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NIHR Signal Non-urgent attendances to emergency departments are more common among younger adults

Published on 9 October 2018

doi: 10.3310/signal-000657

Adults aged 16 to 44 years are more likely to attend emergency departments for non-urgent presentations than older adults. They were more than three times more likely to present for non-urgent reasons than those over 65 years. Non-urgent attendances are also more common during out-of-hours periods, especially at night. 

Emergency departments are consistently under high pressure with long waiting times. Understanding the characteristics of non-urgent attendances that could be managed in the community could help to reduce pressures on emergency and ambulance services.

This NIHR-funded study analysed three years’ worth of data (2011-14) from emergency departments within one large region of England representing rural, urban and suburban areas. Fifteen percent of over 3.6 million first time attendances among adults were non-urgent. Twenty percent of non-urgent attendances arrived by ambulance.

These patients could be managed in more appropriate services. Understanding the underlying reasons for unnecessary emergency services use – such as difficulties accessing primary care or uncertainty around where best to seek care – may help future service reconfiguration.

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Why was this study needed?

The pressure on emergency services in England continues to rise. Hospital Episode Statistics (HES) and A&E Attendances and Emergency Admissions Monthly Situation Reports data showed that in 2017/18 there were 23.8 million attendances in emergency departments in England. This was a 2% increase on 2016/17 and a 22% rise since 2008/09.  The four-hour wait target was achieved for 88% of attendances. The national target of 95% has not been met since 2013/14. Latest Ambulance Quality Indicators data shows there were nine million ambulance call-outs in 2014/15, a 6% rise on the preceding year.

NHS Digital defines unnecessary emergency department attendance as a "First attendance with some recorded treatments or investigations all of which may have been reasonably provided by a GP, followed by discharge home or to GP care." Sixteen percent of emergency department attendances in 2015-17 were defined as unnecessary.

This research aimed to profile such non-urgent emergency department attendances that could be managed in alternative services like primary care or walk-in centres.

What did this study do?

This study analysed three years of HES data for emergency departments across 13 acute trusts in the Yorkshire and Humber region between April 2011 and March 2014. Data was collected on all adults (aged 16 or above) who attended type 1 emergency departments; that is those providing 24-hour, consultant-led, multispecialty services with full resuscitation facilities. 

Patient data included age and gender, time of arrival and assessment, type of arrival (by ambulance or other), source of referral (self-referred or by another professional), investigations, diagnosis and treatment. Non-urgent attendance was defined as first-time access of a type 1 emergency service where the patient did not receive investigations, treatments or referral requiring type 1 facilities, but which could have been provided routinely in primary care. Patients who left the emergency department without being seen were also considered to be non-urgent attendees.

What did it find?

  • Over three years, 554,564 of a total 3,667,601 first time attendances (15.1%) were defined as non-urgent. However, there was a small decrease during this period of 205 fewer attendances each year (95% confidence interval [CI] -294 to -115).
  • Nearly two-thirds of non-urgent attendances, 346,274 (62.4%) occurred during out-of-hours periods. Patients with non-urgent reasons for attendance were 19% more likely to present out-of-hours (odds ratio [OR] 1.19, 95% CI 1.18 to 1.20). This tended to be late night/early morning each night, but with a peak on Sunday mornings between the hours of 3 and 4am.
  • Younger adults aged 16 to 44 years accounted for two-thirds, 365,716 (65.9%) of all non-urgent attendances. This age group had more than tripled odds of non-urgent presentation compared with those aged 65 and over (OR 3.81, 95% CI 3.78 to 3.85).  Most of these presentations among adults aged 16 to 44 years (68%) were also out-of-hours.
  • Twenty percent of all non-urgent presentations arrived by ambulance. Three-quarters of all of these ambulance arrivals were in the out-of-hours period.  The proportion of non-urgent cases arriving by ambulance went down over the three years studied.
  • More than one in seven patients in one region attended emergency departments for non-urgent reasons.

What does current guidance say on this issue?

The NHS Five Year Forward View initiative aims to transform urgent and emergency care services. Strategies include:

  • providing round-the-clock urgent care centres to divert non-urgent cases from emergency departments;
  • increasing GP evening and weekend appointments;
  • implementing changes to ambulance and 111 delivery models to reduce the rate of growth in demand for emergency department services; and
  • increasing specialist mental health care so that it is available in all emergency departments 24 hours per day.

Similar approaches have been implemented in recent years in NHS Wales, particularly to expand out-of-hours services.

What are the implications?

This research provides valuable insight into patterns of non-urgent emergency services use, notably that it is most common out-of-hours and among younger adults. Younger adults may not be aware of other services for less serious conditions or could have lower thresholds for attending emergency departments, perhaps because of work commitments. The service needs to continue to find ways of diverting these people to more appropriate services and take the pressure off busy emergency departments. 

Another important finding from this study was that one in five non-urgent cases arrived by ambulance, largely out of hours.  This proportion went down over the three years studied and may have reduced further since 2014 given efforts by ambulance trusts to increase non-conveyance rates where appropriate.  

