Patients’ pathways to the emergency department: a scoping review

doi:10.21203/rs.3.rs-2202462/v1

Download PDF

Research Article

Patients’ pathways to the emergency department: a scoping review

https://doi.org/10.21203/rs.3.rs-2202462/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 02 May, 2024

Read the published version in International Journal of Emergency Medicine →

Version 1

posted

You are reading this latest preprint version

Background

Emergency Department (ED) crowding is a common healthcare issue. The causes are multifactorial, and some causes may be found by analyzing patient trajectories prior to ED visits. The aim of this scoping review is to identify and examine studies that describe patient trajectories prior to ED arrival.

Methods

The scoping review was performed according to the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A literature search was done to identify studies describing where patients come from and/or their pathway of care before the ED visits. The search was conducted in MEDLINE, Embase, and the Cochrane Library from inception up to March 17^th, 2022 and updated on December 5^th, 2022. Two reviewers independently screened the records at all stages of the review process.

Results

Out of 6,465 records screened, 14 papers from Australia, Canada, Haiti, Norway, Sweden, Switzerland, Belgium, Indonesia and the UK met the inclusion criteria. Four studies reported on where patients originated from. Seven studies reported on who referred them. Ten reported how patients were transported and five reported if alternative care or advice was sought prior to visiting an ED. Data were sparse for these categories of information; not all studies reported the full spectrum of patients within each category.

Conclusion

There are knowledge gaps when it comes to describing patients’ pathways to the emergency department. The data reported provided limited insight, and the lack of uniform data prohibits comparisons across studies. Further studies that comprehensively describe patient trajectories prior to an ED visit are paramount to help understand the reasons for the increased patient influx and ED crowding.

Emergency department

crowding

patient pathway

patient trajectories

Patient visits to emergency departments (EDs) around the world have significantly increased over the last few years [1, 2, 3]. This increase has led to ED crowding, which represents a mismatch between supply and demand [4]. Despite differences in national healthcare systems within Europe [5] and in the rest of the world, increased patient visits and ED crowding is a common healthcare issue [1, 2]. ED crowding is a serious problem that leads to inappropriate and delayed treatment, increased length of stay (LOS), worse patient outcomes, and lower patient and staff satisfaction [6]. This rise in patient volume is not well understood but is likely due to a combination of several factors [7]. There is extensive literature on strategies to control patient demand [4]. It is essential to identify where the pinch points in health services may occur to introduce tailored solutions that consider full systems of care. A conceptual model used to describe crowding in the ED defines three major phases: input, throughput, and output [4]. Each phase has its characteristics and means to manage patient logistics, though all components need to be addressed to improve patient flow.

A systematic review by Morley et. al. demonstrated that the problem lies foremost outside of the ED, and that the whole system should be included when identifying causes of crowding [1]. To create targeted solutions for predicting and managing ED patient influx, knowledge of patient trajectories before ED arrival is paramount. Previous research on patient pathways has only been conducted on specific groups; cohorts referred by doctors to the ED (i.e. from the perspective of a general practitioner), patients who arrive by ambulance (i.e. from an emergency services perspective), or ED patients with specific chief complaints or symptoms (i.e. chest pain, abdominal pain, etc.). In contrast to this approach, we sought to describe the trajectories of the complete patient population from an ED perspective. The aim of this scoping review was to explore where ED patients arrive from and/or their pathways of care before an ED visit.

The scoping review was undertaken according to the principles presented in the JBI Manual for Evidence Synthesis [7] and followed criteria set out in the PRISMA-ScR checklist [8].

Inclusion criteria about population, concept, and context (PCC) were defined. As per a protocol, studies that concerned the full spectrum of patients who arrive at an ED were eligible for inclusion; those that focused on selected groups (i.e. specific chief complaints, clinical findings, or demographics) were excluded. Eligible studies also had to describe one or both of the following:

1) where patients originated from and/or where they were referred from (e.g. GP, urgent care, outpatient clinic, self-referral, ambulance, or nursing home);

2) what actions or pathways they took before they visited the ED (i.e. how patients contacted or obtained acute health care services).

