Emergency Department and Urgent Care Centre

Transcription

Faculty of
Health
Patient Survey City Hospital Birmingham:
March 2009
Patient Survey City Hospital Birmingham
Patient Survey City Hospital Birmingham:
A Report Prepared for Heart of Birmingham (Teaching) Primary
Care Trust
By Lucy Land
Birmingham City University
March 2009
Copyright © Faculty of Health, Birmingham City University, Franchise Street,
Perry Barr, Birmingham B42 2SU.
All rights reserved.
ISBN 13
978-1-901073-02-7
No part of this report may be reproduced by any means or transmitted or translated
without the written permission of the publisher.
Printed by Birmingham City University
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Emergency Department and Urgent Care Centre March 2009
Research Team
Sue Lillyman
Neil Meredith
Jaspreet Bhogal
Grace Nicholas
Harjinder Sagoo
Jessica Pass
Robert Lillyman
The Urgent Care Project Team
The Team
Mark Curran
Heart of Birmingham Teaching Primary Care Trust
Commissioning Manager - Out of Hours and Urgent Care
Dr Sirjit Bath
Heart of Birmingham Teaching Primary Care Trust
General Practitioner, Urgent Care lead
Dr Peter Ahee
Sandwell and West Birmingham Hospitals NHS Trust
Consultant in Emergency Medicine
Andrew Brown
Sandwell and West Birmingham Hospitals NHS Trust
Divisional General Manager Medicine ‘A’
Manjit Singh
Patient Representative
There are a number of additional colleagues who have supported this process and
their efforts are greatly appreciated.
We are pleased to present our final report Patient Survey City Hospital Birmingham:
Emergency Department and Urgent Care Centre. The report details the rationale,
methodology, findings, conclusions and recommendations of a study conducted in
the Emergency Department of City Hospital Birmingham concerning attendance
patterns. We hope that our investigation will be helpful as you consider the further
development of Emergency and Acute Services.
Lucy Land
Senior Academic
Project Lead
March 2009
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Acknowledgements
We would like to thank:
All those who agreed to participate in the study, completed the questionnaires
and shared their thoughts and experiences.
For permission to access the Emergency Department and facilitation of the survey:
Peter Ahee, Clinical Director for Emergency Care
Karen Mitchell, Emergency Department Nurse Manager
For Co-operation and participation in the Survey:
Doctors, nurses and administrative staff at City Hospital Emergency Department and
Urgent Care Centre at City Hospital.
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Contents
Executive Summary
Summary of Findings and Recommendations
Introduction
Trust and Hospital Profile
Background
Study Aims and Objectives
Methodology
Population and Sample
Data Collection
Pilot Study
Analysis
Results
Part A Before Treatment
Part B After Assessment and Treatment
Discussion
Urgent Care Centres
Access and Speed of Treatment
Inappropriate attendance: Definitions
The Patient Journey
Ease of Access to Services
Self Referral
Streaming
Triage
Communication and Co-ordination
Treatment and Follow up Care
Strengths and weaknesses of the study
Conclusions and Recommendations
References
Appendices
Appendix A: Questionnaire Parts A & B
Appendix B: Presenting Problems
Appendix C: Glossary of Terms
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List of Tables
Table 1: Number of Questionnaires completed by day
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Table 2: Reasons for attending the Emergency Department rather
than their GP
18
Table 3: Factors influencing attendance at City Hospital
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Table 4: Knowledge of other services available
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Table 5: Perceived need for tests or treatment
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Table 6: Satisfaction with Diagnosis and Treatment
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List of Figures
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Figure 1: Attendance at Emergency Department by Ethnic Origin
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Figure 2: Problems presented by respondents attending the
Emergency Department
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Figure 3: Factors influencing attendance at City Hospital
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Executive Summary
Heart of Birmingham (Teaching) Primary Care Trust determined from data on file
that 40-60% of attendees at City Hospital Emergency Department were seeking care
for ailments and injuries inappropriately and that these people would have been
treated more appropriately in an urgent care setting.
This report details the rationale, methodology, findings, conclusions and
recommendations of a study conducted in the Emergency Department of City
Hospital Birmingham concerning attendance patterns. 485 and 163 people
respectively responded to a two part questionnaire regarding the reasons they had
presented at the Emergency Department for assessment and treatment.
The findings serve to provide evidence that acute hospital services such as the
Emergency Department at City Hospital are seen by patients as the most convenient
point of access for conditions they consider to be deserving of immediate treatment.
Inability to access more appropriate services, which together with a deep rooted
conviction that the ‘hospital’ is the best place to be seen for treatment and a
considerable loyalty and emotional attachment to their local Hospital means that
changing public behaviour would be challenging.
Summary of Findings
The label ‘inappropriate attendance’ is almost exclusively one used by health care
professionals, whilst those attending have often made a rational choice to present
themselves.
Attendance patterns and the range of conditions presented to the department during
the study period were similar to other studies conducted in this country and abroad.
There is a confusing array of options to access primary or urgent care services, but
little in the way of signposting towards the most useful ones either in the available
literature or websites.
Gatekeeping or failure to provide comprehensive out of hours GP services may
provide the justification for people to attend the Emergency Department.
The public view their local hospitals as landmarks of their community and ‘A&E’ as
the obvious point of access to resolve their immediate health care requirements.
There is no evidence to suggest that education will direct people towards more
appropriate services.
Few people knew that Urgent Care facilities existed within the Emergency Department
and some were frustrated at the apparent speed of access to care by those with
apparently trivial problems.
On the whole people who attended were loyal to the service and were happy with the
advice and treatment they received.
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Summary of Recommendations
Capitalise on the fact that people use the Emergency Department for urgent care
problems in order to reduce their confusion and be in a position to marshal
appropriate resources to either service.
Brand and market Urgent Care Centres as specific services within the Health
Economy. Use this as a means of attracting people to the former (shorter waits,
faster treatments) and as a long term strategy to educate people away from
emergency departments.
Consider separate waiting areas for Emergency and Urgent Care Patients.
Consider the use of ‘meet and greet’ personnel who can troubleshoot minor
problems. This may be in addition to interactive technology that provides real time
information on the operational aspects of the department.
Evaluate current pre treatment assessment procedures, there is good evidence to
suggest that eliminating triage in favour of see and treat, results in improved patient
flow.
Incorporate some form of post treatment education about services using leaflets or
other materials.
Improve co-ordination of out of hours care and interprofessional communication
systems by using front of house software. This minimizes duplication of effort in
assessment and record keeping. This has a range of additional benefits including the
ability to perform real time audit.
Provide a single number telephone access system to allow people to make more
realistic decisions about which service to choose.
Identify rather than conceal out of hours services on web sites.
Table 1: Affiliate members of the Centre for Community Mental Health
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Introduction
The difference in the type of people using Emergency Department (ED) Services is
both notable and unique1. The nature and severity of the problems that clients
present with can vary widely, so it is extremely important that the service responds
with optimum levels of intervention and care. Key data suggests that 20% of ED
attendees don’t require ED treatment and that 20-40% of attendees don’t know the
existence of services such as NHS Direct, walk in centres or urgent care facilities.
Few of those that do, know where they are, what they’re for or their opening hours1
The aim of the project was therefore to contribute to an understanding of the number
and nature of presenting individuals using the ED as a primary care service, with a
view to reducing overall attendance.
Trust and Hospital Profile
City Hospital is one of three Hospitals within Sandwell and West Birmingham
Hospitals NHS Trust which is one of the largest acute hospital trusts in England. It
was first built in 1889 and originally comprised a single corridor stretching for a
quarter of a mile with nine Nightingale Ward blocks radiating from it along its length.
