of ‘appropriateness,’ it has highlighted the need for further research into this area. Further use of the Delphi technique is planned to develop a wider data base of health professionals’s views. This would allow for further analysis of the sub groups represented and identification of areas of specific significance both within professions as well as between. Similarly, there is a clear need to examine the perspective of lay people and to determine whether there are points of agreement between health professionals and ‘others.’

Once such research has been undertaken, then it is possible to consider future directions should a consensus definition be developed. This would include the potential to develop a measurement tool to be applied within the NZ setting, which would allow the quantification of ‘inappropriate’ use of EDs. This is a necessary first step to developing possible guidelines or recommendations related to the attendance process.

Overcrowding has many contributors, and ‘inappropriate attenders’ may (or may not) be one of these. Many respondents suggested that inappropriate attendance occurred because of barriers to accessing more appropriate care. If this is a contributor, then solutions could involve increasing access to alternative care sources, rather than raising barriers to ED care. Recognition of ‘appropriateness’ and the best response to this is only one of the issues associated with overcrowding, and on its own is unlikely to provide significant benefits. What is important, however, is the need to ensure a sound evidential base for any interventions, and to develop a sustainable response. For this to happen, research relevant to the issues needs to be undertaken, with context specific features acknowledged.

Conclusion

While there are some areas of general agreement, there is no clear consensus between the professionals surveyed regarding the concept of ‘appropriateness’. This has implications for any interventions aimed at addressing ED ‘overcrowding’ that assume the presence of a consensus understanding of this concept.

Author information: Sandra Richardson, Emergency Nurse Researcher, Emergency Department, Christchurch Hospital, Christchurch; Michael Ardagh, Professor, Emergency Department, Christchurch Hospital and Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch; Phil Hider, Senior Lecturer, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch

Correspondence: Sandra Richardson, Emergency Department, Christchurch Hospital, Private Bag 4710, Christchurch. Fax: (03) 364 0286; email: sandra.richardson@cdhb.govt.nz

References:

Ardagh M, Richardson S. Emergency department overcrowding – can we fix it? N Z Med J. 2004;117(1189). URL: http://www.nzma.org.nz/journal/117-1189/774/ Accessed April 2006.
Asplin BR, Magid D, Rhodes K, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173–80.
Canadian Association of Emergency Physicians and the National Emergency Nurses Affiliation Joint Position Statement. Access to acute care in the setting of emergency department overcrowding. CJEM. 2003;5:81–6.
Haugh H. Rethinking our pressure packed Emergency Departments. Hospital and Health Networks. 2003:67-70.
Weiss S, Arndahl J, Ernst A, et al. Development of a site sampling form for evaluation of ED overcrowding. Med Sci Monit. 2002;8:CR549–53.
Dunham CM. Emergency Department overcrowding in Massachusetts: Making room in our hospitals. Massachusetts Health Policy Forum, held June 7th 2001, Swissotel, Lafayette Place, Boston.
NZHTA Emergency Department attendance. A critical appraisal of the literature. 1998; NZHTA Report No 8.
Robertson-Steel IR. Providing primary care in the accident and emergency department. [Editorial] BMJ. 1998;316:409–10.
Halfon N, Newacheck PW, Wood DL. St Peter RF. Routine emergency department use for sick care by children in the United States. Pediatrics. 1996;98:28–34.
Dale J, Greeen J, Reid F, et al. Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors. BMJ. 1995;31:427–30.
Lowe RA, Bindman AB, Ulrich SK, et al. Refusing care to emergency department patients: evaluation of published triage guidelines. Ann Emerg Med. 1994;23:286–93.
Shesser R, Thomas K, Smith J, Hirsch J. An analysis of Emergency Department use by patients with minor illness. Ann Emerg Med. 1991;20:743–8.
Driscoll PA. Vincent CA. Wilkinson M. The use of the accident and emergency department. Arch Emerg Med. 1987;4:77–82.
Martin A, Martin C, Martin P, et al. ‘Inappropriate’ attendance at an accident and emergency department by adults registered in local general practices: how is it related to their use of primary care? J Health Ser Res Policy. 2002;7:160–5.
Franco SM, Mitchell CK, Buzon RM. Primary care physician access and gatekeeping: A key to reducing emergency department use. Clin Pediatr. 1997;36:63–8.
Gill JM, Reese CL, Diamond JJ. Disagreement among health care professionals about the urgent care needs of emergency department patients. Ann Emerg Med. 1996;28:474–8.
Lowy A, Kohler B, Nicholl J. Attendance at accident and emergency departments: unnecessary or inappropriate? J Public Health Med. 1994;16:134–40.
Afilalo M, Guttman A, Colacone A, et al. Emergency Department use and misuse. The Journal of Emergency Medicine. 1994;13:259–64.
Prince M, Worth C. A study of ‘inappropriate’ attendances to a paediatric Accident and Emergency department. J Public Health Med. 1992;14:177–82.
Derlet RW, Nishio D, Cole LM, Silva J Jr. Triage of patients out of the emergency department: three-year experience. Am J Emerg Med. 1992;10:195–9.
Sanders J. A review of health professionals attitudes and patient perceptions on inappropriate’ accident and emergency attendances. The implications for current minor injury service provision in England and Wales. J Adv Nurs. 2000;31:1097–105.
Norwood S. Research strategies for advanced practice nurses. New Jersey: Prentice Hall; 2000.
Abbott P, Sapsford R. Research methods for nurses and the caring professions. Philadelphia: Open University Press; 1998.
Hider P, Helliwell P, Ardagh M, Kirk R. The epidemiology of Emergency Department attendances in Christchurch. NZMJ 2001;114:157–9.
Washington DL, Stevens CD, Shekelle PG, et al. Next-day care for emergency department users with non acute conditions. Annals of Internal medicine 2002;137:707–14.
Cooke MW, Arora P, Mason S. Discharge from triage: Modelling the potential in different types of emergency department. Emerg.Med J. 2003;20:131–3.
Vertesi L. Does the Canadian Emergency Deopartment Triage and Acuity Scale identify non-urgent patients who can be triaged away from the emergency department? Can J Emerg Med.2004;6:337–42.
Society for Academic Emergency Medicine. Ethics of emergency department triage: SAEM position statement. Acad Emerg Med. 1995;2.990–5.
Richardson S. Emergency departments and the inappropriate attender – is it time for a reconceptualisation of the role of primary care in emergency facilities? Nursing Praxis in New Zealand. 1999;4:13–20.