It would be interesting to see whether findings are similar for children. 

Citation and Funding

O’Keefe C, Mason S, Jacques R, Nicholl J. Characterising non-urgent users of the emergency department (ED): a retrospective analysis of routine ED data. PLoS ONE. 2018; 13(2):e0192855

This study was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Yorkshire and the Humber. 

Bibliography

Appleby J, Dayan M. Nuffield winter insight: briefing 3, the ambulance service. London: Nuffield Trust; 2017.

Carret M L, Fassa A C, Domingues M R. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica. 2009;25(1):7-28

Department of Health. The government’s revised mandate to NHS England for 2017-18. London: Department of Health; 2018

Health in Wales. Unscheduled care improvement. Cardiff: NHS Wales Informatics Service; 2011.

The King’s Fund. What’s going on with A&E waiting times? London: The King’s Fund; 2018.

Monitor. A&E delays: why did patients wait longer last winter? London: Monitor; 2015.

NHS Digital. Unnecessary A and E attendances. London: NHS Digital; 2018.

NHS England. NHS England asks patients, the public and staff to help shape the future of urgent and emergency care. London: NHS England; 2013.

NHS England and NHS Digital. Hospital accident and emergency activity: 2017-18. London: NHS England and NHS Digital; 2018.

NHS Digital. Ambulance services, England – 2014-15. London: NHS Digital; 2015.

Why was this study needed?

The pressure on emergency services in England continues to rise. Hospital Episode Statistics (HES) and A&E Attendances and Emergency Admissions Monthly Situation Reports data showed that in 2017/18 there were 23.8 million attendances in emergency departments in England. This was a 2% increase on 2016/17 and a 22% rise since 2008/09.  The four-hour wait target was achieved for 88% of attendances. The national target of 95% has not been met since 2013/14. Latest Ambulance Quality Indicators data shows there were nine million ambulance call-outs in 2014/15, a 6% rise on the preceding year.

NHS Digital defines unnecessary emergency department attendance as a "First attendance with some recorded treatments or investigations all of which may have been reasonably provided by a GP, followed by discharge home or to GP care." Sixteen percent of emergency department attendances in 2015-17 were defined as unnecessary.

This research aimed to profile such non-urgent emergency department attendances that could be managed in alternative services like primary care or walk-in centres.

What did this study do?

This study analysed three years of HES data for emergency departments across 13 acute trusts in the Yorkshire and Humber region between April 2011 and March 2014. Data was collected on all adults (aged 16 or above) who attended type 1 emergency departments; that is those providing 24-hour, consultant-led, multispecialty services with full resuscitation facilities. 

Patient data included age and gender, time of arrival and assessment, type of arrival (by ambulance or other), source of referral (self-referred or by another professional), investigations, diagnosis and treatment. Non-urgent attendance was defined as first-time access of a type 1 emergency service where the patient did not receive investigations, treatments or referral requiring type 1 facilities, but which could have been provided routinely in primary care. Patients who left the emergency department without being seen were also considered to be non-urgent attendees.

What did it find?

  • Over three years, 554,564 of a total 3,667,601 first time attendances (15.1%) were defined as non-urgent. However, there was a small decrease during this period of 205 fewer attendances each year (95% confidence interval [CI] -294 to -115).
  • Nearly two-thirds of non-urgent attendances, 346,274 (62.4%) occurred during out-of-hours periods. Patients with non-urgent reasons for attendance were 19% more likely to present out-of-hours (odds ratio [OR] 1.19, 95% CI 1.18 to 1.20). This tended to be late night/early morning each night, but with a peak on Sunday mornings between the hours of 3 and 4am.
  • Younger adults aged 16 to 44 years accounted for two-thirds, 365,716 (65.9%) of all non-urgent attendances. This age group had more than tripled odds of non-urgent presentation compared with those aged 65 and over (OR 3.81, 95% CI 3.78 to 3.85).  Most of these presentations among adults aged 16 to 44 years (68%) were also out-of-hours.
  • Twenty percent of all non-urgent presentations arrived by ambulance. Three-quarters of all of these ambulance arrivals were in the out-of-hours period.  The proportion of non-urgent cases arriving by ambulance went down over the three years studied.
  • More than one in seven patients in one region attended emergency departments for non-urgent reasons.

What does current guidance say on this issue?

The NHS Five Year Forward View initiative aims to transform urgent and emergency care services. Strategies include:

  • providing round-the-clock urgent care centres to divert non-urgent cases from emergency departments;
  • increasing GP evening and weekend appointments;
  • implementing changes to ambulance and 111 delivery models to reduce the rate of growth in demand for emergency department services; and
  • increasing specialist mental health care so that it is available in all emergency departments 24 hours per day.

Similar approaches have been implemented in recent years in NHS Wales, particularly to expand out-of-hours services.

What are the implications?

This research provides valuable insight into patterns of non-urgent emergency services use, notably that it is most common out-of-hours and among younger adults. Younger adults may not be aware of other services for less serious conditions or could have lower thresholds for attending emergency departments, perhaps because of work commitments. The service needs to continue to find ways of diverting these people to more appropriate services and take the pressure off busy emergency departments. 