Significant and ongoing developments now find the Hospital with state of the art
facilities in the form of The Birmingham Treatment Centre which opened in
November 2005. This provides one-stop diagnosis and treatment services. It includes
an Ambulatory Surgical Unit with six theatres, extensive imaging facilities, an
integrated breast care centre and teaching accommodation. The site also includes
the Birmingham and Midland Eye Hospital, the West Midlands Poisons Unit and is a
major centre for sickle cell treatment in the region.
The Trust treats over 100,000 patients a year, has a turnover of £320m and employs
approximately 6,000 staff. Located at the centre of the West Midlands conurbation,
the Trust serves some of the most diverse and the most economically deprived
communities in the country. Many of the wards in western Birmingham are home to
large minority ethnic communities with people from Black and Minority Ethnic
groups comprising over 70% of the population in some areas and including large
African Caribbean communities as well as communities originating in India, Pakistan
and Bangladesh. Providing a wide range of acute healthcare services to the population
of western Birmingham, City Hospital, Birmingham has around 700 beds. In 2007/8
the Trust as a whole treated 1.7% more patients that the previous year and the
majority of this rise was driven by an increase in emergencies2.
Background to the Study
At City Hospital, the number of users for ED and the Urgent Care Centre (UCC) in
2007/08 was over 100,000 with approximately 300 people attending each day. When
they arrive at ED, all patients are assessed and at this assessment the decision is
made whether to send patients through to the Emergency Department or to Urgent
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Care. UCC services operate between 10am and 11.30pm; 7 days a week. The purpose
of this survey was to establish the clients’ reason for presenting at the ED,
alternatives that they may have considered and the reasons for their selection of
their preferred option.
In the last decade attendance at EDs rose by 16% an increase of nearly 2 million
people3. Whilst Improvements in emergency care provision have to some extent
absorbed these additional pressures4 a question remains as to the suitability of the
department to deal with presenting conditions other than those that are patently
‘accidents’ or ‘emergencies’. Suitability of treatment in any setting is not an issue
that has or can be viewed in isolation and since the new millennium, health care
policy has evolved around the whole notion of isolating and designating appropriate
resources towards acute care. This has arisen from the increase in complex case
management and the concomitant expense in technological innovations emerging
from acute care to support it5, 6, 7. Clearly, the ED is the ‘front of house’ for acute
services and a realignment of activities towards the assessment and treatment of
those most in need of such care needs to be given priority.
It seems logical then that redesign of ‘non acute’ services (in addition to but as
distinct from chronic care - or more prosaically – care of those with long term
conditions) should take into consideration alternative access to immediate care.
Weight can be added to that proposition when parallel activity concerned with placing
responsibility and resources for the commissioning of care initially with Primary
Care Groups and currently with Primary Care Trusts was initiated8. Current ideology
views patient choice as focal to designing appropriate services and locality as vital
for available and accessible health care9. This has meant that treatment options have
been translated into a range of primary care services including those that were
intended to replace the need for traditional visits to ‘Accident and Emergency’.
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Study Aims and Objectives
The aim of this study was to contribute to reducing the number of individuals using
Emergency Department as a primary care service by establishing which individuals
use City Hospital Emergency Department and their reasons for selecting the
department as the appropriate service to meet their immediate health care
requirements.
The objectives were to establish:
• The patients’ reason for selecting City Hospital Emergency Department
• The service options that patients’ considered
• The role of any other individuals and/or service providers in the patients’ decision
making process
• The patients’ service expectation
• The patients’ knowledge of which health professional provided the service
• The patients’ experience of the service provided
• The likelihood of the patient returning to City Hospital Emergency Department and
for what purpose
• How the patient travelled to City Hospital Emergency Department
• Who accompanied the patient
• Whether the patient had previously seen any other service provider with the same
problem
• Whether the patient is confident about the service or likely to immediately visit
another provider with the same problem
• To search guidance and similar literature
• Provide examples of good practice
• Identify gaps in service
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Methodology
A cross sectional study was designed to employ a questionnaire that was suitable for
both self completion and completion by interview where necessary. The purpose of
the questionnaire was to establish how and why people came to present in the
department and to elicit their views on the care they received. Where possible all
clients who booked in at receptions for advice, care or treatment in the emergency
department or urgent care centre were invited to participate. Researchers did not
approach people whose behaviour appeared aggressive or erratic for reasons of
propriety and safety. The survey used existing assessment and referral systems to
exclude from the survey those people who were designated as priority for rapid
treatment and admission. Clients who were subsequently admitted to hospital were
also excluded. Appropriate approvals and permissions were gained and attendees at
the ED were verbally consented before completing the questionnaire.
The survey was undertaken over a fourteen day period and data collected on seven of
those days to cover for each day of the week, from 10am to 10pm. Data collectors
approached each attendee after they had booked in at reception and before they
were seen by the triage nurse where possible. Amongst the team, there were data
collectors who could speak Punjabi if required and each data collector explained the
nature of the study, assured anonymity of response and helped the participant,
where necessary, to complete the questionnaires.
Population and Sample
The population from which the sample was drawn was estimated to be around 2000.
The population comprised all those anticipated to attend the Emergency Department
in a given week. To optimize the sample, all attendees who appeared eligible and
willing were approached and it was expected that this would provide a minimum of
300 participants.
Data Collection
A questionnaire was considered more appropriate than an open interview so that as
little burden as possible was placed on the participant. The content of the
questionnaire was constructed around current themes from the literature about the
nature of attendance at the ED 9, 10, 11 and was revised in consultation with the Clinical
Director of the Department. A third and final draft was devised with the advice of the
members of the Urgent Care Project Team.
The final questionnaire comprised two parts (See appendix A which includes the raw
data responses) the first part was completed whilst waiting to be seen for treatment
and the second completed after treatment. It was originally proposed that the
questionnaire would be translated into three or four prevalent languages used by the
local population, but following the pilot study it was clear that those willing to
complete the questionnaire had sufficient command of English or someone who was
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with them could assist in the completion. In general the participant was invited to
complete the questionnaire themselves or with the assistance of friends or relatives.
Some participants preferred to be asked the questions by the data collectors who
effectively conducted a structured interview, using the questionnaire.
Pilot Study
The pilot study was conducted on one day between 10am and 10pm and during this
time 80 questionnaires were completed. No changes were made to the questionnaire
or the procedures for data collection as a result of the pilot phase.
Analysis
Data was coded and analysed using the Statistical Package for the Social Sciences
(SPSS). Descriptive Statistics were used to analyse demographic data and
frequencies were used to describe the views and actions of the participants. Cross
tabulation was undertaken to identify any association between specific variables of
interest.
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Results
Part A – Before Treatment
A total of 485 people completed part A of the questionnaire in the main data
collection period, 110 people declined to participate and 6 questionnaires were
unusable. It is not possible to make particular judgments about the people who
refused but often it seemed they were people from a variety of backgrounds, most
seemed unwilling or unable to speak English and refused interpretation services.
It is a reflection of this that the data collectors who were employed to do so
were only required to use Punjabi on two occasions, all other introductions or
interviews were conducted in English. Also among those who refused was a small
proportion of people who said they were too ill, or in too much pain to participate.
All of those who declined were assured that their refusal would not affect their
treatment. The specific number of questionnaires completed each day is identified in
Table 1 below.
Table 1. Number of Questionnaires completed by day
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
n
88
63
57
65
58
78
75
%
18
13
12
13
12
16
16
Attendance seems to assume a pattern familiar to ED staff, namely that Monday will
always see an up surge in numbers as people decide to seek relief from problems
arising over the weekend. A major football fixture occurred on the Wednesday of the
Pilot data collection and the data collectors reported that there were very few
attendees in the evening during the match. This it seems is not unusual.
