Non-urgent and heavy use of the emergency department : intervention and follow-up studies

The "inappropriate" use of emergency departm ents (EDs) - for nonurgent or minor ailments and high-frequency use, "heavy use" - is causing great concern to several Western countries, irrespective of differing health care systems. Through a trial at Huddinge Hospital, about a quarter of the patients who sought care at the ED during day-time were classified by the reception staff as non-urgent cases in the sense of not needing the special resources of an emergency department. Of these non-urgent cases, 55% patients could be referred by a registered nurse to more appropriate care providers. Seven per cent were found to need the resources of the ED after all, 11% did not agree to be referred and 27% could not be referred due to organizational hindrance, mostly insufficient capacity at the primary health care centres. The referred patients were found to have a more positive attitude to the ED than had patients who had been treated in the usual way at the ED (66% versus 48%). However, the attitudes to primary care were not more favourable in referred patients (45% versus 41%). The proportion of patients in the referred group who used the ED the year following the trial was significantly reduced. The users, however, continued to turn to the ED with non-urgent health problems. Heavy ED users were found also to consume considerable amounts of primary care at the health care centres. Long-term follow-up of a population sample showed that without any intervention, heavy ED users continue to have a high utilization of hospital care. Mortality among heavy ED users was significantly elevated: the Standardized Mortality Ratio was 2.0 (95% confidence interval: 1.9 to 2.1) and the risk of dying prematurely (before reaching age 65) was more than four-fold compared with non-users. Violent death, especially suicide and intoxication were six times that of the non-users