Observational/descriptive and registry studies from any country were eligible. Studies reported as abstracts were included if adequate data were reported within the abstract.

The searches were conducted in MEDLINE, Embase and the Cochrane Library from inception up to March 17th, 2022, and updated on December 5th, 2022, without language restrictions. The search was based on thesaurus- and free-text terms for the three main concepts ‘emergency medical services’, ‘pre-hospital’, and ‘descriptive patient data’, and adapted to the various databases (see Additional file 1 for a detailed description of the search strategies used in databases). Resulting records were imported to EndNote, where duplicates were removed prior to the screening.

Screening of titles and abstracts (first pass) and full papers that appeared relevant (second pass) were conducted independently by two sets of reviewers (LPB and MAN or OU and SEK). Each set screened half of the records. Forward and backward citation searching was also conducted on studies deemed relevant. Data were extracted by one of the reviewers and checked by another reviewer (MAN and SEK).

In the first search, 6,125 titles and abstracts were screened and 5,945 were deemed not relevant to the topic area. Of the remaining 180 papers, 12 met the inclusion criteria. The updated search identified a further 340 records of which two were considered eligible (Fig. 1).

Four studies were conducted in Australia, and two were conducted in both Canada and Sweden. One each was conducted in Haiti, Norway, Switzerland, Belgium, Indonesia, and the UK. The publication dates of the included studies spanned from 1993 to 2022, with all but three published in the last 10 years. Data were collected using surveys in seven of the studies and from databases in six; the remaining study used both methods. Additional file 2 shows the study and patient characteristics of these included studies.

An overview of the patient characteristics shows that half of the studies included

only adult patients. In the other half, adult patients were most prevalent (Aluisio et al. (2014) [9], Bjørnsen et al. (2013) [10], Pryce et al. (2021) [11] and Robinson et al. (2015) [12], Strum et al. (2022) [13], Brice et al. (2022) [14], Brasseur et al. (2021) [15]) The proportion of females ranged from 46–66% across the studies. Sample sizes were relatively large and ranged from 332 to 10,941,286. Differences between studies in the amount and level of detail of presenting conditions precluded summary of these data.

Four categories of information were commonly reported across the studies: 1) where patients originated from before visiting an ED, 2) who referred them, 3) how they were transported, and 4) if alternative care or advice was sought prior to visiting an ED. The evidence was, however, limited by the number of papers and by the sparseness of data reported within them. Only one study reported a full picture of where patients originated from before arriving at the ED [9] (Table 1). In this Haitian study, the highest proportion (64%) arrived directly from their homes and the lowest (2%) from a market. Further data from only three studies in Australia, Switzerland, and the UK reported consistently low presentations of patients from nursing homes, ranging from 0.9–2% [13, 14, 15].

Where reported, most patients referred themselves to the ED (in countries where the health systems allow self-referrals), followed by referral by GPs and urgent care centers (see Additional file 3). Regarding transportation, the proportion of patients who arrived by ambulance ranged from 8–43%, with the majority arriving by public or private transport (see Additional file 3). Three studies (Göransson et al. 2103 [19], Pryce et al. (2021) [11] and Strum et al. 2019 [13]) reported that 69–91% self-presented or walked-in (with referral status not reported) as a mode of arrival, but the means of transport were not specified.

Six studies reported on the proportions of patients seeking alternative care or

advice before visiting an ED [12, 18, 19, 20, 21, 22]. While more information could be inferred from some of the referral data, we chose to present data from studies that specifically reported on advice seeking or patient pathways to the ED. It was, however, sometimes unclear if multiple sources of advice were sought for each patient and if so, in what order, or when. Figure 2 shows that, of those who sought alternative care, relatively higher proportions (up to 56%) sought assistance through their GP or a health professional rather than seeking other options that may be available within each study country (e.g. a telephone or internet health service). The rate of patients who went directly to the ED varied from 39% (in Canada) to 89% (in the UK).