“You can tell when there’s football
on or something good on the TV,
like a film premiere, it’s dead in
here. Then when it’s finished they
all come streaming in”
Emergency Nurse Practitioner
The sample comprised 244 males and 241 females, their age ranged from Infancy to
95 years (mean 32, median 28, SD 18.25). Attendance at the Emergency Department
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classified by ethnic origin is shown in figure 1. The ethnic category codes used in the
illustration are defined by NHS conventions.
Figure 1. Attendees by Ethnic Origin
162 (29%)
Not Stated
8 (1.4%)
Other Ethnic Group
2 (0.3%)
Chinese
20 (3.5%)
African
66 (11.7%)
Caribbean
3 (0.5%)
Other Asian
9 (1.6%)
Bangladeshi
52 (9.2%)
Pakistani
53 (9.4%)
Indian
3 (0.5%)
White and Asian
1 (0.2%)
Mixed White and Black African
Mixed White and Caribbean
14 (2.5%)
Other White
15 (2.7%)
9 (1.6%)
White Irish
146 (25.8%)
White British
0
20
40
60
80
100
120
140
160
180
Number of People and (%)
The majority of people (n = 337, 70%) made their way to hospital by private transport,
whilst public transport conveyed 93 (19%) and17 individuals (4%) travelled by
ambulance, the remainder made their way to ED on foot (n = 35, 7%). Similar results
are reported in a study of ED attendance in rural Wales12. A qualitative study,
exploring the reasons people called an ambulance13, found that some patients
presumed it legitimised their need for care or that arriving by ambulance was a way
of becoming a priority for treatment. Whilst this study did not set out to capture the
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particular views of those arriving by ambulance there is no evidence from the data of
those who arrive by Ambulance did so for that reason and neither as Palmer et al12
reported (whereby an ambulance was called for a relatively minor injury and the
relatives followed in the family car to keep the patient company on arrival) did there
appear to be a particular abuse of ambulance services. This may be because the
location of the hospital is situated in the middle of a large conurbation with well
established transport. It would seem more likely that private transport is more
convenient, particularly when considering the journey home.
Distance travelled to reach the ED was not unduly excessive and the attendees
travelled a mean distance of 3.6 miles (Range 0 – 50 miles SD 3.95). There is no
particular ethnic group that appear to have travelled the least or most distance to
the hospital but a distinct proportion seemed to come from neighbouring Winson
Green and Handsworth. There were a notable number who travelled from
Birmingham City Centre because they work there and saw the Hospital as the most
local and convenient to reach. Many who acknowledged the existence of a Walk in
Centre in the City Centre did not consider using it as an alternative.
The reasons declared for seeking help at the ED were many and varied and are
presented in Figure 2. They have been classified according to the major themes that
emerged from the respondents views themselves and no judgment has been made
as to the accuracy of their descriptions. The first category ‘pain’ contains all those
cases where the respondent has described pain as their primary symptom, whether
that is headache, chest or abdominal pain and includes ailments such as ‘ear
infection’ where the pain is the predominant factor. Upper and lower limb injuries
refer to ‘sprains and fractures’, whilst cuts and wounds include upper and lower limb
trauma where the cut or wound was the predominant presenting factor. Head Injury
includes any reference to a presenting problem where trauma to the head has been
declared and does not necessarily indicate severity.
Gynaecological, respiratory, cardiac and urinary system problems are themes that
also arose from attendee’s personal perception of their condition and again reflect a
range of problems with differing levels of severity. The mix of complaints and
ailments that people attended with are similar to those Identified in other
studies10, 11, 12 but it is impossible to make any value judgments how appropriate their
attendance is apart from those who appear to border on the absurd.
“I cut my finger 5 months ago”
17 year old female who was told to
come by her mother and who
answered yes to the question
‘I consider my condition an emergency’
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It is also difficult to make objective comments about those who did or did not appear
to be ‘deserving’ or not deserving priority treatment. From observations of the triage
system by the data collectors it seemed to work well, although people who attended
following an appointment with their GP and who wanted a second opinion appeared
to wait longer as did those who had been to the department before with the same
problem. A reason for this might be that if the attendee admitted they had been given
a clinical assessment before, then the triage nurse would probably weigh in the fact
that the GP or ED staff didn’t consider the problem an emergency and could probably
be safely managed further down the waiting list.
Figure 2. Presenting Problem
3.5%
No Answer
21%
Other
1%
Urinary Tract
1%
Cardiac
4%
Respiratory
3%
Head Injury
Problem
Category
2%
Gynaecological
1%
Work related accident
3%
Car Accident
12.5%
Lower Limb Trauma
11.5%
Upper Limb Trauma
9%
Unwell
7.5%
Cuts or wounds
20%
Pain
0
20
40
60
80
100
120
Number of People
When asked whether they had experienced their presenting problem before 150
(31%) said they had and all of these claimed they had visited their GP with it.
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Questions surrounding the decision to attend the ED rather than an alternative
service were designed to tease out what advice they sought from friends or relatives,
whether they had considered or attempted to go to their GP (if they had one) and
whether they had heard of or considered going to walk in centres or urgent care
centres instead.
The justification for seeking help at the ED rather than going to their GP is
highlighted in Table 2. Although few said they were not registered with a GP, most
claimed that their GP was not available, with the same number appearing to justify
that response by saying that their GP would only have sent them to the ED anyway.
A quarter of respondents thought that they would have to wait for an appointment
but presumably were prepared to wait hours in the ED. This might meant that people
wanted to be assessed the same day but could not be offered a GP appointment
within that time. Moll Van Charante et al11 found that people who self refer expect to
wait to be seen in order to get the treatment they believe they need. Those that came
because they wanted a second opinion were sometimes people whose symptoms had
not dissipated despite reassurance from their GP but more often those who had been
referred by their GP for further investigation but whose appointment was an
unacceptable length of time away.
Table 2. Reasons for attending the Emergency Department rather than their GP
I don’t have
a GP
My GP
was not
available
I don’t
know if my
GP was
available
I didn’t
want to
bother my
GP
My GP
would have
sent me
here
anyway
I did see
my GP but
wanted a
second
opinion
n
31
98
27
25
98
47
%
6
21
6
5
21
10
Anecdotally the locality and the reputation of the Hospital were deciding factors in
their attendance, people who had been in patients for a whole variety of reasons,
placed trust in Hospital, as did those who grew up and lived locally. The reason for
attendance at one Hospital or Centre doesn’t always rely on proximity to the service;
loyalty and trust appear to play a significant role in the choice of service10.
“I had my children here, my
husband had his cancer op here,
I wouldn’t go anywhere else”
Wife of a man waiting to be seen.
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Neither does it seem to rely on age, although it was generally the older population
who seemed to make the most comments about their preference. Generally the
hospital was held in high esteem and it was also interesting to note that comments
made about poor experiences at other hospitals also made a significant impact on
attendees’ choice. Whether this would be a factor in more rural locations where the
community would not have such a choice would be something to note.
Table 3 highlights some of the choices people made about their attendance at ED.
Table 3. Factors influencing attendance at City Hospital
I thought I would
be seen more
quickly here
This Hospital is
nearer than any
other service
This Hospital is
easier to get to
than any other
service
I wanted to see a
Doctor as soon
as possible
n
112
151
104
234
%
23
31
21
48
Participants were asked if they had heard of, considered using or had been directed
by NHS Direct to attend. They were asked about their knowledge of walk in centres,
urgent care centres and polyclinics. The reason for including the latter was that
polyclinics had been the subject of media attention in the weeks preceding the
survey. Despite this very few had heard of them, one being a pharmacist who was
informed because of her professional involvement in their development. Knowledge
of the local walk in centre located in a chemist in the city centre was reasonably
widespread and some had been referred directly from that service. Even though they
had heard of them most people did not consider using the walk in centre despite
having travelled from the city centre to attend the ED. Knowledge of Urgent Care
Centres was on the whole poor and people had therefore not considered them.