Another important finding from this study was that one in five non-urgent cases arrived by ambulance, largely out of hours.  This proportion went down over the three years studied and may have reduced further since 2014 given efforts by ambulance trusts to increase non-conveyance rates where appropriate.  

It would be interesting to see whether findings are similar for children. 

Citation and Funding

O’Keefe C, Mason S, Jacques R, Nicholl J. Characterising non-urgent users of the emergency department (ED): a retrospective analysis of routine ED data. PLoS ONE. 2018; 13(2):e0192855

This study was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Yorkshire and the Humber. 

Bibliography

Appleby J, Dayan M. Nuffield winter insight: briefing 3, the ambulance service. London: Nuffield Trust; 2017.

Carret M L, Fassa A C, Domingues M R. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica. 2009;25(1):7-28

Department of Health. The government’s revised mandate to NHS England for 2017-18. London: Department of Health; 2018

Health in Wales. Unscheduled care improvement. Cardiff: NHS Wales Informatics Service; 2011.

The King’s Fund. What’s going on with A&E waiting times? London: The King’s Fund; 2018.

Monitor. A&E delays: why did patients wait longer last winter? London: Monitor; 2015.

NHS Digital. Unnecessary A and E attendances. London: NHS Digital; 2018.

NHS England. NHS England asks patients, the public and staff to help shape the future of urgent and emergency care. London: NHS England; 2013.

NHS England and NHS Digital. Hospital accident and emergency activity: 2017-18. London: NHS England and NHS Digital; 2018.

NHS Digital. Ambulance services, England – 2014-15. London: NHS Digital; 2015.

Characterising non-urgent users of the emergency department (ED): A retrospective analysis of routine ED data.

Published on 23 February 2018

O’Keeffe C, Mason S, Jacques R, Nicholl J.

Plos One Volume 13 Issue 2 , 2018

Background The pressures of patient demand on emergency departments (EDs) continue to be reported worldwide, with an associated negative impact on ED crowding and waiting times. It has also been reported that a proportion of attendances to EDs in different international systems could be managed in settings such as primary care. This study used routine ED data to define, measure and profile non-urgent ED attendances that were suitable for management in alternative, non-emergency settings. Methods We undertook a retrospective analysis of three years of Hospital Episode and Statistics Accident Emergency (HES A&E) data for one large region in England, United Kingdom (April 1st 2011 to March 31st 2014). Data was collected on all adult (>16 years) ED attendances from each of the 19 EDs in the region. A validated process based definition of non-urgent attendance was refined for this study and applied to the data. Using summary statistics non-urgent attenders were examined by variables hypothesised to influence them as follows: age at arrival, time of day and day of week and mode of arrival. Odds ratios were calculated to compare non-urgent attenders between groups. Results There were 3,667,601 first time attendances to EDs, of which 554,564 were defined as non-urgent (15.1%). Non-urgent attendances were significantly more likely to present out of hours than in hours (OR = 1.19, 95% CI: 1.18 to 1.20, P<0.001). The odds of a non-urgent attendance were significantly higher for younger patients (aged 16–44) compared to those aged 45–64 (odds ratio: 1.42, 95% CI: 1.41 to 1.43, P<0.001) and the over 65’s (odds ratio: 3.81, 95% CI: 3.78 to 3.85, P<0.001). Younger patients were significantly more likely to attend non-urgently out of hours compared to the 45–64’s (OR = 1.24, 95% CI: 1.22 to 1.25, P<0.001) and the 65+’s (OR = 1.38, 95% CI: 1.35 to 1.40, P<0.001). 110,605/554,564 (19.9%) of the non-urgent attendances arrived by ambulance, increasing significantly out of hours versus in hours (OR = 2.12, 95% CI: 2.09 to 2.15, P<0.001). Conclusions Younger adults are significantly more likely as older counterparts to use the ED to obtain healthcare that could be provided in a less urgent setting and also more likely to do this out of hours. Alternative services are required to manage non-urgent demand, currently being borne by the ED and the ambulance service, particularly in out of hours.

Expert commentary

It is widely accepted that a proportion of patients who attend an emergency department have non-urgent problems that could be managed in other parts of the healthcare system. But the exact proportion is widely debated.

This well-conducted research, using routine data and building on previous studies by the same group, provides a reliable and clinically plausible estimate of the proportion of non-urgent adult emergency department attendances in a single English region. It also confirms that non-urgent presentations are more common outside routine office hours (presumably because other services are not available at this time), and in younger adults. Unfortunately, the researchers did not include children in their analysis, which is an area of rapid growth in emergency department demand.

Nevertheless, this paper provides reliable evidence on which commissioners and service planners can base initiatives to manage emergency department demand, and provide alternative healthcare services, more effectively.

Jonathan Benger, Professor of Emergency Care, University of the West of England; Consultant in Emergency Medicine, University Hospitals Bristol NHS Foundation Trust