Aim
The aims of the “Better Data, Better Planning” (BDBP) study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland.
Setting
In Ireland the Health Service Executive (HSE) is the national publicly funded organisation responsible for the provision of health and social services. The HSE employs all health and social care professionals apart from GPs who work as independent contractors. A wider network of other primary care and allied health professionals (AHP) such as public health nurses (PHN), physiotherapists, occupational therapists, speech and language therapists, community pharmacists, dieticians, community welfare officers, dentists, chiropodists and psychologists also provide services for the population of hospital group as Primary Care Teams (PCT) [20]. The Irish public hospital system is financed by a combination of public and private spending. Patients generally fall under three categories – those with a General Medical Services (GMS) card, those with private insurance and patients with no medical cover. The “Medical Card” allows the use of most health services free of charge for patients meeting eligibility criteria based on income thresholds and burden of illness. This includes visits to a General Practitioner (GP), all inpatient and outpatient services in public hospitals and use of the ED. Without a Medical Card attendance at the ED costs €100 [21]) although this fee is waived with a referral letter from a GP. Ireland is the only western European country without universal coverage for primary care [22] and an out-of-pocket payment to visit a GP costs from €45–65 [23].
The hospitals in Ireland are organised into seven Hospital Groups; Ireland East Hospital Group, Royal College of Surgeons in Ireland (RCSI) Hospital Group, Dublin Midlands Hospital Group, University of Limerick Hospitals, South/Southwest Hospital Group, Saolta Hospital Group and Children's Health Ireland (CHI). The services delivered at these hospitals include inpatient scheduled care, unscheduled/emergency care, maternity services, outpatient and diagnostic services [24]. The setting for the BDBP study was regional EDs of selected academic teaching hospitals in urban and rural locations across Ireland (Fig. 1). Selection of hospital sites was based on a combination of geographical location, urban/rural case mix and socio-economic factors. The study includes representatives from five of the seven Hospital Groups, Midlands Regional Hospital Tullamore (MRHT); Dublin Midlands Hospital Group, University Hospital Limerick (UHL); University of Limerick Hospitals, St. Vincents University Hospital (SVUH); Ireland East Hospital Group, St. James University Hospital (SJUH), Dublin Midlands Hospital Group and University Hospital Kerry (UHK); South/Southwest Hospital Group. As the inclusion criteria specified adult participants only, the CHI hospital group was not eligible for inclusion in the BDBP Study.
Design
This was a multi-centre, cross-sectional study profiling demographic and clinical characteristics of Irish ED attendees and investigating the factors influencing ED attendance from the patients’ perspective. This is the first report from the larger “Better Data, Better Planning” (BDBP) project investigating potentially avoidable ED attendances nationally. A pilot study was conducted in December 2019 to refine the study design and recruitment protocol, followed by trial commencement in January 2020. On 11th March, 2020 the World Health Organisation declared the COVID-19 outbreak as a pandemic [26] “Lockdown 1” commenced in Ireland on 27th March 2020 and concluded on 18th May 2020 with a phased reopening. Therefore the BDBP Census began prior to “Lockdown 1” in Ireland and the COVID-19 pandemic delayed data collection on some regional sites, which is a confounding variable in this study.
Data were collected at each site over separate 24-h periods during the course of a year to account for diurnal and seasonal variation in attendance patterns. The sampling frame for each census was Thursday at 12 pm—Friday at 12 pm. Data collection occurred at five sites throughout 2020 (Fig. 1.); January (MRHT), February (UHL) September (SVUH), November (SJUH) and December (UHK).