Anecdotally even fewer realised that there was a UCC located in the hospital itself
and this included several staff who reported to ED for treatment. The responses from
this set of questions are illustrated in Table 4.
Table 4. Knowledge of other services available
Heard of other
Services
NHS Direct
n
263
%
53
Walk in Centres
Urgent Care
Centres
PolyClinics
194
34
2
39
7
<1%
The majority of people (n = 272, 56%) stated that family and/or friends advised them
to come to hospital, this figure also includes advice given by pharmacists or walk in
19
centre staff. 234 (48%) people had made their own decision to attend hospital and
there was an equal split between men and women who had made this decision, this
is in contrast to an Israeli study which found that there were a clear majority of men
who self referred10. 60 people (12%) said they were advised to attend by their GP but
from the symptoms they reported the veracity of this data is questionable.
“….Why do you think I’m here?
….my GP sent me ‘cos I’ve broken
my leg.”
Male 28 years. Stood for over an hour
waiting to be seen. Subsequently
refused to answer post treatment
questions. Appeared angry and
refused to believe that he had not
broken any bones, he resolved to seek
another opinion.
People principally attended the ED for three reasons, either under the assumption
that it was a condition that required emergency treatment, that it was serious, or
that if not an emergency, then something that required immediate attention.
“I work during the day and there is
no evening surgery, it is the only
way I can get to see a doctor”
Female, admitted she had a ‘minor
ailment’. Agreed with the question
‘I don’t consider my problem an
Emergency’
213 (44%) considered their problem an emergency and 209 (43%) when questioned
thought their condition was serious. Comparing the results from a previous question
regarding a second opinion from their GP it appears that 2% of those seeking a
second opinion did so because they had been to another hospital with the same
problem. The need for reassurance that their problem wasn’t serious was a factor
20
for 132 people (27%), only 26 (5%) people thought they might be admitted as a result
of their problem.
“There was a lot coming through
the back so I went out to tell the
people in the waiting room that
their wait would be really long and
if they felt they could, they should
go and see their GP tomorrow
morning. When I came back 2 hours
later all the people with real
problems like the old ladies (made
a gesture with wrist suggesting a
fracture) had gone and all those
with cut fingers were still there.”
Emergency Nurse Practitioner
A significant proportion of people (n = 141, 30%) didn’t regard their condition as
serious but thought it needed attention, whilst 15 (3%) didn’t consider their condition
serious but didn’t know where else to go. In making their decision people came to
the ED because they needed specific tests or treatments, Table 5 illustrates these
results. The perceived need for a test, such as an X-ray or stitches, for example,
supports the belief that the best place to seek help from is the place that has the
facilities they feel they need11.
Table 5. Perceived need for tests or treatment
I thought I
needed
An X-ray
Stitches
A tetanus
injection
A blood test
A test of
some sort
n
133
29
17
22
93
%
27
6
3
5
19
It appears that 146 (30%) thought they were treated in the Emergency department
whilst 339 (70%) were treated in the Urgent Care Centre.
21
Part B – After Assessment and Treatment
Of the 485 original responses a total of 163 people completed the questionnaires
following their treatment. The responses are therefore proportional and based on the
163 respondents. Of these, 84 (52%) didn’t feel they had to wait too long to be seen.
Only 19 (4%) people who responded to part B thought they had waited longer than
they should and only 8 (<1%) thought they should have been seen before other
people. The reason for this wouldn’t have been immediately obvious, however from
observations by the data collectors those triaged to the minor injuries section of the
ED often waited much longer to be seen than those triaged to the UCC and were
seen relatively quickly by an Emergency Nurse Practitioner. Also not clear to some of
those waiting was the fact that a specialist (such as an obstetrician) from another
part of the hospital had been paged and ED staff were waiting for them to arrive. 23
(5%) respondents felt they waited longer than they should but appreciated that there
were other people worse off than themselves. In terms of diagnosis and treatment,
Table 6 illustrates respondents’ satisfaction with their care.
Table 6. Satisfaction with Diagnosis and Treatment
My
condition
was
Diagnosed
properly
Not
Diagnosed
properly
Treated
Properly
Not treated
properly
I am still
not happy
about my
condition
I intend
to go
elsewhere
for a second
opinion
n
70
29
23
26
9
4
%
14
6
5
5.5
2
1
61/161 people (38%) thought they had been given all the information they needed
about their condition, although 10 (6%) did not. 3 people (2%) said they were not
happy with the way they were treated, but further analysis reveals that they were
expressing dissatisfaction with previous treatment, not the treatment they received
at City Hospital.
Whilst 32 ( 20%) of the attendees didn’t feel they would need to come back, 87 (55%)
said they would come back if they didn’t improve and 77 (49%) would return to this
department if they had another problem. 4 people expressed the view that they
would go elsewhere if they had a different problem.
22
Discussion
Urgent Care Centres
There have been substantial developments in the array of initiatives and innovations
to support the assessment and treatment of relatively minor but none the less
urgent cases. People have been able to choose between accessing their GP if they
have one; Primary Care Surgeries, minor injury units and walk in centres and latterly
Urgent Care Centres. These, as iterated, might be led by General Practitioners or
Nurses and provide differing levels of treatment options. Add to this recommendations
to the public that they could self refer to pharmacies or receive telephone advice
from NHS Direct and it is not surprising that service users are bewildered by the
choice. Despite a proliferation of such apparently varied services, the current
position and value of Urgent Care Centres in primary and out of hours provision is
sparsely evaluated in the literature and there has been no direct comparison with
Emergency Departments as to cost and efficiency8.
Urgent care is defined as14
‘The range of responses that health and care services provide to people who require
– or who perceive the need for – urgent advice, care, treatment or diagnosis. People
using services and carers should expect 24/7 consistent and rigorous assessment of
the urgency of their care needs and appropriate prompt response to that need’
Urgent Care Centres have been located into several urban hospital Emergency
Departments and several reports suggest that there are very good, historic reasons
for doing so15-20. UCCs co-located in EDs have been advocated on the basis that,
rather than dissuading people from going to hospital, they reflect an acknowledgement
that people need to be treated where they choose to be treated. Alternatively those
UCCs that are dedicated centres, away from hospitals, represent the view that this
service is designed to relieve pressure on EDs. A final justification for the provision is
that UCCs are a more appropriate environment than EDs, where people might feel
more comfortable in being treated. What isn’t clear in the current literature are the
specific benefits and costs are associated with the choice of location, neither is there
any indication of reduced demand of associated services.
Access and speed of treatment
There is also little evidence to support the notion that improved access to primary
care somehow affects the type of patient that will attend the ED or the speed of
treatment they receive in these settings. The Department of Health reported that
although primary care gatekeeping can reduce ED attendance, its safety is
uncertain16. Neither is there evidence that the placement of GP’s in EDs reduces
waiting times. The report also cites that there are incidences where triage can
actually cause delays in treatment, but accepts that it is a valid risk management
tool for busy periods. Triaging out of the ED was another option considered in the
23
report, but again the potential risks of this strategy are, as yet, unknown.
Despite the lack of evidence about objective measures to reduce ED waits and the
most effective use of skilled professional resources, there is a persistent concern
that people requiring urgent care direct themselves inappropriately at the
Emergency Department.