These results demonstrate that there are very few studies on patient trajectories prior to ED arrival and that detailed information regarding where ED patients are coming from, and who referred them, are lacking. We attempted to include studies that represented the full spectrum of ED patients, but some of the included studies did not report on children or excluded some patients presenting for specialty care from their studies.

The contextual structure of healthcare systems reveals substantial differences in patients’ trajectories. It was also impossible to make comparisons because of inconsistent data captured, different categorizations of the data, and the use of varied terminology and definitions across the studies. In a report by Rowe and colleagues [23], the lack of uniform reporting from EDs is described as an under-recognized problem resulting in an inability to study the causes, characteristics, and results of ED crowding.

Another finding is the lack of studies presenting linked data between different levels of health services; only three of the included studies used data linkage: Arendts et al. 2012 [16], Carron et al. 2018 [17], and O’Loughlin et al. 2019 [21]. For future studies, linkage between EMS and hospital data will provide the ability to track patients across health service levels and provide a basis for describing complete patient trajectories [24].

Prior studies have shown varying levels of success when it comes to solutions for tackling ED crowding [25]. We need to explore every aspect of patient influx to find potential new trategies. One approach is to understand where the patients come from and which services they have used before attending the ED. By doing this we will be able to pinpoint specific target areas where an intervention could help manage, predict, and/or control patient flow.

This scoping review has shown that there are knowledge gaps when it comes to describing patients’ pathways to the emergency department. The data reported provided limited insight, and the lack of uniform data prohibits comparisons across studies. Further comprehensive published data that describe patient pathways before visiting an ED are needed to help understand and find solutions to the global health issue of ED crowding.

Ethics approval and consent to participate

This study involves neither human participants nor unpublished secondary data. This work analyses existing research studies, and therefore, involves no patients or members of the public. As such, approval from a human research ethics committee is not required.

Consent for publication

Not applicable

Availability of data and material

All data used and analyzed during this study are included in this published article

Competing interests

The authors declare that they have no competing interests or disclosures.

Funding

The authors received no external funding.

Author`s contributions

LPB conceived the idea behind and is guarantor for this study. MAN, LPB, SEK and OU jointly developed the research questions. SAP conducted the search. SAP and SEK constructed the search map in the supplemental file. MAN, LPB, SEK, and OU screened the records and full-text articles. MAN, LPB, SEK, and OU outlined and wrote the manuscript. All authors further revised the paper and approved the final text.

Acknowledgments

We would like to thank Hege Torsvik for contributing to making Figure 2.

Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS ONE. 2018;13(8):e0203316.
Pines JM, Hilton JA, Weber EJ, Alkemade AJ, Al Shabanah H, Anderson PD, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2011;18(12):1358–70.
Javidan AP, Hansen K, Higginson I, Jones P, Lang E. The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary. Emerg Med J. 2021;38(3):245–6.
Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42(2):173–80.
Organization WH, et al. Emergency medical services systems in the European Union: report of an assessment project co-ordinated by the World Health Organization-Data book. Copenhagen: WHO Regional Office for Europe; 2008.
Javidan-Arshia A, The International Federation for Emergency Medicine Report on Emergency Department Crowding and Access Block. : A Brief Summary Javidan AP1, 2, Hansen K3, 4, Higginson I5, Jones P6, 7, Lang E8, 9 on behalf of the IFEM Task Force on Emergency Department Crowding and Access Block 1Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Peters MD, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H et al. Chapter 11: scoping reviews (2020 version). JBI manual for evidence synthesis, JBI. 2020;2020.
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.
Aluisio AR, Gore R, Decome I, De Wulf A, Bloem C. Prehospital characteristics in the North East Department of Haiti: a cross-sectional study from a low-income setting without prehospital systems. Prehosp Disaster Med. 2014;29(3):230–6.
Bjørnsen LP, Uleberg O, Dale J. Patient visits to the emergency department at a Norwegian university hospital: variations in patient gender and age, timing of visits, and patient acuity. Emerg Med J. 2013;30(6):462–6.
Pryce A, Unwin M, Kinsman L, McCann D. Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow. Int Emerg Nurs. 2021;54:100956.
Robinson C, Verrall C, Houghton L, Zeitz K. Understanding the patient journey to the emergency department–a South Australian study. Australasian Emerg Nurs J. 2015;18(2):75–82.
Strum RP, Drennan IR, Mowbray FI, Mondoux S, Worster A, Babe G, et al. Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to Canadian. J Emerg Med. 2022;24(7):742–50.
Brice SN, Boutilier JJ, Gartner D, Harper P, Knight V, Lloyd J, et al. Emergency services utilization in Jakarta (Indonesia): a cross-sectional study of patients attending hospital emergency departments. BMC Health Serv Res. 2022;22(1):1–10.
Brasseur E, Gilbert A, Servotte JC, Donneau AF, D’Orio V, Ghuysen A. Emergency department crowding: why do patients walk-in? Acta Clin Belg. 2021;76(3):217–23.
Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: an analysis of patient outcomes. Intern Med J. 2012;42(1):75–82.
Carron PN, Mabire C, Yersin B, B ̈ula C. Nursing home residents at the emergency department: a 6-year retrospective analysis in a Swiss academic hospital. Intern Emerg Med. 2017;12(2):229–37.
Jankowski RF, Mandalia S. Comparison of attendance and emergency admission patterns at accident and emergency departments in and out of London. BMJ. 1993;306(6887):1241–3.
Göransson KE, De Waern M, Lindmarker P. Patients’ pathway to emergency care: is the emergency department their first choice of care? Eur J Emerg Med. 2013;20(1):45–50.
Han A, Ospina MB, Blitz S, Strome T, Rowe BH. Patients presenting to the emergency department: the use of other health care services and reasons for presentation. Can J Emerg Med. 2007;9(6):428–34.
O’Loughlin M, Harriss L, Thompson F, McDermott R, Mills J. Exploring factors that influence adult presentation to an emergency department in regional Queensland: a linked, cross-sectional, patient perspective study. Emerg Med Australasia. 2019;31(1):67–75.
Henricson J, Ekelund U, Hartman J, Ziegler B, Kurland L. Bj ̈ork Wilhelms D. Pathways to the emergency department-a national, cross-sectional study in Sweden. BMC Emerg Med. 2022;22(1):1–9.
Rowe BH, Bond K, Ospina MB, Blitz S, Schull M, Sinclair D, et al. Data collection on patients in emergency departments in Canada. Can J Emerg Med. 2006;8(6):417–24.
Blanchard I, Williamson T, Ronksley P, Hagel B, Niven D, Dean S et al. Linkage of Emergency Medical Services and Hospital Data: A Necessary Precursor to Improve Understanding of Outcomes of Prehospital Care.Prehospital Emergency Care. 2021;p.1–10.
Kelen GD, Wolfe R, D’Onofrio G, Mills AM, Diercks D, Stern SA et al. Emergency department crowding: the canary in the health care system.NEJM Catalyst Innovations in Care Delivery. 2021;2(5).

Table 1 is available in the Supplementary Files section.

No competing interests reported.

Table1Studiesthatreportedwherepatientsphysicallyoriginatedfrom.pdf
Table 1. Studies that reported where patients physically originated from
Additionalfile1Descriptionofthesearchstrategiesusedindatabases.pdf
Additionalfile2Patientandstudycharacteristics.pdf
Additionalfile3WhoreferredpatientstotheED.pdf
Additionalfile4PatientsmodeofarrivalormethodoftransporttotheED.pdf
Additionalfile5Legendstoadditionalfiles.pdf

Download PDF

Journal Publication

published 02 May, 2024

Read the published version in International Journal of Emergency Medicine →

Version 1

posted

You are reading this latest preprint version

Patients’ pathways to the emergency department: a scoping review

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1