Participants and procedure
All adult patients attending each ED over the sampling frame were potentially eligible for recruitment. The Manchester Triage System (MTS) is used in most Irish and UK EDs to assess the degree of severity of cases, based on presenting signs and symptoms. It assigns an order of clinical priority by allocating patients to one of five urgency categories (Immediate, Very Urgent, Urgent, Standard and Non-urgent) which determine safe waiting times in the ED [27]. The following inclusion criteria were applied A) Adult aged ≥ 18 years B) Medically stable MTS categories 2–5 C) Patient has capacity and willingness to provide informed consent. Exclusion criteria include; A) Scheduled admissions to the ED B) Mental Health presentations C) Patients with altered capacity due to drug or alcohol intoxication D) Inability to communicate sufficiently in English to participate. Patients who were COVID-19 coronavirus positive or suspected of having the viral infection were also recruited. At each site, local infection control policies and protocols were adhered to by the research team. All patients meeting the criteria, were invited to participate and served as the study denominator, with the final sample size dependant on the number of patients consenting to participate, who had sufficient time to complete the questionnaire during their ED stay. Depending on potential participants’ presenting complaint, referral route and MTS, the Research Nurses (RNs) determined when and where recruitment and informed consent could be attained within the ED (Minors, Majors, Resus). Permission was granted at each site to access electronic systems which allowed the RNs to further assess ED attendees for suitability and track their progress and allocation within the ED. In consultation with the wider Multidisciplinary Team, the RNs determined when the participant could be recruited without impacting on any treatment or diagnostics they were receiving. Patients who were initially deemed unable to participate due to e.g. pain, nausea or distress were re-assessed once they had received treatment.
Primarily, the Triage Nurses, ED Staff Nurses, Administrative Staff and Clinical Nurse Managers acted as the Study Gatekeepers and written informed consent was obtained by the RNs. Participants completed a self-report questionnaire and provided consent for access to medical charts including; demographics, public/private health insurance, socioeconomic status, presenting complaint, triage category, Length of Stay (LOS) and disposition. The questionnaire was developed by a multidisciplinary team of EM clinicians in collaboration with the researchers, it was externally reviewed, piloted internally and questions were refined based on feedback prior to full implementation. The response rate (i.e. proportion of eligible adults recruited by ED site) ranged from 75–100% and did increase chronologically from site to site (Fig. 1) which may have been a function of learning from past experience and the increasing expertise of the team of research nurses as the study progressed.
The questionnaire design incorporated open-ended questions, rating scales and multiple-choice questions. For multiple-choice questions, all responses were included in the analysis and % respondents was reported. The questionnaire explored the following categories; demographics, healthcare utilisation, service awareness and factors influencing decision to attend the ED. Demographic variables included marital status, living arrangements, education level and occupational status. Socioeconomic status was recorded by electoral division as these are the smallest legally defined administrative areas in the State for which Small Area Population Statistics (SAPS) are published from the Census. There are a total of 3,440 electoral divisions in the state, with an average population of 1,447 and average area of 20.4 square kilometres [28]. Proximity to health services (i.e. distance to GP and ED in kilometres from home address) was self-reported by participants.
Data was collected on the duration of presenting complaint and community services accessed prior to attendance. Utilisation of healthcare services in the past year was documented including hospital services (out-patient appointment, ED, hospital admission) and community services (GP, PHN and other AHP). Awareness of alternative services for emergency care including Injury Units and out-of-hours GP (OOH-GP) were also recorded. The questionnaire explored reasons for ED attendance, including self-assessment of pain and level of concern regarding presenting complaint, on a numeric rating scale [1,2,3,4,5,6,7,8,9,10].
Patient and public involvement
Direct patient and public consultation was not undertaken, however this research was informed by previous studies detailing service user experiences of emergency care in Ireland. [8, 29].
Data analysis
Data were entered into Excel (Microsoft, San Diego, CA), coded for analysis and analysed in SPSS (IBM SPSS Statistics Version 26, Armonk, NY). Variables were tested for normality using the Kolmogorov–Smirnov test. Categorical data are presented as frequencies and percentages and the chi-square test was used to examine relationships between variables. Continuous variables are presented as mean (standard deviation; SD) or median (Interquartile Range; IQR), depending on distribution. To compare groups, ANOVA or the Kruskall-Wallis test was used, followed by post hoc Mann–Whitney U tests. P < 0.05 was considered statistically significant.