Inappropriate Attendance: Definitions
The failure to reduce attendance at EDs over the last decade has been attributed in
some measure to the belief that more people are attending with minor ailments as
opposed to true emergencies. However there is a particular difficulty in defining
inappropriate attendance as it is abundantly clear that people go to the ED because
they do think it is appropriate. Rassin et al10 use the term ‘justified visit’ as a
definition and classifies visits into four categories; life threatening, urgent,
non-urgent and trivial but admits there is a lack of definition and a certain ambiguity
regarding these terms. A definition provided by Bezzina et al21 views inappropriate
attendance as those who are not in need of resuscitation, urgent attention or rapid or
complex diagnosis work up. The study makes several observations about the
configuration of services and argues that the problem demonstrates a lack of clear
role boundaries due in part to similarities between the services. For instance, they
identify opposing attributes that could lead to confusion about the proper role of out
of hours care, these are:•
•
•
•
The patient-focused approach versus the service-focused approach
GP view versus ED clinician views
The ‘inappropriate’ patient versus the ‘primary care’ patient
Retrospective assessment versus prospective assessment
Ultimately the study defines inappropriate ED attendance as an indictment of the
failure to provide comprehensive and accessible GP Services. There is support for
the view that around half ED attendees could be managed by other services22 and
more specifically by General Practitioners (GP’s). Minor illnesses and injuries have
constituted part of the primary GP role for many years and as such have become
deemed ‘inappropriate’ for treatment by ED staff23.
Ainsworth24 believes that there is a myth of unreasonable attendance to ED and this
is elevated by harassed staff to the status of urban legend. In a literature review of
emergency professional’s attitudes23 fifty two studies are cited that researched or
made reference to inappropriate attendance. The review concludes that the label
stems from the health professions perceptions of what constitutes a valid
attendance. Only conditions that increase knowledge, improve skills and competence
and improve prospects for professional progression are considered appropriate.
It appears that ED staff have a set of unwritten rules about what constitutes
appropriate attendance, this is despite several studies showing that if asked
retrospectively, health professionals and in particular nurses, consider very few of
the people they treat as having attended inappropriately10, 25 ,26.
24
The debates in the health care literature surrounding the propriety and need for
urgent care facilities have, in part, been based upon surveys of the characteristics of
Emergency Department attendees; qualitative exploration of the choices made by
service users and both rhetoric and espoused policy from Government departments.
The different array of service models proposed by Primary Care Trusts around the
Country appears to justify the demand for an investigation into the local issues of
providing appropriate access and treatment for people with urgent care needs.
In a recent urgent care population survey27 it was reported that people seeking care
may not attend or consult a single service but will try a number of different options
in order to resolve their problems, yet this view does not seem consistent with the
findings of this study. An overall view emerged that people did not really consider any
alternatives but turned up to the Emergency Department because it is a well
established local landmark. They are certain in the knowledge of what the ED is
there for and that they should be there, they also know they will not be turned away
without some advice or treatment. The idea of the hospital as a landmark is not
something that has emerged from other studies, although many of the responses
that reflect a person’s specific decision to attend hospital rather than anywhere else
appears to be consistent with similar surveys conducted both nationally and
internationally10, 11 ,25 ,28.
The label ‘emergency’ or ‘Urgent Care’ reflects Policy maker’s distinctions28 and it
seems that service users have great difficulty in distinguishing between the two. To
the lay person, an ‘emergency’ means blue flashing lights, but urgent could also
mean an emergency as well as the need to be seen quickly by non urgent services.
The problem seems to lie in the lack of consistency about terminology and there
needs to be some mechanism to ensure that all communications, between
managers, administrators, health professionals and patients, contain the same set
of definitions and explanations and that these are phrased in lay terms.
The Patient Journey
Using the idea of the ‘patient journey’ a view can be gained of how people enter the
system, how they are ‘processed’ and how their experiences shape their future
decisions. Subsequently it can be used to identify how well a system works. The
system is an important concept here29, 30 and in order to evaluate its effectiveness, the
performance of the whole system needs to be measured as well as the services
within it. The first part of the journey could be identified as how someone enters into
the system in the first place and raises issues about access to care.
Ease of Access to Services
The distinction between primary care and urgent care becomes blurred when access
to the system is difficult or denied. Deprived of their first choice of access to GP’s or
NHS Dentists because of appointment times or waits is certainly an issue reflected
in the data, but another is whether at this point of access, those gatekeeping primary
25
care services feel the patient has a deserving case and indeed whether the patient
sees themselves as deserving27. Although it’s safety is uncertain, it is argued that
gatekeeping that directs the patients towards rather than away from primary care
has shown to be effective in reducing ED attendance7.
From the responses in this study relating to GP access it seems that rather than try
and justify an urgent GP appointment, people would rather attend ED to be seen
more quickly and thus make an attempt to justify their attendance by quoting a
problem with access to primary care services27, 28. Following the initial idea that
emergency and urgent care terminology needs to be consistent it is evident that role
boundaries between primary and urgent care should also be defined and serious
attempts should be made towards maintaining that boundary so that patients don’t
need to resort to justifying their need for care21.
Self Referral
Moll Van Charante et al28 suggests that in fact, patients make reasonable choices
about whether to attend the Emergency Department and that only 1.3% of cases can
be viewed retrospectively as inappropriate25. To those attending, their declared
ailments were legitimate and warranted the type of diagnostic and treatment
services available at the ED. The perceived need to access the necessary facilities
such as radiography, specific laboratory tests and simple treatments such as
sutures are themes identified amongst the responses and such, this self diagnosis is
a means by which they can receive treatment more efficiently.
“…. In part, patients’ perceptions and circumstances will always determine whether
or not they use (emergency) departments. Short of attempting to change public
perceptions there is little to be done other than to arrange to cater for such
patients.” Lowy et al30
Education has little effect of patient behaviour and it seems that it is better to
capitalize on the fact that people prefer to go to an Emergency Department within a
hospital and design services appropriately. There are a few strategies which may
have some effect in simplifying decision making, such as using one telephone
number as a means to accessing a range of health care services.
To make an impact on patient choice one PCT designed a logo using a thermometer
with a range of service options, blue at the bottom of the thermometer for self care
through to red for ‘A & E’ and ‘999’ to illustrate which level of service could help with
a variety of conditions. The thermometer was used on leaflets and videos and
demonstrated some success in directing people towards appropriate services.
Streaming
People attending the Emergency Department had little idea that they had the
opportunity to access two different types of service; this is similar to the findings of
another study into the co-location of walk in centres in ED’s9 where few had a
26
distinct visible identity. This highlights several issues in the data about waiting times
and who should have priority care. Not knowing that there were two streams and
that one would move faster because the relatively minor nature of the problems in
the UCC stream could be dealt with more quickly was a source of frustration for
those waiting, because they had no idea why it was happening. If it was made clear
that there were, in effect two queues with different waiting areas, then staff within
the department would probably not have to spend time fielding complaints.
There were all sorts of worries that people waiting to be seen experienced, they
didn’t know for example whether they had time to get a drink or use the toilet in case
they missed their place in the queue. This could be avoided with a ‘live’ display of
waiting times for both the ED and UCC. Although there is a VDU displaying
anticipated waiting times and a ‘loop’ of health information it didn’t take long for
people to work out that this was static and usually set at just under the four hour
wait target. Throughout the fourteen day study period this display was often not
working. There were also several stands that were supposed to contain information
leaflets and one in particular about UCC’s was empty for the whole of the study
period.
Interactive screens may be a solution to that type of problem but it may be worth
considering a ‘meet and greet’ individual (in a neighbouring hospital volunteers fulfil
this function) who could troubleshoot basic enquiries, direct people towards facilities
such as the pharmacy and radiography. They could also make simple explanations
about the nature of the wait, who the patient was waiting to see and why they were in
a particular place in the queue. There were also issues such as people needing
tissues or vomit bowls or someone to notify that they were going to the toilet should
their name be called.
A person stationed in the waiting room could also help with incidents that were
witnessed during the study such as a man who urinated on the floor. Health
professionals were not there to witness it, and reception staff could not see what was
happening from their position. It took over an hour for someone to be called to clean
it up and could have been the cause of someone slipping and further injuring
themselves. There were also incidents of aggressive begging and groups of individuals
who seemed to meet for a social gathering, but were clearly avoiding security
personnel. All these incidents have some effect on the healthcare personnel and
diverted them from their primary role.
Triage
The first point of access for patients is to be ‘clerked’ by a receptionist followed by a
wait to see the triage nurse and then a further variable wait to be allocated to the ED
or UCC. This model is under question by a number of reports that suggest that triage
by a single nurse may not be the best method of streaming the patients and that in
fact it may cause delays in care31, 32.
27
Figure 3. Example from Poole Hospital See and Treat Pathway
Patient arrives at front desk
Patient booked in by reception staff and presenting complaint identified
Reception staff use the ‘sieve questions’ to decide if patient needs further assessment
No
Yes
Cas-card placed in ‘waiting’ box in see and
treat area in chronological order.
Patient waits in waiting room
Reception staff accompany patient to triage room and call see and treat nurse
to assess patient quickly. If there is no treatment nurse, calls any member of
clinical staff
Suitable for see and treat
Patient very quickly assessed and a set of observations performed
Patient can be seen in see and treat
area but needs more urgent attention
Patient is really a majors case
Cas-card placed in waiting box to see
and treat area as ‘need to be seen’
Patient is accompanied to majors
area and handed over to
appropriate staff
Alternatives appear in the literature and the first suggests that initial streaming to
ED or UCC is undertaken by a receptionist using ‘sieve’ questions and that minor
problems can then be addressed using a see and treat principle32 (see Figure 3)
There is good evidence to suggest that fast track systems work for minor injury
patients6. A simpler alternative is to dispense with triage altogether and see patients
on a first come first serve basis. Numbered tickets could be given to patients as in
the phlebotomy department and the next available slot easily identified. Patients
would know where they were in the queue and identify roughly how long that would
mean they had to wait. A third alternative is to make the triage process much more
evidence based and systematic using a set of established criteria which can be used
across settings such as GP practices, ambulance services and of course the ED
department33, 34. The effect of a more structured approach to triage could also have an
positive effect on interprofessional communication and co-ordination of care.
Communication and Co-ordination
The questionnaire was not specifically aimed at those people who attended regularly
28
or who probably required more complex care needs, but it was evident that the
involvement of Police, voluntary and social services were an everyday part of the
department’s life. The frustration of those who were in the system who could not get
relatively simple resolution to their problem was also evident, largely due to the lack
of systematic communication. Without a time and motion study into the efficiency of
verbal or written transfer of assessments, diagnosis and treatments it is impossible
to quantify the resources dedicated to essential communication. If the triage system
does cause delays in care because histories have to be recounted there needs to be a
more efficient way of managing essential information.
There are software solutions to this problem which have achieved great success
elsewhere in the country34. The Adastra application which is described as a case
management and data distribution engine with advanced clinical functions. It can
provide a database for case entry; prioritization and streaming of cases; tracking and
distribution of information as well as a database for prescribing and stock
management; staff rostering and even vehicle movement. This software also has the
capacity for identifying and coordinating the management of longer term conditions.
Ubiquitous software such as this should be seen as essential to the need for services
to ‘talk’ to each other flagged up (if rather emotively) by the ‘Baby P’ case.
Treatment and Follow up care
It is evident from the survey that, on the whole, those people who answered part B
of the questionnaire that they were happy with their treatment. Although the
ineffectiveness of education is highlighted in reports, there may be an opportunity
here to provide the patient with information leaflets regarding future episodes and
alternative means of accessing appropriate services.
29
Strengths and Weaknesses of the Study
The study provided a good opportunity to examine a ‘slice of life’ in the Emergency
Department. The questionnaire addressed the issues identified in the brief and the
response rates were above expectations. In addition both staff and patients were
willing to add their personal experiences so that some of the stories behind ED
attendance could unfold. There were a cross section of people, who for one reason or
another declined to participate, but the sample appears to remain representative of
the population studied.
The difficulty in tracing people through the department hindered completion of the
second part of the questionnaire and in hindsight it seemed that some questions
were not valid indicators of appropriate or inappropriate attendance. Self completion
of the questionnaires turned out to be a more useful method of capturing accurate
data and more could have been made of observation techniques to support the self
report findings.
30
Conclusions and Recommendations
There are several studies that have addressed various aspects of patterns of
attendance in the Emergency department. Comparison with these studies has
revealed commonalities in the results both nationally and internationally. The
overarching theme seems to be that given the history of ‘Accident and Emergency’
Departments and perhaps the light entertainment reinforcement that it is the right
place to go (it is difficult to see ‘Urgent Care Centre’ replacing ‘Casualty’ at the top of
the weekend TV ratings) that accommodating everyone who perceives a need to
attend hospital because of an unexpected health event should be capitalized upon.
Making the distinction between ED and the place of the UCC within it seems useful
so that people get used to an idea that they have visited a specific service and if that
experience was satisfactory they can take away and remember that experience in the
future. To that end it would seem appropriate to brand and market the UCC as a
distinct entity within the ED. It may be possible to persuade people that by identifying
their need as urgent rather than an emergency they are likely to be dealt with more
quickly.
Using a systems approach it seems that branding and marketing starts with a view
to explaining as clearly as possible what people can expect from various primary
care services. Demarcation of primary care and urgent care services should mark
the departure point for objective measurement of the whole system.
It follows that services dedicated within this system should then be identified and
role boundaries set. That is not to imply that people won’t still try and access
‘inappropriate’ services but it improves the opportunity to measure activity and
identify strategies to achieve stated role objectives.
Trawling some Primary Care Trust websites it was difficult to find information on
urgent care services. There seems to be no option between dialing ‘999’, attending
ED or taking the time to register with a GP and the wait that would entail. There will
always be those who will fail to register with a GP so rather than hide it would seem
more useful to allow people easier access to information about alternative out of
hours care and then perhaps to use telephone or internet based triage to direct
people to the most appropriate services. Using a single telephone number would
help in this respect.
Communication across all role boundaries is essential and it seems counter
productive not to harness technology that reduces repetitive tasks and procedures
and one that would allow more freedom for health professionals to undertake their
primary function. The development of software applications to support a wide range
of clinical and administrative functions is now well established and has also great
potential for instant audit of activities across the primary/urgent care divide.
Support for people whilst waiting for treatment needs evaluating. Again this may be
a realignment of values between making the waiting room environment barely
31
adequate for people so they don’t overuse the service, or an admission that those
who consider they have a need will visit anyway and the service should do its best to
make the visit a satisfactory experience. Using interactive technology is one option
and using personnel to meet, greet and troubleshoot would seem a valuable asset
and one which might even come from the voluntary sector.
Dealing with people within this particular service is something that needs reassessing
now, that Urgent Care as an entity has been established within the emergency
department. Whether it is establishing that the current system of single nurse triage
is more than adequate to support the best throughput and treatment of individuals or
whether other options should be considered. In addition, different assessment
options might be considered for ED and UCC.
Finally, there could be targeted information in the form of leaflets aimed at directing
people towards urgent care options in the future.
People in the locality held the hospital and its services in high esteem and it
shouldn’t be too difficult to realize improvements to ED and Urgent Care Services to
maintain that view.
32
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2. Sandwell and West Birmingham Hospital Trust: Trust Review 2008
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ER for non-urgent conditions and comparison of urgency evaluation between
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35
Appendices
Appendix A: Questionnaire Part A - Based on 485 Responses
Accident and Emergency Attendance Questionnaire
I travelled to Hospital:
By Motor Vehicle
337
By Public Transport
93
By Ambulance ‘999’
17
On Foot/Other
35
39
I came to Hospital today because: See Appendix B
Please tick all those that apply:
I have had this problem before
150
I contacted NHS Direct about this problem
I have been to my GP with this problem
153
I have not had this problem before
I have been to this Hospital with this
problem before
89
I have been to another Hospital with
this problem before
39
I have access to a telephone
470
I cannot use a telephone
5
Someone will telephone for me if
I need them to
79
I don’t like using the telephone
8
I don’t have a GP
31
I thought I would be seen more quickly
here
112
My GP was not available
98
I consider my condition an emergency
213
I don’t know if my GP is available
27
I didn’t want to bother my GP
25
N/A
I would have to wait for a GP
Appointment
My GP would only have sent me here
anyway
I did see my GP but wanted a second
opinion
121
98
47
This Hospital is nearer to me than any
other service
This Hospital is easier to get to than
any other service
I wanted to see a Doctor as soon as
possible
I wanted to see a Nurse as soon as
possible
Other Reason please specify:
151
104
234
101
N/A
What other Services have you heard of that you might have used? %
36
NHS Direct
99
Walk in Centres
56
Urgent Care Centres
10
Poly Clinics
2
Questionnaire continued
Please tick all that apply:
My family said I should come to hospital
182
I thought I needed an X-ray today
133
A friend said I should come to hospital
90
I thought I needed stitches
29
It was my decision to come to Hospital
234
I thought I needed a tetanus Injection
17
My GP said I should come to Hospital
60
I thought I needed a blood test
22
I was told to come here by a Nurse
0
I thought I needed some tests
93
Please tick all that apply:
I thought my condition was serious
209
I knew my condition wasn’t serious but
thought it needed attention
141
I wanted a second opinion
61
I knew my condition wasn’t serious but
didn’t know where else to go
15
I needed reassuring my condition
wasn’t serious
132
I didn’t think my condition was serious
but friend/family told me to come
33
I thought I would be admitted to Hospital
26
I thought It was an emergency
107
I expect to be treated by a Doctor
245
I expect to be treated by a Nurse
110
I don’t know who will treat me
135
Treated in Emergency Dept
146
Treated in UCC
339
37
Appendix A: Questionnaire Part B - Based on 165 Responses
Accident and Emergency Attendance Questionnaire
I expected to be treated by a Doctor
N/A
I was treated by a Doctor
79
I expected to be treated by a Nurse
N/A
I was treated by a Nurse
43
9
It didn’t matter who treated me
24
I didn’t have to wait too long to be seen
84
I was happy with the way I was treated
83
I waited longer to be seen than I should
19
I wasn’t happy with the way I was treated
3
I waited a long time but I realise that there
were others who were worse off than me
23
I thought I should have been seen before
some of people I was waiting with
8
I felt my condition was diagnosed properly
70
I didn’t think my condition was
diagnosed properly
29
I don’t think my condition was treated
properly
10
I felt my condition was treated properly
23
I was given all the information I needed
about my condition
61
I wasn’t given all the information
I needed about my condition
10
I was given all the treatment I needed for
my condition
63
I am still not happy about my condition
8
I don’t know who treated me
I wasn’t given all the treatment I needed
about my condition
I intend to go somewhere else to get
another opinion
26
4
38
If my condition doesn’t improve I will
come back
87
I won’t need to come back about this
condition again
32
If I have something else wrong with me
I will come back to this hospital
77
If I have another problem I would rather
go to another Hospital
4
Appendix B: Presenting Problems
Transcribed exactly from Questionnaires
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Dr Advised coming straight to A and E
involved in car accident
injured wrist
redress finger injury
pain in right side
sprained neck
injured wrist
trapped hand
hurt knee last Wednesday
broken leg
arm painful
threatened miscarriage
head pain
fell and injured leg
hurt wrist
my son has passed out the last four months
at least
head injury
leg infection
cut hand at work
gp referral
injury to thumb
pregnant with pain
loss of feeling to fingers
breast abscess
dislocated shoulder
injury to both legs
suspected appendicitis
abdominal pain
knee injury
accident at work
stomach ache
asthma
chest/back pains
stomach pains
injured finger
shoulder pain
nose bleed
blurred vision motorcycle accident
feel sick urine infection
injured finger
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abscess
urine infection
passing blood
chest pain
problems with ear
pain on left hand side and down leg
dizzy, stomach pain
severe abdominal pain in my right side
I am ill
short of breath
motorcycle accident
fell on wrist
lump in stomach
my nose started bleeding suddenly
I have burnt my chest
back pain
needle injury
kidney pain
abscess
no answer
injured wrist
pins and needles down left side/chest pain
car accident/shoulder pain
refused emergency treatment yesterday
fall/chest pain
hurt foot
hit face falling over
bumped head
accident 3wks ago still in pain
sliced top off finger
injured wrist
injured foot
ongoing knee injury
sprained wrist
hurt ankle/fall
swelling in face referred by doctor
injured elbow
wheezing
being sick
something in foot
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dressing change
pains
suspected sprained wrist
hurt ribs in fall
foot jumped on
knee - osteoporosis
hand injury - during martial arts lesson
because I couldn't see my doctor
bumped head
no answer
pains in right side
heart pain
? Appendix
injured hand
asthma attack
stomach pains and spotting
pain in chest
I was beaten up yesterday and today
right foot swollen
nail in foot
my son's not well
I have a cut my wrist
I feel hurt for my kIdney - kidney stone
deep cut on hand
kidney stone
pain when pu
foot painful
lump!
hand swollen
abdominal pain
abdominal pain
accident
took ill in Jamaica doctor suggested I return
to England
hand injury
trapped hand in car door
no answer
bad ear infection
chest pain
a foot problem
I had accident on the bus
I think I have got an allergy
I have really bad back ache
I have done something to my hand
my arm is swelled up
• fell over and injured head and right side of
body
• cut eye
• ankle Injury
• I hurt my finger at work and it required an
x-ray
• my tonsils were bleeding
• son hit foot during PE lesson
• I have some problem with my ear
• ill following tonsillectomy
• wound on right leg
• knee injury
• I injured my finger at school playing netball
• I wanted to take out stitches in my daughter
• no ans
• puncture wound to hand with kitchen knife
(accident)
• broken toe for 3 weeks
• swollen ankle
• I have burnt myself with hot ol
• I have influenza and a high temperature and
a sore throat
• my doctor requested
• I have hurt my left knee and right index
finger
• appendicitis
• I have car crash
• hurt his eye
• chest pain
• I slipped of the curb and hurt my foot
• tetanus - bitten
• low sodium
• dislocated shoulder day before
• small accident at work bruise on thumb and
small cut
• I was knocked off my motorbike
• might have appendicitis
• chest pains - referral by GP
• I got hit by a car and hurt my leg
• my grandad has come for an x-ray check up
fractured right hand
• my son has been suffering with asthma
• he hurt is leg and is in some discomfort
• my leg is very bad
• chest pains
• a serious injury to my left arm
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stomach pain
kidney stone
arm is hurting
appendix ?
no answer
stomach cramps
I have a head ache and pain in my body
whitlow
lower abdominal pain
rash on feet
alcohol related
arm and leg pain
problem with ears
generally not well
banged finger - very painful
food stuck in throat
I have migraine problem
blood pressure problems
stomach pains
on going problems
I fell on my back fence and caught leg on a
spike
I feel unwell
foot injury
tonsillitis
hurt/injured
I want to be seen by a gynaecologist
I slipped in kitchen and fell on my neck
I may have a cracked rib
Punched in face
I have hut my thumb
doctor sent my due to breathlessness
gp suggested visit due to lump in neck
pains in forearm
kidney problem?
referred by GP
son is sick
I may have broken my nose
no answer
I have bleeding
my little girl has diarrhoea and is vomiting
urinary problem
I have hurt my back and neck
serious earache
car accident
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cut thumb
pregnant - aches and pains
an injury to my ear that needs checking over
broken middle finger
cotton bud in ear canal
I had an operation last week and my stitches
hurt
earring stuck in ear
I have injured my left arm
my little brother was finding it difficult to
breathe
I was not feeling well
insects attacked my legs. They hurt and I
want the
of my son have pain
pain in abdomen
no answer
my eye is hurting and is very sore and reddish
involved in road accident - hurt back and
neck
I cannot get my doctor and I have pain in my
ovary
back and hip pain
numbness left arm
injured wrist
my daughter hurt her eye at school
chest pains
bleeding while passing urine
my leg hurts
my grandfather was feeling ill, fever
symptoms
lower back pain affecting my walking
I can't breathe properly and abdominal pain
one of my friends is sick
no answer
fell on right hand
twisted ankle
I have been punched during a robbery
no answer
experience chest pain
my daughter cut her leg - won't stop
bleeding
head injury
my son has had a head injury
heavy bleeding severe tummy ache and
vomiting
41
• I was attacked and punched in the face and
my upper body
• had amputation last week and wound has
opened
• accident to limbs 3 weeks ago
• swallowed a hair grip
• hurt my heel
• knee injury
• I've got leg pain
• I had a fit
• hurt my knee roller skating
• head injury
• I have bleeding because of piles
• I need to remove my plaster
• pain in ribs
• I'm pregnant and have bleeding
• a lump in my throat
• my sons wheezing problem
• my daughter had an accident at school
• back pain and tummy
• I have a blotchy red rash on my arms and
legs
• I have a skin infection
• insect bite, swelling, irritation
• involved in a car accident
• cut to head
• cut to head
• cut to back of leg
• no answer
• of my ears
• difficulty in passing water from yesterday
• I was in need of medical treatment
• under lots of pain. passed out etc.
• because of my little sister
• my arm is in pain after an operation
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dressing change
injured nose
no answer
hurt foot
private
I feel bad
upset stomach
cut hand
back ache
pregnant fell over having stomach cramps
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pain in foot
recurring rash
asthma attack, diabetic
I injured my calf playing football
injury to finger
doctor sent me
my daughter is unwell
I have a health concern
bump to head
can't breath chest pains
fractured arm
pain
hurt right arm
no answer
no answer
daughter pinched her finger
my son has hurt his arm
a dog bit my hand
boil on face
back pain
of a chest infection
injury to thumb
It was more convenient for myself to get to
hospital
fracture shoulder
car accident injury to wrist
cut finger
broken fingers
SOB
chesty
I have chest pain
I have fractured my right foot
heart pain
I am feeling pain in my chest and back
I need stitches in my arm
I had a fall and I've got a bad knee
sent from Sandwell hospital to ENT
of my injuries 2 months ago, having difficulties
personal problem
a fall
my son is not well
fell on grinder/1st time
my sons are sick
no answer
daughter ill
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I have had a reaction to something I've used
chest pain
no answer
on bus and got foot injury
I cut my finger
ovaries problem
my eye is very swollen and sore
Axilla abscess
RTA
sand in eye
I got bit by a dog
I have been getting chest pains
knee got swollen
foot injury
my son has tonsillitis surgeon based here
bad cut to finger
I injured my arm playing cricket
problems with neck
asthma attack
lump in breast
ref by gp
period pain
no answer
infection in lungs
rash and temp
extreme skin reaction
pain in lower back
sore swollen legs
severe arm pain
I have pain in my right ear
twist wrist
leg problem
I hurt my hand by closing a door
I think I broke my hand
back pain
my father is unwell
leg freckles ?
bad foot injury
hurt thumb
pregnancy concerns
dental pains following tooth extraction
lump on the back of my neck
whiplash injury
doctor told
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injury to wrist
abdominal pain
stomach pains
cut my hand
take off stitches
I have a ear infection
vomiting and headache
chest pain
stiff neck and shoulder
severe pain on left side of eye and head
pain
dr referred/optician
had appendix out/scar leaking pus, smells
and
not feeling well
strong headache
problems breathing
cough
my son fell from stairs
head injury
my back was killing me
head injury
• ear problems
• pain in stomach which led to blood down
below
• damage foot
• chest complaint
• bleeding following aborted laser prostate op
• I am not feeling well
• I have torn a ligament in my leg
• not well infection
• my nephew bumped his head
• my head hurts
• I had a fall on a pavement
• I fall down on the curb
• because of of my teeth
• because of my little brother
• I've injured my hand
• I have raised moles
• foot
• I cannot walk
• I was involved in a car accident
• foot injury
• I have a problem
• eye problem
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back pain
abscess - getting it checked
my son has severe eczema
stomach pains for 6 days have been to GP
swelling to face pain unwell
pain
painful leg
foot/heel injury
pain in legs
wound on right foot
foot
pain in hand - maybe broken
son hurt back
bad back pain
some kind of insect bite
injury to right knee
v unwell
finger
my son has very bad cough and breathing
difficulty
stomach pains
my son is not well
broke wrist, gp said broke elbow too
I've had a swollen ankle for 3 months!
my chest was hurting and it felt very tight
high temperature diabetic
because daughter is sick
pain in the back of shoulder blade
pain
hurt my ankle
I have a problem with my knee
for a dressing for burnt hand
if I knew I would be a doctor! Stomach pains
ear ache
I had TB, now I have a rash on my back,
doctors cl
injured hand at work
remove splinter from hand
twisted ankle 2 weeks ago but swelling not
subside
of a foot injury
assaulted
head lice - can't get rid of it
of stomach pains
chest pains
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accident to hand and wrist
have trouble passing water
I've got pain in neck
referred by my gp
my mouth is swollen and I am being sick
foot/ankle swollen
stomach pains
feel something lodged in wind pipe
belly pains
had accident hurt my finger
broken toe
hurt right arm
asthma
knee pain
stroke symptoms
I was in severe pain
rash
no answer
pain in right ear
been bitten by insect
bad thumb
my daughter has hurt her arm
fell on pavement and hurt shoulder
see not in OTHER
Appendix C: Glossary of Terms
Acute Care
Medical or surgical treatment usually provided in a district
general hospital (also called an acute hospital).
Commissioning
Commissioning is the strategic planning and resource
allocation function of the NHS, mostly done by Primary Care
Trusts (PCTs). It involves buying in services from a range of
health service providers (including GPs, dentists, and
community pharmacists, NHS and private hospitals, and
voluntary sector organisations) to meet the health needs of
local people, and monitoring how well they are being
delivered.
Emergency
Department
The department of a hospital responsible for the provision of
medical and surgical care to patients arriving in need of
immediate care.
Integrated Care
Centre
A centre where a variety of health care services are provided
including intermediate care, primary care community care
and outreach services from hospitals.
Intermediate Care
A bridge between hospital and home care for non-urgent cases.
NHS Direct
24 hour, nurse led, telephone helpline providing nation-wide
access to healthcare advice, nurses and crisis teams.
NHS Plan
This was published in July 2000 listing radical changes to the
NHS. The NHS Plan in the Government’s 10-year plan for the
modernisation of the health service in England. It aims to
provide a wider range of choice, introduce new services,
reduce the time patients wait for appointments and move
health care closer to people’s homes.
Primary Care
GP-led services provided by family doctors and those who
work with them including district nurses, therapists, local
dentists, pharmacists, opticians and other community health
professionals.
Primary Care Trust
A NHS trust that provides all local GP, community and primary
care services and commission hospital services from other
NHS trusts. They are managed by a Board elected from local
GPs, community nurses, lay members, the Health Authority
and Social Services.
Urgent Care Centre
A facility dedicated to the delivery of medical care outside of a
hospital emergency department, usually on an unscheduled,
walk-in basis. Urgent care centres are primarily used to treat
patients who have an injury or illness that requires immediate
45
care but is not serious enough to warrant a visit to an
emergency room.
Walk-in Centre
46
Centres managed by the NHS that provide information on the
NHS, social services and other local healthcare organisations
as well as advice on self-care.
47
Faculty of Health
Birmingham City University

Emergency Department and Urgent Care Centre

Transcription

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